Asian Low- And Middle-income Countries Research Articles

An opportunity missed: Strengthening health system data on multisystem inflammatory syndrome in children from low- and middle-income countries in Asia

BackgroundMultisystem inflammatory syndrome in children (MIS-C) is a severe complication associated with SARS-CoV-2 infection. The clinical epidemiology of MIS-C is not completely understood in low- and middle-income countries (LMICs) due to limited reporting, including in Asia where there was a substantial burden of COVID-19. We aimed to discuss the challenges of diagnosing MIS-C and factors which may cause children from Asian LMICs to have an increased risk of MIS-C. MethodsNot applicable. ResultsThe burden of MIS-C in Asian LMICs may be disproportionately high due to underlying risk factors, resource-limited health systems, and the increased infectivity and transmissibility of recent SARS-CoV-2 variants. Complex clinical features of MIS-C contributed to missed or delayed diagnosis and treatment, while underlying risk factors including ethnicity, chronic health conditions, and socioeconomic factors may have predisposed children in Asian LMICs to MIS-C. ConclusionsThere was a lack of data on the clinical epidemiology of MIS-C in Asian LMICs during the COVID-19 pandemic, despite reports of higher paediatric mortality rates compared to high-income countries. This highlights the need for LMICs to have strong surveillance systems to collect high-quality and timely data on newly emerging complications associated with a pandemic, such as MIS-C. This will lead to rapid understanding of these emerging complications, and inform clinical management, disease prevention and health system planning.

Mixed-methods needs assessment for development of school-based mental health implementation science capacity in low- and middle-income countries: Vietnam as a case example.

Worldwide, the majority of youth reside in low- and middle-income countries (LMIC). School-based mental health (SBMH) services are particularly important in LMIC, in part because of LMIC's limited mental health infrastructure. Among the challenges to developing SBMH in LMIC are limited implementation science (IS) capacity, critical for identifying barriers to evidence-based intervention (EBI) use and dissemination, etc., specific to the local country context. A key step in IS capacity development is conducting a needs assessment, to identify barriers (and their solutions) to IS development itself within the local context. The present study conducted an IS needs assessment focused on SBMH in the Southeast Asian LMIC of Vietnam. Seventy-five Vietnamese mental health professionals in SBMH-related fields participated in a mixed-methods study. Vietnamese SBMH researchers and practitioners most likely to have experience and/or interest in IS were selected for study recruitment. Professionals' formal understanding of and experience with IS as a scientific field was highly limited. However, after reading a brief but detailed description of IS, participants' interest in IS training was high, and their mean rating of its potential utility for Vietnam to develop SBMH was 4.7 on a 1-5 scale. Participants also reported on barriers and potential solutions for EBI use in SBMH in Vietnam. Contrary to expectations, the most frequent and severe barriers were not financial but related to limited stakeholder engagement. Overall, these and other study results provide some suggestions how IS capacity to support SBMH may be most efficiently developed in settings such as Vietnam. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Digital rights and mobile health in Southeast Asia: A scoping review.

Digital technology has the potential to support or infringe upon human rights. The ubiquity of mobile technology in low- and middle-income countries (LMICs) presents an opportunity to leverage mobile health (mHealth) interventions to reach remote populations and enable them to exercise human rights. Yet, simultaneously, the proliferation of mHealth results in expanding sensitive datasets and data processing, which risks endangering rights. The promotion of digital health often centers on its role in enhancing rights and health equity, particularly in LMICs. However, the interplay between mHealth in LMICs and digital rights is underexplored. The objective of this scoping review is to bridge this gap and identify digital rights topics in the 2022 literature on mHealth in Southeast Asian LMICs. Furthermore, it aims to highlight the importance of patient empowerment and data protection in mHealth and related policies in LMICs. This review follows Arksey and O'Malley's framework for scoping reviews. Search results are reported using the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) checklist. Frequency and content analyses were applied to summarize and interpret the data. Three key findings emerge from this review. First, the digital rights topics covered in the literature are sparse, sporadic, and unsystematic. Second, despite significant concerns surrounding data privacy in Southeast Asian LMICs, no article in this review explores challenges to data privacy. Third, all included articles state or allude to the role of mHealth in advancing the right to health. Engagement in digital rights topics in the literature on mHealth in Southeast Asian mHealth is limited and irregular. Researchers and practitioners lack guidance, collective understanding, and shared language to proactively examine and communicate digital rights topics in mHealth in LMIC research. A systematic method for engaging with digital rights in this context is required going forward.

