Developing a national health research agenda for Lao PDR: prioritising the research needs of stakeholders

Background

Currently the health research system in Lao PDR is fragmented and largely donor led. Capacity among national public health institutes is limited to select priority research questions for funding.

Objective

The objective of this capacity building and practice-oriented study is to describe the process and outcome of the first National Health Research Agenda for Lao PDR and how the agenda contributes to institutional capacity of the Ministry of Health, in order to contribute to evidence-informed public health policy making.

Method

This activity used a mixed-methods approach. The overall design is based on principles of the interactive Learning and Action approach and consists out of 6 phases: (1) identification of needs, (2) shared analysis and integration, (3) nation-wide prioritization of research domains, (4) exploring specific research questions, (5) prioritization of research avenues, (6) dialogue and planning for action. The process involved interviews with experts in health policy and research (n = 42), telephone-based survey with district, provincial and national health staff (n = 135), a two-round Delphi consultation with experts in health policy and research (n = 33), and a workshop with policymakers, researchers, international organisations and civil society (n = 45) were held to gather data and conduct shared analysis.

Results

11 research domains were identified and prioritised: Health-seeking behaviour; Health system research; Health service provision; Mother and child health (MCH); Sexual & reproductive health; Health education; Non-communicable diseases (NCDs); Irrational drug use; Communicable diseases (CDs); Road traffic accidents; Mental health. Within these domains over 200 unique research questions were identified.

Conclusion

Our approach led to a comprehensive, inclusive, public health agenda for Lao PDR to realise better informed health policies. Questions on the agenda are action-oriented, originating in a desire to understand the problem so that immediate improvements can be made. The agenda is used within the MoH as a tool to fund and approve research. 

Effects of therapeutic zinc supplementation for diarrhea and two preventive zinc supplementation regimens on the incidence and duration of diarrhea and acute respiratory tract infections in rural Laotian children: A randomized controlled trial

Background

Diarrhea and respiratory tract infections are leading causes of childhood morbidity and mortality. This individually randomized, double-blind placebo-controlled trial was designed to evaluate the effects of different zinc supplementation regimens on the incidence and duration of diarrhea and acute lower (ALRI) and upper (AURI) respiratory tract infections among rural Laotian children. The study included 3407 children, 6-23 months at enrollment.

Methods

Children were randomized to one of four study groups: therapeutic zinc supplements for diarrhea treatment (20 mg/d for 10 days with each episode; TZ), daily preventive zinc tablets (7 mg/d; PZ), daily multiple micronutrient powder (10 mg/d zinc, 6 mg/d iron and 13 other micronutrients; MNP), or daily placebo powder for 9 months. Incidence and duration of diarrhea (≥3 liquid stools/24 hours), ALRI (persistent cough with wheezing, stridor or chest in-drawing) and AURI (purulent nasal discharge with cough) were assessed by parental report during weekly home visits and analyzed using negative binomial models.

Results

Baseline mean age was 14.2 ± 5.1 months, and 71% had low plasma zinc (<65 μg/dL). Overall diarrhea incidence (0.61 ± 0.01 episodes/100 days at risk) and duration (2.12 ± 0.03 days/episode) did not differ by study group. Age modified the impact of the interventions on diarrhea incidence (P = 0.06) and duration (P = 0.01). In children >18 months, TZ reduced diarrhea incidence by 24% vs MNP (P = 0.035), and 36% vs Control (P = 0.004), but there was no difference with PZ. This patterned remained when analyses were restricted to diarrhea episode occurring after the first treatment with TZ. Also, in children >18 months, TZ reduced diarrhea duration by 15% vs PZ (P = 0.03), and 16% vs Control (P = 0.03), but there was no difference with MNP. There were no overall effects of study group on incidence of ALRI (overall mean 0.005 ± 0.001 episodes/100 days, P = 0.14) or AURI (overall mean 0.09 ± 0.01 episodes/100 days, P = 0.72).

Conclusions

There was no overall impact of TZ, PZ or MNP on diarrhea, ALRI and AURI. However, in children >18 months, TZ significantly reduced both the duration of diarrhea episodes and the incidence of future diarrhea episodes compared with placebo.

Trial registration

ClinicalTrials.gov: NCT02428647.

Are dietary intake and nutritional status influenced by gender? The pattern of dietary intake in Lao PDR: a developing country

Background

Recognition of discrepancies between men and women in nutritional intake is important to tackle food and nutrition insecurity and the often-double burden of malnutrition. The purpose of this study was to assess nutritional status and dietary intake of the Lao population, with a focus on possible influences of gender.

