EQUITY IN A CHANGING WORLD

Older Adults in Nursing Homes, ... Changing Trends on Caloric Intake and Diet in Asean: ... Medical Cost of Surgical Diseases on the Early Implementat...

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EQUITY IN A CHANGING WORLD 4th Annual International Conference on

New Voices in Global Studies and Wellbeing 2016

4 MARCH 2016 | THAILAND SCIENCE PARK CONVENTION CENTER, PATHUMTHANI, THAILAND

Content Page

Editor and Technical Committee V Conference Agenda VI Welcome Address:

How Global Health Fits into Global Wellbeing by Dr. Chaiyuth Chavalitnitikul Inter-cultural Education of Global Health Students: Sharing North-South Experience by Associate Professor Dr. Nitaya Vajanapoom

Key Note Address:

Equity at Risk in a Changing World by Professor Dr. Somkit Lertpaithoon

XI XIII

XV

Oral Presentations Session 1: Issues of Cultural Violence Women’s Perception about Spousal Violence: Unheard Voices in Rural Bangladesh (O-1) 2 Halima Sultana Haque, Ashraful Alam, Shaila Hossain, Tania Islam, Mostafa Kamal Pasha, Shuvashis Saha, Abdullah Al Mamun War Crimes and State Accountability in Indonesia: The Indonesian Comfort Women in Post-World War II Era (O-2) Maya Dania

8

Sexual Violence in Conflict Settings: A Health-System Response in Lebanon (O-3) Christelle Moussallem

15

Stigmatizing Attitude and Knowledge about HIV Transmission among Nurses in Indonesia (O-4) Siti Urifah, Monthana Hemchayat, Boosaba Sanguanprasit

21

Session 2: Issues of Gender Inequity and Gender Empowerment Gender Awareness and Women’s Empowerment in Rural Bangladesh: A Silent Crisis (O-5) Md Ashraful Alam, Halima Sultana Haque, Md Rizwanul karim,

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Shahana Sultana, Jahanara Ferdous Khan, Tithi Das, Shahina Haque Maternal and Neonatalcomplications of Teenage Pregnancy at Justice Jose Abad Santos General Hospital, Manila, Philippines (O-6) Lorelina F. Viana, Vandita Rajesh, Nitaya Vajanapoom

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Session 3: Issues of Food, Food Security and Nutrition Factors Enhancing Food Insecurity in East African Countries: A Case Study of Somalia (O-7) Sharon Chipo Manzvera



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The Underlying Determinants of Food Insecurity in Southern Africa: a Case Study of Zimbabwe (O-8) Tapiwa Murevanemwe

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The Relationship between Perceived Self-Efficacy, BMI and Physical Activity among Adolescents in Kudus, Central Java, Indonesia (O-9) Umi Faridah, Sunanta Thongpat, Yupaporn Tirapaiwong

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Session 4: Issues of Work Environments and Occupational Safety Health Literacy, Safety Behaviors, and Organizational Safety Culture on Worksite Accidents among International Migrant Workers in Thailand (O-10) Wassanan Namthep, Pimpan Silpasuwan, Dusit Sujirarat

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Psychosocial Work Environment and Work Ability among Agricultural Cambodian Migrant Workers in Buriram Province, Thailand (O-11) Akkaradet Awatsadarak, Charnchudhi Chanyasanha, Orawan Kaewboonchoo

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Session 5: Aging Impact of Social Support Networks on Loneliness among Elderly in Myanmar (O-12) Khin Myo Wai

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The Relationships between Social Determinants and Quality of Life among Older Adults in Nursing Homes, East Java Province, Indonesia (O-13) Fatma S. Ruffaida, Benjamas Sirikamonsathian, Knokwan Wetasin

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Effect of Self-Management Support Program on Knowledge and Self-Care Behaviors of Community-Dwelling Older Adults with Congestive Heart Failure (O-14) Ketchayanee Waenkaew, Kwanjai Amnatsatsue, Patcharaporn Kerdmongkol

94

Poster Presentations Early Marriage and Adolescent Pregnancies in Nepal: Promoting Gender Equity (P-1) Hari Jung Rayamazi, Marc Van der Putten, Charlie Thame

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Changing Trends on Caloric Intake and Diet in Asean: What Endangered Their Status? (P-2) Samittra Pornwattanavate, Vandita Rajesh, Marc Van der Putten

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Pharmaceutical Companies’ Promotions of Antibiotics for Upper Respiratory Infections and Equity in Access to Treatment in Nepal (P-3) Pramesh Koju, Stéphane P. Rousseau, Marc Van der Putten