Cultural adaptations and methodological innovations to group model building for the systems actions to reduce malnutrition in all its forms in Southeast Asian countries and China (SYSTAM CHINA-SEACS International Consortium) project

BackgroundGroup Model Building (GMB) is a participatory system dynamics method increasingly used to address complex public health issues like obesity. GMB represents a set of well-defined steps to engage key stakeholders to identify shared drivers and solutions of a given problem. However, GMB has not yet been applied specifically to develop multi-duty interventions that address multiple inter-related issues such as malnutrition in all its forms (MIAIF). Moreover, a recent systematic review of empirical applications of a systems approach to developing obesity interventions found no published work from non-western, low- and middle-income countries (LMICs). In this paper we describe adaptations and innovations to a common GMB process to co-develop systemic MIAIF interventions with Chinese decision-makers.MethodsWe developed, piloted and implemented multiple cultural adaptations and two methodological innovations to the commonly used GMB process in Fang Cheng Gang city, China. We included formal, ceremonial and policy maker engagement events before and between GMB workshops, and incorporated culturally tailored arrangements during participant recruitment (officials of the same seniority level joined the same workshop) and workshop activities (e.g., use of individual scoring activities and hand boards). We made changes to the commonly used GMB activities which enabled mapping of shared drivers of multiple health issues (in our case MIAIF) in a single causal loop diagram. We developed and used a ‘hybrid’ GMB format combining online and in person facilitation to reduce travel and associated climate impact.ResultsOur innovative GMB process led to high engagement and support from decision-makers representing diverse governmental departments across the whole food systems. We co-identified and prioritised systemic drivers and intervention themes of MIAIF. The city government established an official Local Action Group for long-term, inter-departmental implementation, monitoring and evaluation of the co-developed interventions. The ‘hybrid’ GMB format enabled great interactions while reducing international travel and mitigating limitations of fully online GMB process.ConclusionsCultural and methodological adaptations to the common GMB process for an Asian LMIC setting were successful. The ‘hybrid’ GMB format is feasible, cost-effective, and more environmentally friendly. These cultural adaptations could be considered for other Asian settings and beyond to address inter-related, complex issues such as MIAIF.

Relations between risk perception, perceptions of peers' driving, and risky driving among Cambodian adolescents.

Traffic accidents are a leading cause of death globally, with substantial economic impact particularly in low-and-middle-income countries (LMIC). Adolescents are at particular risk, partly due to their tendency to engage in risky driving. However, most research designed to identify potential causes of risky adolescent driving has been conducted in Western, high-income countries, which often have substantial cultural differences from LMIC that potentially influence risky adolescent driving. The present study, one of the first focused on this topic in Southeast Asia, cross-sectionally assessed 425 adolescent motorbike drivers in the Southeast Asian LMIC Cambodia. Adolescents' (a) beliefs about peers' driving (social norms) and (b) driving risk perception were assessed as predictors of four risky driving behaviors: aggressive driving; distracted driving; intoxicated driving; violating driving laws. Canonical correlation analysis identified a general relation between (a) beliefs about peers' driving, and (b) all four risky driving behaviors, with R2 = 0.35 indicating over one-third of the variance in risky driving was explained by perceptions of peers' driving. Risk perception was not involved in the significant canonical relation, however. Gender moderated two of the underlying relations, with females showing larger relations between perceptions of friends' driving, and distracted driving and violating driving laws. These findings provide useful directions for future research (e.g., assessing the accuracy of Cambodian adolescents' perceptions of peers' driving) useful for helping stakeholders tailor road safety programs (e.g., providing adolescent drivers with accurate information regarding their peers' actual driving behaviors) for adolescent motorcyclists in Cambodia and similar countries.