Methods

Dietary intake was assessed in a national cross-sectional study of 1771 randomized participants aged from 1.01 to 89 years, using 24-h dietary recall. Dietary reference intakes were used to assess nutrient insufficiency. Chi-square test was used to evaluate gender differences and multiple univariate logistic regression to examine associations between gender, nutritional status, demographics and nutrient insufficiency.

Results

Nutrient insufficiencies were higher among pregnant and lactating women than other adult men and women, especially for protein and micronutrients such as vitamin B3, B1, C and other vitamins. Dietary intake and BMI were similar between men and women; all had insufficient intake of all types of nutrients, except sodium. However, women had lower intake than men for almost all nutrients and age groups. The prevalence of overnutrition was higher among those aged 18 years and over for both sexes. Among adult women (15–49.9 years old) and older adult women (50 years old or above), the proportions were: underweight 8.6% (both groups), overweight 18.4 and 20.5%, and obese 34.2 and 39.1%, respectively. Among pregnant and lactating women, the rates of underweight were 7.5 and 1.4%, of overweight were 17.8 and 27.1%, and obese, 21.9 and 40.0%. Among adult and older men, 3.2 and 8.3% were underweight; 21.0 and 18.6% were overweight and 28.2 and 27.6% were obese. Multiple univariate logistic regressions revealed that the factors rural area, dry season and Northern-Lowland region were associated with inadequate micronutrient intake among children, adolescents and adults of both genders.

Conclusions

Dietary intakes were alarmingly micronutrient-insufficient. Macronutrient imbalance and double burden of malnutrition were confirmed in both sexes. Gender differences were limited; men and women had similarly insufficient intakes, but pregnant and lactating women were disproportionately affected. Nutritional interventions should also take men and older people into account to solve nutrition problems.

Cognitive function measured with the Revised Hasegawa's Dementia Scale among elderly individuals in Lao PDR

In Lao PDR, measurement of cognitive function has rarely been conducted among elderly individuals. This study aimed to investigate the cognitive function among elderly individuals who lived at their homes with family in Lao PDR. Participants were elderly individuals aged 60 years or over registered with the local government in urban (Vientiane capital; VC) and rural areas (Khammouane province; KP). Those with serious mental/physical diseases, those who could not walk by themselves, or those who could not speak the Lao language were excluded. The information was collected through interviews with the participants and their family members. A newly developed Lao version of the Revised Hasegawa’s Dementia Scale (HDS-R) was applied to measure cognitive function. The participants were 414 elderly individuals (224 males and 190 females) aged 60 to 98 years. The average HDS-R score was 23.0 among 115 men in VC, 22.7 among 92 women in VC, 20.3 among 109 men in KP, and 17.5 among 98 women in KP. The main caregiver was a daughter (40.6%) followed by a spouse (31.4%). Among 414 elderly individuals, 42 (10.0%) stated the necessity of support. Those with HDS-R < 20 accounted for 38.8% in men and 48.9% in women. The adjusted odds ratio of HDS-R < 20 was significant for those in rural areas (3.83) relative to those in urban areas. Among superficially healthy elderly individuals residing with their families, those with reduced cognitive function were more common among women and in rural areas.

Impact of Two Forms of Daily Preventive Zinc or Therapeutic Zinc Supplementation for Diarrhea on Hair Cortisol Concentrations Among Rural Laotian Children: A Randomized Controlled Trial

Zinc supplementation has been shown to reduce the morbidity burden among young children, and may reduce chronic stress. Hair cortisol has been promoted as an indicator of chronic stress. We assessed the impact of different strategies for delivering supplementary zinc on hair cortisol concentrations (HCC) in young Laotian children and examined risk factors associated with HCC. In a randomized double-blind controlled trial (NCT02428647), children aged 6⁻23 mo were randomized to one of four intervention groups and followed for ~36 weeks: daily preventive zinc (PZ) tablets (7 mg/day), daily multiple micronutrient powder (MNP) sachets (containing 10 mg zinc and 14 other micronutrients), therapeutic zinc (TZ) supplements for diarrhea treatment (20 mg/day for 10 days) or daily placebo powder. HCC of 512 children was assessed at baseline and endline. ANCOVA and linear regression models were used to assess group differences in HCC and to examine the risk factors associated with HCC, respectively. At enrollment, mean HCC was 28.8 ± 43.9 pg/mg. In models adjusted for age at enrollment, health district, and baseline HCC there was no overall effect of the interventions on endline HCC and change in HCC. When controlling for additional predetermined covariates, there was a marginally significant effect on change in HCC (p = 0.075) with a slightly lower reduction of HCC in TZ compared to PZ (mean change (95% CI): -4.6 (-7.0; -2.3) vs. -9.4 (-11.7; -7.0) pg/mg; p = 0.053). At baseline, consumption of iron rich foods was negatively associated with HCC, whereas AGP (α1-acid glycoprotein) levels, elevated AGP and C-reactive protein and high soluble transferrin receptor were positively associated with HCC. In young Laotian children, MNP, PZ and TZ had no impact on HCC. The marginal difference in change in HCC between the PZ and TZ groups was too small to be considered of health significance.

