Knowledge, Attitude, and Practice Toward COVID-19 Among Sherubtse College Students in Bhutan: A Web-Based Cross-Sectional Study

Bhutan has reopened schools and colleges after an initial closure to contain coronavirus disease 2019 (COVID-19) transmission. However, the risk of transmissions is higher in the schools and colleges due to crowding. Therefore, this study aimed to assess the level of knowledge, attitude, and practice (KAP) toward COVID-19 among the students of Sherubtse College in Bhutan. A cross-sectional study using a questionnaire was conducted in September 2020 among the students of Sherubtse College, Bhutan. The questionnaire was made in the Google Forms and administered through a social forum WeChat app. The KAP scores were calculated that include mean scores. The association between the KAP was assessed using the Pearson's correlation coefficient. A total of 613 students participated in the survey. The majority of the participants (57%) were female and 56% were from the third year. The mean knowledge score was 10.7 (SD = 1.7; range 0–14), mean attitude score of 3.67 (SD = 1.0; range: 0–5), and mean practice score of 5.19 (SD = range: 0–6). A majority of the students had good knowledge (98%) and practice (93.5%) scores, and a positive attitude (86.6%) toward COVID-19. A positive but weak correlation between good knowledge and practice (r = 0.1, p = 0.0126) was observed. Having a positive attitude led to practicing appropriately most of the time (r = 0.1866, p < 0.001). The students had good KAP scores and followed the COVID-19 prevention protocols advocated by the government. Good knowledge and a positive attitude were translated into good practice. Therefore, the education campaign of the Bhutan government seems to be effective in the students.

Prevalence, Pattern, and Factors Associated With Self-reported Disability Among the Bhutanese Population: A Secondary Data Analysis of Population and Housing Census

We analyzed the Population and Health Census of Bhutan (PHCB) 2017 to assess the prevalence and pattern of self-reported disability among people aged ≥15 years and the associated factors. The PHCB 2017 used the Washington Group Short Set on Functioning questionnaire to assess the disability ("lot of difficulty" or "cannot do at all") in seeing, hearing, mobility, cognition, self-care, and communication. Of the 536 443 persons included in the analysis, 384 101(71.6%) were aged <45 years, 283 453(52.8%) were men, and 206 103(38.4%) were from the rural area. The prevalence of any self-reported disability was 2.8%, among whom 34.2% reported multiple disabilities. The disability prevalence (any) was significantly higher among people aged ≥65 years, illiterate, economically inactive, permanent residents, residing in a rural area, and from central and eastern regions of the country compared with their respective counterparts. Further research on access to rehabilitation and linking with social protection schemes for the disabled is required in this country.

Rates and indications of caesarean section deliveries in Bhutan 2015-2019: a national review

BACKGROUND

Bhutan has made much efforts to provide timely access to health services during pregnancy and increase institutional deliveries. However, as specialist obstetric services became available in seven hospitals in the country, there has been a steady increase in the rates of caesarean deliveries. This article describes the national rates and indications of caesarean section deliveries in Bhutan.

METHODS

This is a review of hospital records and a qualitative analysis of peer-reviewed articles on caesarean deliveries in Bhutan. Data on the volume of all deliveries that happened in the country from 2015 to 2019 were retrieved from the Annual Health Bulletins published by the Ministry of Health. The volume of deliveries and caesarean deliveries were extracted from the Annual Report of the National Referral Hospital 2015-2019 and the data were collected from hospital records of six other obstetric centres. A national rate of caesarean section was calculated as a proportion out of the total institutional deliveries at all hospitals combined. At the hospital level, the proportion of caesarean deliveries are presented as a proportion out of total institutional deliveries conducted in that hospital.