Perceptions and priorities for the development of multiplex rapid diagnostic tests for acute non-malarial fever in rural South and Southeast Asia: An international modified e-Delphi survey

Fever is a common presenting symptom in low- and middle-income countries (LMICs). It was previously assumed that malaria was the cause in such patients, but its incidence has declined rapidly. The urgent need to develop point-of-care tests for the most important causes of non-malarial acute febrile illness is hampered by the lack of robust epidemiological data. We sought to obtain expert consensus on analytes which should be prioritized for inclusion in fingerprick blood-based multiplex lateral flow rapid diagnostic tests (LF-RDTs) targeted towards four categories of patients with acute non-malarial fever in South and Southeast Asian LMICs, stratified by age (paediatric vs. adult) and care setting (primary vs. secondary care). We conducted a two-round modified e-Delphi survey. A total of 84 panellists were invited, consisting of seven each from 12 countries, divided into three regional panels (Mainland Southeast Asia, Maritime Southeast Asia, and South Asia). Panellists were asked to rank their top seven analytes for inclusion in LF-RDTs to be used in each patient category, justify their choices, and indicate whether such LF-RDTs should be incorporated into algorithm-based clinical decision support tools. Thirty-six panellists (43%) participated in the first round and 44 (52%) in the second. There was consensus that such LF-RDTs should be incorporated into clinical decision support tools. At a minimum, these LF-RDTs should be able to diagnose dengue and enteric fever in all patient categories. There was a clear preference to develop LF-RDTs for pathogens not readily detected by existing technologies, and for direct diagnosis through antigen detection. Pathogen biomarkers were prioritized over host inflammatory biomarkers, with CRP being the only one ranked consistently highly. Our results provide guidance on prioritizing analytes for inclusion in context-specific multiplex LF-RDTs and similar platforms for non-malarial acute febrile illness, for which there is an urgent unmet need.

Awareness and Utilization of Palliative Care Among Advanced Cancer Patients in Asia.

To date, little is known about palliative care (PC) awareness and utilization in low- and middle-income countries (LMICs) in Asia. This study aimed to investigate PC awareness and its predictors, utilization of PC services, and perceived utilization barriers among advanced cancer patients from select hospitals in Asian LMICs. This cross-sectional study analyzed data of 759 advanced cancer patients at major hospitals of four LMICs in Asia (i.e., Bangladesh, Philippines, Sri Lanka, and Vietnam). The predictors of PC awareness were investigated using multivariable logistic regression. Overall PC awareness was 30.8% (n = 234). Patients with higher education (OR=1.0; CI=1.0,1.1), from upper-middle or high-income households (compared to low-income) (OR=2.0; CI=1.2,3.3), awareness of disease severity (OR=1.5; CI=1.0,2.2), and higher pain severity (OR=1.1; CI=1.0,1.2) had higher odds of PC awareness. Compared to patients who perceived themselves as being very informed about disease trajectory, those who were unsure (OR=0.5; CI=0.3,0.8) or uninformed (OR=0.5; CI=0.3,0.9) had lower odds of PC awareness. The PC utilization rate was 35.0% (n = 82) among those with PC awareness, and 47.8% (n = 66) among patients recommended PC by a healthcare professional (n = 138). The most cited PC utilization barriers were currently receiving anti-cancer treatment (n = 43; 33.9%), and having insufficient information about PC (n = 41; 32.3%). The low awareness of PC services in these major hospitals in Asian LMICs highlights that more effort may be required to promote the awareness of PC in this region. The efforts should especially focus on those from disadvantaged groups to reduce the gap in PC awareness.

Prevalence of adverse childhood experiences among Vietnamese high school students

BackgroundAdverse childhood experiences (ACE) are linked to a range of negative health outcomes. However, the majority of research has been conducted in high-income-countries and little is known about ACE prevalence in low-and-middle-income-countries (LMIC), where the majority of the world's youth reside. ObjectiveAssess ACE prevalence and demographic correlates in two provinces of the Southeast Asian LMIC Vietnam. MethodsPrevalence of ACE were assessed among 644 Vietnamese high-school students, using the WHO Adverse Childhood Experiences-International Questionnaire. ResultsAbout 74% of participants reported experiencing at least one ACE, with 27% reporting experiencing three or more ACE. Prevalence of sexual abuse was above 10% for both males and females. Sex differences were non-significant, suggesting child protective services should give consideration to both males and females. Factor analysis identified two patterns of ACE: Violence and Aggression in Family and Community, and Family Member Dysfunction. Three ACE (sexual abuse, emotional neglect, physical neglect) did not load on either factor. Thus, at least in our sample, sexual abuse was independent of other ACE, which indicates that it can occur in any context, among children in otherwise well-functioning families, an important consideration for child protective services. The lack of significant sex differences in sexual abuse means that Vietnamese boys need equal consideration for protection and support as girls. ConclusionsResults indicate that ACE are a prevalent public health problem in Vietnam. Future research evaluating potential ACE risk factors such as authoritarian parenting may be useful to identify possible targets for prevention programs in Vietnam.