Comparison of two forms of daily preventive zinc supplementation versus therapeutic zinc supplementation for diarrhea on young children's physical growth and risk of infection: study design and rationale for a randomized controlled trial

Background

Zinc is an essential nutrient that is required for children’s normal growth and resistance to infections, including diarrhea and pneumonia, two major causes of child mortality. Daily or weekly preventive zinc supplementation has been shown to improve growth and reduce the risk of infection, while therapeutic zinc supplementation for 10–14 days is recommended for the treatment of diarrhea. The overall objective of the present study is to compare several regimens for delivering zinc to young children, both for the prevention of zinc deficiency and the treatment of diarrhea.

Methods

The present study is a community-based, randomized controlled trial in the Lao People’s Democratic Republic (PDR). Three thousand, four hundred children 6–23 months of age will be randomized to one of four intervention groups (daily preventive zinc dispersible tablet, daily preventive multiple micronutrient powder, therapeutic zinc dispersible tablet for diarrhea, or placebo control); interventions will be delivered for 9 months and outcomes measured at pre-determined intervals. Primary outcomes include physical growth (length and weight), diarrhea incidence, hemoglobin and micronutrient status, and innate and adaptive immune function. Secondary outcomes include mid-upper-arm circumference, neuro-behavioral development, hair cortisol concentrations, markers of intestinal inflammation and parasite burden. Incidence of adverse events and the modifying effects of inherited hemoglobin disorders and iron status on the response to the intervention will also be examined. We will estimate unadjusted effects and effects adjusted for selected baseline covariates using ANCOVA.

Discussion

Many countries are now rolling out large-scale programs to include therapeutic zinc supplementation in the treatment of childhood diarrhea, but few have established programs demonstrated to be effective in the prevention of zinc deficiency. This study will address how best to deliver supplemental zinc to prevent zinc deficiency and reduce the severity of diarrhea-related health complications.

Trial registration

Trial registration identifier (NCT02428647) ; Date of registration: April 29, 2015.

Comparison of haemoglobin assessments by HemoCue and two automated haematology analysers in young Laotian children

Background

Haemoglobin (Hb) assessment by Hemocue is used widely for anaemia screening in both adults and children. However, few studies have compared the diagnostic accuracy of Hemocue with an automated haematology analyser in young children.

Aim

To compare Hb concentrations by Hemocue Hb301 and two automated haematology analysers in young children in rural communities of Lao PDR.

Methods

Capillary blood was collected from 6-month-old to 23-month-old children (n=1487) for determination of Hb concentration by Hemocue Hb301. On the same day, venous blood was collected for complete blood count using one of two haematology analysers (XT-1800i, Sysmex, and BC-3000Plus, Mindray Medical International). In a subsample of children (n=129), venous Hb was also measured by HemoCue Hb301. Agreement between the two methods was estimated using Bland-Altman plots.

Results

Mean capillary Hb by Hemocue was significantly higher than mean venous Hb by haematology analysers combined (108.4±10.3 g/L vs 102.3±13.1 g/L; P<0.001), resulting in a significantly lower anaemia prevalence (Hb <110 g/L) by Hemocue (53.7% vs 73.9%; P<0.001). The Bland-Altman assessment of agreement showed a bias of 6.1 g/L and limits of agreement were −11.5 g/L to 23.7 g/L. Mean venous Hb concentration by Hemocue Hb301 (113.6±14.0 g/L) was significantly higher than mean capillary Hb concentration by Hemocue Hb301 (110.0±10.7; P=0.03 g/L), which in turn was significantly higher than mean venous Hb concentration by the Mindray BC-3000Plus (102.3±17.4 g/L).

Conclusion

Capillary and venous Hb concentrations assessed by Hemocue Hb301 showed poor agreement compared with venous Hb by automated haematology analysers, resulting in significantly different anaemia prevalences.