RESULTS

For the period 2015-2019, the average national rate of caesarean section was 20.1% with a statistically significant increase from 18.1 to 21.5%. The average rate at the six obstetric centres was 29.9% with Phuentsholing Hospital (37.2%), Eastern Regional Referral Hospital (34.2%) and Samtse General Hospital (32.0%) reporting rates higher than that of the National Referral Hospital (28.1%). Except for the Eastern Regional Referral and Trashigang Hospitals, the other three centres showed significant increase in the proportion of caesarean deliveries during the study period. The proportion of emergency caesarean section at National Referral Hospital, Central Regional Referral Hospital and the Phuentsholing General Hospital was 58.8%. The National Referral Hospital (71.6%) and Phuentsholing General Hospital reported higher proportions of emergency caesarean sections (64.4%) while the Central Regional Referral Hospital reported higher proportions of elective sections (59.5%). The common indications were 'past caesarean section' (27.5%), foetal distress and non-reassuring cardiotocograph (14.3%), failed progress of labour (13.2%), cephalo-pelvic disproportion or shoulder dystocia (12.0%), and malpresentation including breech (8.8%).

CONCLUSION

Bhutan's caesarean section rates are high and on the rise despite a shortage of obstetricians. This trend may be counterproductive to Bhutan's efforts towards 2030 Sustainable Development Goal agendas and calls for a review of obstetric standards and practices to reduce primary caesarean sections.

Control of travel-related COVID-19 in Bhutan

Bhutan—a landlocked country in South Asia—has reported 3381 COVID-19 cases per million population and three deaths until August 2021. The country implemented stringent public health measures to prevent widespread outbreak of COVID-19. This paper describes travel-related measures taken by Bhutan and discusses the way forward after COVID-19 vaccination.

Physiotherapy services in patient care in Bhutan

Physiotherapy and rehabilitative services are an integral part of patient care, but in many developing countries they are not considered a priority and are either not available or not easily accessible to those who need them. Bhutan is one such country where healthcare is provided free of cost to all, but as of 2021 physiotherapy services were available only in 26 of 48 hospitals and 19 of 20 districts. The number of physiotherapy professionals per 10,000 population is 1.4 with significant rates of attrition. There is lack of awareness among patients and other health professionals about physiotherapy and rehabilitation services. The country needs to integrate physiotherapy and rehabilitation services into the overall health policy framework and develop proper planning of human resources and infrastructure to meet the current and future demands.

Self-learning on COVID-19 among medical students in Bhutan: A cross-sectional study

Background

Bhutan lacks a medical school and all medical students are trained in Sri Lanka, Bangladesh and India. When the COVID-19 pandemic led to the closure of medical schools in these countries in March–April 2020, the medical students were repatriated to Bhutan. Upon return, they were kept in government-sponsored facility quarantine for 21 days. This study assessed their knowledge on COVID-19 as a part of self-learning and their attitude towards participation in government's health response to COVID-19.

Methods

This was a cross-sectional study among medical students who had returned to the country. The survey was conducted through an online questionnaire while the students were in facility quarantine. The sample size calculated was 129 and convenient sampling was used. Knowledge was assessed using 20 questions, each scored 1/20. Knowledge was considered “good” if the cumulative score was ≥80%, “satisfactory” if ≥60–79% and “poor” if <60%. Correlation between knowledge score and duration of clinical clerkship was tested using Pearson's correlation coefficient. Attitude of students towards their willingness to participate in the national COVID-19 response was tested using rating scales. Data were analysed using Stata 13.1.

Results

120 medical students responded to the survey (response rate = 93%). Eighty-eight (74%) had good knowledge, 28 (23%) had satisfactory knowledge and only four (3%) had poor knowledge on COVID-19. The students scored high on the symptomatology, mode of transmission, prevention and treatment options and on local epidemiology; and scored low on the forms of mechanical ventilation and on home-management of non-critical cases. The knowledge score correlated with the duration of clinical clerkship they had undertaken (r = 0.326, p = 0.001). The primary source of information were social media sites (102, 85%), television (94, 78%) and newspapers (76, 63%). The majority (78, 65%) were willing to participate in the government's COVID-19 response but could not identify what roles they could play. The fear of contracting COVID-19 was reported by eight students (7%).