Predictors for detecting chronic respiratory diseases in community surveys: A pilot cross-sectional survey in four South and South East Asian low- and middle-income countries.

BackgroundOur previous scoping review revealed limitations and inconsistencies in population surveys of chronic respiratory disease. Informed by this review, we piloted a cross-sectional survey of adults in four South/South-East Asian low-and middle-income countries (LMICs) to assess survey feasibility and identify variables that predicted asthma or chronic obstructive pulmonary disease (COPD).MethodsWe administered relevant translations of the BOLD-1 questionnaire with additional questions from ECRHS-II, performed spirometry and arranged specialist clinical review for a sub-group to confirm the diagnosis. Using random sampling, we piloted a community-based survey at five sites in four LMICs and noted any practical barriers to conducting the survey. Three clinicians independently used information from questionnaires, spirometry and specialist reviews, and reached consensus on a clinical diagnosis. We used lasso regression to identify variables that predicted the clinical diagnoses and attempted to develop an algorithm for detecting asthma and COPD.ResultsOf 508 participants, 55.9% reported one or more chronic respiratory symptoms. The prevalence of asthma was 16.3%; COPD 4.5%; and ‘other chronic respiratory disease’ 3.0%. Based on consensus categorisation (n = 483 complete records), “Wheezing in last 12 months” and “Waking up with a feeling of tightness” were the strongest predictors for asthma. For COPD, age and spirometry results were the strongest predictors. Practical challenges included logistics (participant recruitment; researcher safety); misinterpretation of questions due to local dialects; and assuring quality spirometry in the field.ConclusionDetecting asthma in population surveys relies on symptoms and history. In contrast, spirometry and age were the best predictors of COPD. Logistical, language and spirometry-related challenges need to be addressed.

Mental health literacy at the public health level in low and middle income countries: An exploratory mixed methods study in Vietnam.

PurposeMental health literacy (MHL) is key for mental health development, particularly in low-and-middle-income countries (LMIC) where mental health resources are limited. MHL development can be thought of as occurring at two levels: the individual person level (via direct contact, with specifically-targeted individuals), and the public health level (via indirect contact through public media, targeting the general public). Each approach has advantages and disadvantages.MethodsThe present mixed methods study assessed the status of and best approaches for development of mental health literacy in the Southeast Asian LMIC Vietnam. Because there has been relatively little discussion of MHL development at the public health level, this assessment focused on the public health level, although not exclusively. Because mental health professionals generally have the most in-depth understanding of their mental health system, study participants were 82 Vietnamese mental health professionals who completed a quantitative survey, with 48 participating in focus groups.ResultsMost of the professionals viewed MHL in Vietnam as low or very low, and that it was difficult or very difficult for the general public to find effective mental health services. Main barriers underlying these problems and more generally for developing MHL in Vietnam identified in the focus groups were: (a) misinformation in the media regarding mental health and mental illness; (b) lack of licensure for non-medical mental health professionals (e.g., psychologists; social workers); (c) lack of interest in mental health from upper-level leadership.ConclusionsTo the best of our knowledge, this is the first study assessing professionals’ perceptions regarding mental health literacy at both the public health and individual-person levels. Although sampling was restricted to Vietnamese professionals, results may provide initial preliminary guidance for other LMIC considering mental health literacy development at multiple levels.

COVID-19: Challenges and viewpoints from low-and-middle-income Asian countries perspectives

The crisis of coronavirus disease (COVID-19) is growing and has a potential impact on low-and-middle-income countries (LMICs), particularly in Asian regions, which, have reported less so far. The main purpose of this article is to discuss the challenges of COVID-19 management in Asian LMICs and propose some future guidelines to control the transmission and spread. Due to a highly dense population, low-resourced health system, lack of testing kit, and tracing, the ultimate impact could be lasting. It is highly likely that Asian LMICs were not in the center of receiving high priority by the international community in order to take effective prevention strategies. This might upsurge caseloads. Like the symptoms, mode of transmission varies largely due to a number of unknown clinical features of the virus, defining a risk group only based on some limited criteria such as age and disease with comorbidity could be risky. Recently some of the Asian LMICs launched contact tracing app. However, the study has identified several healthcare challenges in Asian LMICs such as shortage of supply of PPE, inadequate long-term care services, the socio-cultural differences which require utmost consideration. In addition, to control infection and enhance prevention, some pertinent problems need to be addressed. Based on that, some multifactorial approaches can be taken in line with international guidelines. Finally, this paper recommends developing a strong and resilient healthcare monitoring system.

Atherosclerotic cardiovascular disease screening and management protocols among adult HIV clinics in Asia

ObjectivesIntegration of HIV and non-communicable disease services improves the quality and efficiency of care in low- and middle-income countries (LMICs). We aimed to describe current practices for the screening and management of atherosclerotic cardiovascular disease (ASCVD) among adult HIV clinics in Asia. MethodsSixteen LMIC sites included in the International Epidemiology Databases to Evaluate AIDS – Asia-Pacific network were surveyed. ResultsSites were mostly (81%) based in urban public referral hospitals. Half had protocols to assess tobacco and alcohol use. Protocols for assessing physical inactivity and obesity were in place at 31% and 38% of sites, respectively. Most sites provided educational material on ASCVD risk factors (between 56% and 75% depending on risk factors). A total of 94% reported performing routine screening for hypertension, 100% for hyperlipidaemia and 88% for diabetes. Routine ASCVD risk assessment was reported by 94% of sites. Protocols for the management of hypertension, hyperlipidaemia, diabetes, high ASCVD risk and chronic ischaemic stroke were in place at 50%, 69%, 56%, 19% and 38% of sites, respectively. Blood pressure monitoring was free for patients at 69% of sites; however, most required patients to pay some or all the costs for other ASCVD-related procedures. Medications available in the clinic or within the same facility included angiotensin-converting enzyme inhibitors (81%), statins (94%) and sulphonylureas (94%). ConclusionThe consistent availability of clinical screening, diagnostic testing and procedures and the availability of ASCVD medications in the Asian LMIC clinics surveyed are strengths that should be leveraged to improve the implementation of cardiovascular care protocols.

A rapid assessment of the political economy of health at district level, with a focus on maternal, newborn and child health, in Bangladesh, Indonesia, Nepal and the Philippines.

Low- and middle-income countries (LMICs) face many challenges and competing demands in the health sector, including maternal and newborn mortality. The allocation of financial and human resources for maximum health impact is important for social and economic development. Governments must prioritize carefully and allocate scarce resources to maximum effect, but also in ways that are politically acceptable, financially and institutionally feasible, and sustainable. Political economy analysis (PEA)-that gets what, when and why-can help explain that prioritization process. We used PEA to investigate how four Asian LMICs (Bangladesh, Indonesia, Nepal and the Philippines) allocate and utilize resources for maternal, newborn and child health (MNCH). Using mixed research methods including a literature review, field interviews at national and sub-national level, and policy, process and budget analysis in each country, we examined three political economy issues: (1) do these countries demonstrably prioritize MNCH at policy level; (2) if so, is this reflected in the allocation of financial and other resources and (3) if resources are allocated to MNCH, do they achieve the intended outputs and outcomes through actual programme implementation? We also considered the influence of transnational developments. We found that all four countries demonstrate political commitment to health, including MNCH. However, the health sector receives comparatively low public financing, governments often do not follow through on plans or pronouncements, and capacity for related action varies widely. Poor governance and decentralization, lack of data for monitoring and evaluation of progress, and weak public sector human resource capacity were frequent problems; engagement of the private or non-government sectors is an important consideration. Opportunities exist to greatly improve equity and MNCH outcomes in these nations, using a mix of evidence, improved governance, social engagement and the media to influence decisions, increase resource allocation to and improve accountability in the health sector.

Explanatory variables for women's increased risk for mental health problems in Vietnam.