Conclusions

Medical students had good knowledge on COVID-19 and had self-learned through social media, television and newspapers. The students held positive attitude towards participation in the government's COVID-19 response.

Probable rabies in a child in a Bhutanese town bordering India, 2020

Rabies is a neglected tropical disease that causes mortality and high economic burden in many developing countries. Rabies is a vaccine-preventable disease if timely post-exposure prophylaxis is available after animal exposure. The control of rabies requires limiting the transmission of the virus in the animal reservoir, effective public health measures to control outbreaks and increasing accessibility and uptake of rabies post-exposure prophylaxis. Bhutan is a small Himalayan country where rabies is endemic. In this article, we describe the death of a 3-year-old female child due to probable rabies in a Bhutanese village located along the border with India. The child had a furious form of rabies with encephalitic syndrome developing 57 days after a category III dog bite on the chest. The child was managed at a district hospital with the available resources. This is the first rabies death in Bhutan in the last 5 years and the 18^th since 2006. This case report focuses on the efforts required to increase the timely uptake of post-exposure prophylaxis in a free healthcare system in Bhutan.

Gender-neutral HPV elimination, cervical cancer screening, and treatment: Experience from Bhutan

Cervical cancer is preventable and also curable when detected early and treated adequately, yet it remains a leading cause of morbidity and mortality among women. In Bhutan, cervical cancer is the most common cancer among women. Bhutan was the first country among the low- and middle-income economies to have instituted a national HPV vaccination program, in 2010, and has achieved >90% coverage. In 2019, Bhutan launched a cervical cancer elimination flagship program well ahead of WHO's launch of the global strategy for accelerated elimination of cervical cancer. Bhutan initiated vaccination of adolescent boys and adopted a gender-neutral vaccination program beginning September 2020 through its well-established network of primary healthcare centres. The flagship program aims to screen women aged 30-69 years with HPV testing using liquid-based cytology (LBC) as triaging for screen positive women. For women aged 25-29 years, LBC will be continued as per American Society of Colposcopy and Cervical Pathology guidelines. Colposcopy and treatment will be performed in camps to decrease loss of follow up of screen positive women. This program is also expected to improve early diagnosis of cervical cancer and provide timely and adequate cancer treatment and palliative care services. This article reviews the progress made and the challenges facing the 2030 cervical cancer elimination targets in Bhutan.

Dietary behavior of school-going adolescents in Bhutan: Findings from the global school-based student health survey in 2016

OBJECTIVES

Bhutan is experiencing a dual burden of undernutrition and overnutrition among adolescents. Understanding dietary behavior is vital to designing evidence-based interventions to improve adolescent nutrition and prevent non-communicable diseases in adults. The aim of this study was to assess the pattern of dietary behavior and associated sociodemographic, behavioral, and metabolic risk factors among school-going adolescents in Bhutan.

METHODS

The Bhutan Global School-based Student Health Survey 2016 studied students in grades 7 to 11 (N = 7576), sampled from 50 schools, randomly selected based on probability proportional to enrollment size, using a standardized self-administered questionnaire. Consumption of adequate fruits and vegetables (each at least twice daily, or a combination of at least five times daily), high-protein food at least twice weekly) in the past 30 d, no fast food in the past week, and no carbonated/sweetened drinks in the past 30 d were studied. Weighted prevalence of dietary behaviors and adjusted prevalence ratio (95% confidence interval) for factors associated with them were calculated.

RESULTS

Of 5809 students from 13 to 17 y of age comprising 3255 (56%) girls and 3184 (54.8%) day students, 1166 (20.1%) were underweight, 1655 (28.5%) were tobacco users, and 1349 (23.2%) were alcohol users. Adequate fruit and vegetable intake, high protein consumption, not consuming fast foods and carbonated beverages were reported by 29.6%, 31.8%, 9.6%, and 14.9%, respectively. Being a day student, sex, and not reporting health risk behaviors were significantly associated with any healthy dietary behavior.