The United Nations Sustainable Development Goals include gender equality for women, including health, as one of seventeen targets. Within this broad domain, a wide range of research indicates that being female is associated with increased risk for mental health problems, particularly in low- and middle-income countries (LMIC). What is less clear are the trans-diagnostic demographic and environmental risk factors in LMIC that may underlie this increased risk. The purpose of the present study was to identify socio-economic and related disadvantages potentially underlying increased risk for women for mental health-related problems in the Southeast Asian LMIC of Vietnam. Nine hundred and seventy-seven adults were randomly selected from five provinces in central coastal Vietnam. Individuals were assessed cross-sectionally for depression (PHQ-9), anxiety (GAD-7), post-traumatic stress disorder symptoms (PDS), somatic syndrome (SCL-90-R), alcohol dependence (ICD-10), functional impairment (PDS life functioning section), and self-perceived general physical health (SF-36). Trans-diagnostic risk factors assessed included financial stress, education level, exposure to traumatic events, and others. At the multivariate level, gender explained approximately 5% of the variance in mental health symptoms, with women significantly higher in all mental health domains except alcohol dependency. The trans-diagnostic risk factors explained slightly over half of this variance, with financial stress and lower education levels the two strongest individual explanatory variables for women's increased risk for mental health problems. These results suggest that support for gender equality including in regard to economic stability and education may be critical for reducing broad gender disparities in mental health functioning.

Assessing the relationship between out-of-pocket spending on blood pressure and diabetes medication and household catastrophic health expenditure: evidence from Pakistan

BackgroundTreatment of non-communicable diseases (NCDs) in low-and-middle-income countries (LMICs) is costly and could expose households to financial hardship and vulnerability. This paper examines the association between medication costs of two major NCDs – hypertension (blood pressure) and diabetes, and household-level incidences of catastrophic health expenditure (CHE) in a South Asian LMIC, Pakistan.MethodsThe study analyzes self-reported blood pressure and diabetes (BPD) medication expenditure from the latest version (2015–16) of the Household Integrated Economic Survey (HIES) of Pakistan, a nationally representative survey of 24,238 households. The incidence of CHE is defined as households’ out-of-pocket (OOP) medical expenditure exceeding 10% of the total household expenditure. Using a linear probability model, we estimate the adjusted differences in CHE incidence between households that are spending and ‘not’ spending on BPD medication. We also analyze several hypothetical scenarios of BPD medication cost coverage, and compare the estimated CHE incidences of respective scenarios with the status quo.ResultsWe find that the average monthly medical expenditure, and average medical expenditure share are significantly higher for households spending on BPD medication, compared to households ‘not’ spending. The incidence of CHE is found 6.7 percentage point higher for the households consuming BPD medication, after controlling for relevant socioeconomic attributes. If 25, 50, and 100% of the BPD medication OOP cost is covered, then the CHE incidence would reduce respectively by 5.9, 12.7, and 21.4% compared to the status quo.ConclusionMedication cost for managing two major NCDs and household catastrophic health expenditure have strong associations. The findings inform policies toward ensuring access to necessary healthcare services, and protecting households from NCD treatment related financial hardship.

Harm from others’ drinking-related aggression, violence and misconduct in five Asian countries and the implications

BackgroundHarm from alcohol-attributable aggression and violence is linked to diminished personal safety and reduced physical and mental health and wellbeing in many countries. But there has been limited evidence on these harms in low- and middle-income countries (LMICs). This study measured harm from others’ drinking-related aggression, violence and misconduct in five Asian LMICs (Thailand, Sri Lanka, India, Vietnam, and Lao PDR), aiming to compare the magnitude and pattern of harm across countries by gender, age group, educational level, rurality, and country-level indicators. MethodsData from 9832 respondents from the WHO/Thai Health International Collaborative Research Project on the Harm from Others’ Drinking undertaken between 2012 and 2014 were analysed. Findings50–73% of respondents from five countries reported being harmed at least once in the past year. Public disorder and feeling unsafe due to someone else’s drinking was frequently reported, followed by harassment, assaults and threats, traffic harm, and property damage. In most countries, men were more likely than women to report traffic harms, property harm, and assaults, whereas women were more likely to report feeling unsafe in public. Being young, less educated, living in urban areas, and one’s own drinking were significant predictors of more harm from others’ drinking for both genders. ConclusionsThis study revealed a consistently high prevalence of alcohol-related aggression and violence in the five Asian countries. Patterns of harm within countries and populations at most risk for different forms of harms were identified. Alongside services for those affected, efforts to strengthen alcohol policies are needed in each society.

Global nutrition 1990–2015: A shrinking hungry, and expanding fat world

ObjectivesFollowing its publication in 2008, the Global Nutritional Index (GNI) which captures the triple burden of malnutrition, has been updated to assess the overall nutritional status and nutritional trends of countries, regions and the world, including both under-nutrition and over-nutrition.MethodsThe GNI was modeled on the Human Development Index, using geometric means of three normalized indicators: protein-energy malnutrition (PEM, measured by Disability-Adjusted Life Years (DALYs) from PEM), micronutrient deficiency (MID, measured by DALYs from MID), and penalizing obesity (percent female obesity). GNI (range 0–1) was calculated from 1990–2015 for 186 countries, in seven World Bank income and WHO region groupings.ResultsWorld GNI increased from 0.433 to 0.473 as decreased deficits overcompensated for the rise in obesity. GNI for African low- and middle-income countries (LMIC) (median 0.301 to 0.392) and South-East Asian LMIC (0.456 to 0.564) improved significantly (P<0.001), while for high-income countries (0.657 to 0.611) worsened significantly (P<0.001). GNI for American LMIC (0.459 to 0.457), European LMIC (0.571 to 0.575), Eastern Mediterranean LMIC (0.484 to 0.483) and Western Pacific LMIC (0.433 to 0.494) were unchanged. The disaggregation of the GNI showed that in nearly all the seven country groups there was a significant decrease in both PEM and MID (all P<0.01) (except in HIC where only PEM dropped), and a significant increase in obesity (all P<0.001).ConclusionThese trends are the result of the reciprocal changes between decreased under-nutrition and increased over-nutrition, which has become a major cause of malnutrition worldwide. We suggest, therefore, that future Sustainable Development Goals should include alongside “zero hunger”–“reduce obesity”.

Social Demography of Transitional Dietary Patterns in Thailand: Prospective Evidence from the Thai Cohort Study.

In recent decades, a health-risk transition with changes in diet and lifestyle in low and middle-income countries (LMICs) led to an emergence of chronic diseases. These trends in Southeast Asian LMICs are not well studied. Here, we report on transitional dietary patterns and their socio-demographic predictors in Thai adults. Dietary data in 2015 were from a random sub-sample (N = 1075) of 42,785 Thai Cohort Study (TCS) members who completed all three TCS surveys (2005, 2009, 2013). Principle Component Analysis identified dietary patterns and multivariable linear regression assessed associations (Beta estimates (ß) and confidence intervals (CIs)) between socio-demographic factors and dietary intake pattern scores. Four dietary patterns emerged: Healthy Transitional, Fatty Western, Highly Processed, and Traditional. In women, higher income (≥30,001 Baht/month vs. ≤10,000) and managerial work (vs. office assistant) was associated with lower scores for Traditional (ß = −0.67, 95% CI −1.15, −0.19) and Fatty Western diets (ß = −0.60, 95% CI −1.14, −0.05), respectively. University education associated with lower Highly Processed (ß = −0.57, 95% CI −0.98, −0.17) and higher Traditional diet scores (ß = 0.42, 95% CI 0.03, 0.81). In men and women, urban residence associated with higher Fatty Western and lower Traditional diets. Local policy makers should promote healthy diets, particularly in urban residents, in men, and in low-SEP adults.

Early identification and intervention services for children with autism in Vietnam.

In high income countries in Europe and North America, early identification and intervention for autism spectrum disorders (ASD) have been linked to improved long-term outcomes. However, in most low and middle income countries (LMIC) little is known about use or availability of such services, which limits the ability of policy and development planning. The purpose of the present study was assess the use of ASD services in Vietnam, an Asian LMIC, in order to identify areas within the field that should be specifically targeted to improve ASD services in Vietnam. Surveys were conducted in six different cities across Vietnam with 90 parents/caregivers of children with ASD, 115 professionals working with children with ASD, and 10 directors of agencies providing ASD services. Parents/caregivers' survey assessed demographics and information regarding their child's symptoms and services the child received. Professionals' survey assessed their demographic and professional background, the ASD services they provide, and their perspective on the quality of ASD services at their agency. Directors' survey included these same questions as well as additional questions regarding the operation of the agency. Early identification and intervention ASD services are available in Vietnam, at least in major cities. However, there is a lack of well-trained professionals, the tools used for evaluation and diagnosis are limited, outdated and unstandardized, and the quality of services is questionable. Most importantly, a scientific evidence base for services is absent, and the country lacks an official governmental policy for supporting children with ASD. Research directly assessing the quality of ASD services in Vietnam is needed. Most centrally, efforts at facilitating governmental policy and support advocacy are needed to increase the likelihood that families and children with ASD will receive appropriate and effective services.