CONCLUSION

Healthy eating behavior was low among Bhutanese adolescents. Policies influencing availability, affordability, and acceptability of healthy diets through peer-led, school- and community-based interventions are required to promote adolescent health and prevent non-communicable diseases.

Human papillomavirus vaccination uptake in low-and middle-income countries: a meta-analysis

BACKGROUND

The proportion of incident cases of HPV-attributable cancers is highest in the low- and middle-income countries (LMICs) but many are yet to initiate HPV vaccination programs. This meta-analysis was performed to assess the uptake of HPV vaccination in LMICs at the beginning of the global strategy to eliminate cervical cancer and describes the gaps and challenges.

METHODS

A systematic search was conducted in PubMed, EMBASE, Scopus, Web of Science, and CENTRAL databases for observational studies that reported the uptake of HPV vaccination until October 2020. The meta-analysis was done using a random-effects model to assess the pooled estimate of HPV uptake. CRD42021218429.

FINDINGS

During 2008-2020, an estimated 3.3 million females received at least one dose of HPV vaccine with 61.69% of the target population vaccinated. In countries with high uptake, the pooled estimate of uptake was higher in females than males (45.48% vs 8.45%) and showed significant decline in 2015-2020 compared to 2006-2014 (89.03% vs 41.48%). In countries with low uptake, the estimate of uptake was low in both males and females (5.31% vs 2.93%) and showed increase in uptake in 2015-2020 compared to 2006-2014 (0.76% vs 5.22%). In countries with high uptake, compared to routine programs, the estimate was higher when delivered through demonstration programs (89.94% vs 59.74%).

INTERPRETATION

The major concern was a significant drop in the uptake in countries that started with high uptake, challenges in the maintenance of vaccine uptake, sustainability of funding and the lack of standard monitoring and reporting.

Recurrent ear bleed with profound bilateral sensorineural hearing loss: A case of Munchausen syndrome

Factitious disorders and Munchausen syndromes present with history and physical symptoms to all specialties, and they are often extensively evaluated. Diagnosis of Munchausen syndrome is a challenge and patients often do not receive the correct diagnosis and appropriate care especially in settings where access to mental health professionals is difficult. We present a case of recurrent bleed from the right ear, bilateral profound hearing loss and jerky movement of limbs that was extensively evaluated and followed up for 4 years until a diagnosis of Munchausen syndrome was reached. This case reports the risk of harm to the patient and wastage of healthcare resources unless physicians begin to actively evaluate for factitious disorders.

Knowledge and understanding of obstetric danger signs among pregnant women attending the antenatal clinic at the National Referral Hospital in Thimphu, Bhutan: a cross-sectional study

BACKGROUND

The third Sustainable Development Goal for 2030 development agenda aims to reduce maternal and newborn deaths. Pregnant women's understanding of danger signs is an important factor in seeking timely care during emergencies. We assessed knowledge of obstetric danger signs using both recall and understanding of appropriate action required during obstetric emergencies.

METHODS

This was a cross-sectional study among pregnant women attending antenatal clinic at Bhutan's largest hospital in Thimphu. Recall was assessed against seven obstetric danger signs outlined in the Mother and Child Health Handbook (7 points). Understanding of danger signs was tested using 13 multiple choice questions (13 points). Knowledge was scored out of 20 points and reported as 'good' (≥80%), 'satisfactory' (60-79%) and 'poor' (< 60%). Correlation between participant characteristics and knowledge score as well as number of danger signs recalled was tested using Pearson's correlation coefficient. Association between knowledge score and participant characteristics was tested using t-tests (and Kruskal-Wallis test) for numeric variables. Socio-demographic and clinical characteristics associated with the level of knowledge ('good' versus 'satisfactory' and 'poor' combined) were assessed with odds ratios using a log-binomial regression model. All results with p < 0.05 were considered significant.

RESULTS

Four hundred and twenty-two women responded to the survey (response rate = 96.0%). Mean (±SD) knowledge score was 12 (±2.5). Twenty women (4.7%) had 'good' knowledge, 245 (58.1%) had 'satisfactory' knowledge and 157 (37.2%) had 'poor' knowledge. The median number of danger signs recalled was 2 (IQR 1, 3) while 68 women (20.3%) could not recall any danger signs. Most women were knowledgeable about pre-labour rupture of membranes (96.0%) while very few women were knowledgeable about spotting during pregnancy (19.9%). Both knowledge score and number of danger signs recalled had significant correlation with the period of gestation. Women with previous surgery on the reproductive tract had higher odds of having 'good' level of knowledge.

CONCLUSIONS

Most pregnant women had 'satisfactory' knowledge score with poor explicit recall of danger signs. However, women recognized obstetric emergencies and identified the appropriate action warranted.

Indications and factors associated with cesarean section in Bhutan: A hospital-based study

OBJECTIVE

To investigate the factors associated with cesarean section (CS) in Bhutan.

METHODS

This was a cross-sectional study, using the retrospective data from the birth registers maintained in comprehensive emergency obstetric care centers for the year 2018. The data were entered in excel 2013 and analyzed using STATA 13. Multiple logistic regression was used to understand the factors associated with CS in Bhutan.

RESULTS

The rate of CS in Bhutan was 18.7%. The indications for CS were previous CS, fetal distress, prolonged labor, and failed induction. The factors associated with CS were maternal age over 25 years, male child, women with smaller number of living children, multiple pregnancy, and gestation over 40 weeks. In addition, mothers delivering in Samtse Hospital and Central Regional Referral Hospital had higher odds of CS.

CONCLUSION

In Bhutan, CS was commonly performed for mothers with previous CS, fetal distress, and prolonged labor. Increasing maternal age, multiple pregnancy, and postdated pregnancy and those with one child, or none, were more likely to undergo CS. To reduce the CS rate, Bhutan should focus on decreasing the primary CS rate as well as preventing over-diagnosis of prolonged labor by focusing on the partograph.

The Gross National Happiness Framework and the Health System Response to the COVID-19 Pandemic in Bhutan

Bhutan is a lower-middle–income country with limited tertiary-care health infrastructure and shortage of human resources. The country’s response to the COVID-19 pandemic is guided by the principle of Gross National Happiness (GNH), which prioritizes the well-being and happiness of people over conventional socioeconomic indicators. The king’s leadership and government’s decisions based on public health science helped in the control of the pandemic and reduce economic losses. The government implemented some unique and unconventional public health measures such as facility quarantine for those with high-risk exposure, an increase in quarantine period to 21 days, free testing and treatment, and population-based screening tests. Early and extensive contact tracing, extensive testing, effective communications, zoned travel restrictions, and adoption of physical distancing and hygiene measures limited COVID-19 transmissions within the country. Community participation from voluntary groups and civil society organizations helped deliver non-health services while hospitals provided uninterrupted routine health services through its primary healthcare network. All COVID-19 cases were treated in hospitals, and the country has had zero reported COVID-19 deaths. This article describes how the concept of GNH provided the framework for the government to respond to this pandemic.

Knowledge, attitude and practice towards health research and its utilization among health professionals in Bhutan: Results of a nationwide cross-sectional survey in 2019

OBJECTIVES

Research is an important tool for sustainable development and the advancement of health. In Bhutan, the need for strengthening the national health research effort has been recognized only in recent years. As a part of research capacity building, this study was conducted to assess the knowledge, attitude and practices of the country's health care professionals towards research.

METHODS

This was a nationwide cross-sectional study. Simple random sampling was used to obtain a proportionate composition of health professionals. A self-administered questionnaire was developed to assess knowledge through 10 multiple-choice questions, attitude through rating statements, and practices through assessing experiences with research. Knowledge was scored out of 10. Besides analysing proportions, correlation and simple linear regression coefficients were calculated to assess the association of knowledge score with age, work experience, qualification, and the number of research projects undertaken.

RESULTS

A total of 420 valid questionnaires were collected (response rate = 95.2%). The mean knowledge score was 6.2 (±2.0) out of 10. There was a negative correlation between the knowledge score and the participant's age (r = -0.15, p = 0.002) and work experience (r = -0.17, p < 0.001). Participants' knowledge score increased by 0.58 (95% CI: 0.50-0.65, p < 0.001) for each unit increase in qualification level and by 0.75 (95%CI: 0.64-0.87, p < 0.001) for every research project conducted. The majority believed that local research would contribute to better clinical decision making (92.8%) by building local evidence (90.3%). Four out of five participants expressed interest in conducting research. However, only 27.4% had ever conducted research, 6.0% had published in journals and 4.3% had presented in scientific conferences. Less than half of the respondents had read (35.2%) or participated in discussions (42.1%) of research articles in their workplace. The major challenges were lack of knowledge (61.2%), time (49.9%) and resources to undertake literature searches (42.6%).

CONCLUSIONS

Self-reported knowledge about health research was fair, and the conduct of research and utilization of research articles were poor. However, the majority hold positive attitudes and there is a need for supporting professional development in this area.

Assessment of knowledge, attitude and practice on tuberculosis among teacher trainees of Samtse College of Education, Bhutan

Background

Tuberculosis (TB) is a major public health problem in Bhutan despite the implementation of directly observed treatment short-course since 1997. This study aimed to assess the knowledge, attitude and practice on TB among the teacher trainees of Samtse College of Education.

Methodology

A cross-sectional study was conducted among the teacher trainees of Samtse College of Education. A standardized pretested questionnaire was distributed and self-administered. The participants were selected randomly using randomization. The data was entered in Epi-data 4.4.2.1 and analysed using STATA version 13. A score of 1 point for a correct answer and 0 for wrong/don’t know answer was given. The knowledge, attitude and practice score were divided into good and poor based on 50% cut off. Logistic regression was used for the analysis to identify the significant covariates.

Results

A total of 420 trainees responded to the survey questionnaire. The average knowledge score on TB was 10.7 (Range = 0–21). Two hundred and forty respondents (58.6%) had low knowledge (mean score 7.8±2.5) on TB. Cough, chest pain and weight loss were correctly reported as the symptoms of TB by 306 (72.9%), 187(44.5%) and 187 (44.5%) participants. Eighty-nine-point five percent (376) of participants reported coughing as the main route of TB transmission and 85% (357) of the participants said that it could be prevented by covering the mouth while coughing. In multivariable analysis; the trainees in the junior years of college had good knowledge of TB compared with the senior years (adjusted odds ratio [AOR] 2.02; 95% confidence interval [CI] 1.18–3.5; p-value 0.011). Respondents previously treated for TB were more likely to have good knowledge on TB compared to those who never had TB in the past (AOR 2.39; 95% CI 1.07–5.31; p-value 0.033). The majority (93%) of respondents had a good attitude towards TB cases. Female trainees were 2.4 (95% CI 1.02–5.62; p-value 0.045) times more likely than male trainees to have a positive attitude towards TB. Eighty-eight percent of the respondents reported that they would visit the hospital if they had TB symptoms. The mean score for the practice on TB was 1.33±0.59 (Range:0–2).

Conclusion

In this study, the majority of the trainees had poor knowledge on TB, especially among the trainees in senior years of college and those who had never suffered from TB. The attitude towards TB was good especially among the female trainees. However, the overall practice was poor among the participants. Therefore, the Ministry of Health should collaborate with relevant stakeholders especially the Ministry of Education to incorporate topics on TB in the syllabus of students and colleges to create awareness on it.

Treatment outcome of tuberculosis patient of Samtse General Hospital, Bhutan

Background

Tuberculosis (TB) is one of the major public health problems in Bhutan. Evaluation of treatment outcomes of TB and identification of the risk factors are important components for the success of National TB control program. Therefore, this study was undertaken to assess the TB treatment outcome and factors associated with it in Samtse General Hospital.

Methods

This was a retrospective, cross sectional study using the TB data from Samtse General Hospital from 2008-2019. A univariate and multiple logistic regression was used to check for associations between the outcome and other independent variables.

Results

The study included a total of 634 TB patients. Of this, 44.0% (279) were smear positive TB (PTB+), 36.1% (229) were extra pulmonary TB (EPTB) and 19.9% (126) were smear negative TB (PTB-). During the study period, 56.2% (356) of them completed treatment, 33.3% (211) were declared cured, 0.2% (1) had defaulted, 5.1% (32) died and 5.4% (34) had treatment failure. The mean treatment success rate (TSR) was 89.4% (567). The TSR was highest for EPTB with 96.9% (222/229), followed by PTB- at 88.1% (111/126) and lowest for PTB+ with 83.9% (234/279). Successful treatment outcome was observed in EPTB patients (AOR: 7.3; 95% CI: 2.46-21.36), patients in age 15-28 years (AOR: 3.4; 95% CI: 1.59-7.46) and 29-42 years (AOR: 9.1; 95% CI: 2.44-33.61).

Conclusion

The treatment outcome of TB in Samtse General Hospital is satisfactory and at par with the national level. Since, smear positive TB and elderly patients are prone to develop poor treatment outcome, they need to be monitored and followed up adequately.

Circumstances of human conflicts with bears and patterns of bear maul injuries in Bhutan: Review of records 2015-2019

Bhutan is one of the biological hotspots in the world where humans and natural flora and fauna co-exist in close proximity. Bhutan is home to two species of bears: Sloth Bear and Himalayan Black Bear. Human conflicts with bears are reported from all over the country. This study describes the profile of the victims and the pattern of injury resulting from bear attacks and circumstances around human conflicts with bears in Bhutan between 2015 and 2019. This was a cross-sectional study with a review of hospital records of patients treated at the National Referral Hospital from 01 January 2015 till 31 December 2019. Data were extracted into a structured pro forma and entered into EpiData Entry 3.1 and analysed in STATA 13.1. There were thirty-four patients who were provided care for bear maul injuries, with an average annual caseload of 6.8 cases per year. The injury prevalence was 100% and the kill prevalence was 0%. Bear attacks were reported from fourteen of twenty districts of the country. The mean age of the victims was 49 (±13) years. Males (26, 76%) and farmers (26, 76%) were the common victims; the risk of bear attacks was 0.16 per 100,000 farmers per year. The commonest region of the body attacked was the face (29, 85%) and victims were provided emergency and rehabilitative care within and outside the country. Thirty-three victims (97%) were provided post-exposure prophylaxis for rabies. All victims received antibiotics despite the lack of national guidelines on the choice of antibiotics post-bear maul. Human-bear conflict is multi-faceted, puts a considerable strain on bear-conservation efforts and requires multi-disciplinary efforts in the prevention of human injury and socioeconomic losses.

Internet Addiction among Secondary School Adolescents: A Mixed Methods Study

INTRODUCTION

Excessive use of internet can lead to "Internet Addiction". A sharp rise in the number of internet users among adolescents in Bhutan have been observed lately which could have potential side-effects on their health. The aim of this study was to find the prevalence of internet addiction and psychological co-morbidities among the secondary school-going adolescents.

METHODS

This is a descriptive cross-sectional quan-qual sequential mixed method design with a quantitative component and qualitative component. The study was conducted between 1st May and 30st November 2017 conducted in twelve schools across Bhutan after taking ethical clearance was from Research Ethics Board of Health of Bhutan. Data were doubleentered in EpiData Entry, validated and imported into STATA version 12.0 for analysis. Point estimate at 95% CI was calculated along with frequency and proportion for binary data.

RESULTS

Among 721 adolescents from twelve selected schools, prevalence of internet addiction was 248 (34.440%) at , 95% Confidence Interval (31-38%). Out of A total of 586 (81%) preferred smartphone for internet use with 388 (54%) actually using it. Depression and anxietywere the associated psychological co-morbidities seen along with internet addiction. Internet addiction was high among those using internet at home, using smartphone for internet access, social networking and night time internet use were associated with internet addiction. Boredom, stress/anxiety and peer pressure were triggers of internet use. Internet addiction also affected academic performance, social interactions and sleep.

CONCLUSIONS

Prevalence of internet addiction among adolescents in Bhutan is high comparing to previous standard data which requires immediate attention.

Socio-demographic and Clinical Characteristic of Women Availing Pap Smear Services in Samtse District, Bhutan

Background: The case burden of cervical cancer has been increasing globally especially in developing countries without proper health system. Cervical cancer can be eliminated with timely vaccination and screening program as it usually takes years for pre-malignant lesions to develop into malignant lesion. Bhutan has committed to eliminate cervical cancer. Thus, it is important to understand the factors associated with abnormal Pap test findings. Methodology: A retrospective study was conducted using the Pap smear data for the year 2018. It was extracted from the records maintained in the cytology unit of Samtse General Hospital. Result: The abnormal slide rate in this study was 2.5%. The majority of women seeking Pap smear services were women in reproductive age group and housewife by occupation. There were significant differences between age groups and marital status among normal in the Pap test results. Conclusion: The slide abnormality of Pap smear in Samtse District is low. The abnormality is more common among married and older women. Therefore, additional screening efforts needs to be put into this group to detect pre-malignant lesions.

Epidemiological and histopathological characteristics of head and neck cancers in Bhutan from 2011 to 2017: a retrospective descriptive study

BACKGROUND

Head and neck cancers are among the commonest cancers in the developing world. Personal habits, such as the use of tobacco, betel nut and alcohol are strongly associated with the development of head and neck cancers at certain sites. Therefore, they are among the preventable cancers. In Bhutan, there has not yet been a study conducted on head and neck cancers.

OBJECTIVE

To describe baseline epidemiological and histopathological characteristics of head and neck cancers in Bhutan.

METHODS

This is a 7-year descriptive study of all cases of head and neck cancers presented at the Jigme Dorji Wangchuk National Referral Hospital from 2011 to 2017. The data were collected from the hospital's medical records section, histopathology records, patient referral unit and some treatment centres in India. Prior approval was sought from the Research and Ethics Board for Health, the Ministry of Health and the hospital management.

RESULTS

There were a total of 515 cases of head and neck cancers from 2011 to 2017. The crude incidence rate was 10 per 100,000 and the overall age adjusted rate was 12.3 (95% CI 9.5-15.1) per 100,000 population. The prevalence during this 7-year period was 69.1 per 100,000 population. The commonest cancers are thyroid, oral cavity, hypopharyngeal, laryngeal and nasopharyngeal cancer in decreasing order. Head and neck cancers are more common in males than females in the majority of sites except thyroid, salivary gland and sinonasal malignancies. Thyroid cancers and nasopharyngeal cancers are found to affect younger age groups. Tashigang (48) followed by Paro (43) recorded the highest number of cases. Squamous cell carcinoma is the commonest histopathology type in almost all the cases, while papillary carcinoma is the commonest among thyroid cancers. Personal habits, such as smoking, chewing tobacco, betel nut and alcohol consumption, were found to be more common among patients suffering from oral cavity, laryngeal, hypopharyngeal and oropharyngeal cancers.

CONCLUSION

Head and neck cancers are the third most common cancer in Bhutan after stomach cancer and cervical cancer. Thyroid, oral cavity and hypopharynx are the top three anatomical sites for head and neck cancers in Bhutan. The current epidemiological and histopathological profile of head and neck cancers will form a baseline of information and basis for further research on head and neck cancers in Bhutan.