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Comparative Study on Prevalence and Modifiable Risk Factors for Diabetes Mellitus in Eritrea (P-4) Elias Teages Adgoy, William Brady, Uma Langkulsen

116

Barriers to Accessing Adolescent Sexual and Reproductive Health Services among Undocumented Migrants in South Africa: A Documentary Review (P-5) Keith Mukondwa

123

Medical Cost of Surgical Diseases on the Early Implementation of National Health Insurance in a top Referral Hospital: Case Study from Indonesia (Abstract only) (P-6) Annette d’Arqom, Abdul Khairul Rizki Purba, Kuntaman Kuntaman

128

Relationship between Hygiene Behaviors with Protozoa and Intestinal Parasitic 129 Infections of the Student in Wat Santithamratbamrung School, Nakhornnayok (Abstract only) (P-7) Pattakorn Buppan, Pimchanok Tamchuay, Rungnapa Khunset, Punchaporn Sudchalit Food Preferences, Taste Preferences and Physical Activities in Relation to Body 130 Mass Index of Students in Srinakharinwirot University, Ongkharak Campus (Abstract only) (P-8) Chanakarn Charoenphan, Patticha Boonyanet, Paphassara Borngern, Kun Silprasit, Sirikul Thummajitsakul A Review on Barriers to PMTCT Services of HIV Infected Mother and Child in India and Indonesia (P-9) Nang Sam Si Phong, Vandita Rajesh, Nitaya Vajanapoom

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Women’s Autonomy in Family Planning among Myanmar Migrant Women in Pathum Thani, Thailand: A Pilot Study (Abstract only) (P-10) Hlwan Moe Paing, Charlie Thame, Uma Langkulsen

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Exploring Business Models at the Bottom of Bangalore´s Pyramid (Abstract only) (P-11) Sprunken, J.C.E., Angeli, F.

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Stakeholder Perceptions in Challenges of the Ghanaian Mental Health care System and Implementation of the New Mental Health Act (P-12) Anne van Driessche

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Food Security on St. Eustatius: Perceptions of Agricultural Development (Abstract only) (P-13) Erin H.C. Kuipers, Teresa E. Leslie, Agnes M. Meershoek

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The Role of Strengthening Primary Health Care Service Provider’s Accountability in Improving Maternal Health in Nepal (P-14) Kritika Dixit, Charlie Thame, Marc Van der Putten

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Policy Reform for Sex Work: Criminalization and Decriminalization in 157 the Context of Feminist Ideologies, Social Determinants of Health and Human Rights (Abstract only) (P-15) Khine Su Win, Fabio Saini An Approach to Assessing Disease Surveillance in Myanmar (Abstract only) (P-16) Wai Phyo Thant

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Sustainable Change Through Socially Responsive Design (P-17) Istvan Rado

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Case Studies from Ethiopia and Nepal - What Variants in Social Determinats Make Girls Vulnerable to Trafficking for Sexual Exploitation? (P-18) Elin, M. Longard

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The Role of Traditional Life and Colonial Authority in the Formulation of Post-Colonial Identity for Women in Cameroon (Abstract only) (P-19) Amanda J Pierz, Leonie N Dapi

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Hidden in Plain Sight: Community-Based Research on Undocumented Children Living along the Thai-Myanmar Border (Abstract only) (P-20) Amanda Mowry, Therese Caouette, Treasure Shine

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Inclusiveness of Disability Practice for Children with Disabilities in Nepal (P-21) Lina Brandt

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Effects of Motivational Interviewing on Treatment Adherence of Tuberculosis Patients in the Philippines (Abstract only) (P-22) Ritzmond Loa

185

Mothers’ Behaviors in Preventing Diarrhea in Children Aged 1 - 5 Years and Its Related Factors in Buol District, Indonesia (P-23) Helmi Rumbo, Susheewa Wichaikull, Boosaba Sanguanprasit

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Working Group 192

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Editor Assoc. Prof. Stephen J. Atwood, M.D.

Technical Committee 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.

Assoc. Prof. Dr. Nitaya Vajanapoom Consultant Dr. Istvan Rado Chairman Assoc. Prof. Stephen J. Atwood, M.D. Member/Co-Lead Ajarn William Edward Brady Member Prof. Dr. Marc Van der Putten Member Asst. Prof. Dr. William Leggett Aldis, M.D., FACP Member Dr. Twisuk Punpeng Member Assoc. Prof. Dr. Oranut Pacheun Member Dr. Decha Tangseefa Member Assoc. Prof. Dr. Anja Krumeich Member Dr. Abdalla Siedahmed Osman Member Asst. Prof. Dr. Kwanjai Amnatsatsue Member Assoc. Prof. Dr. Toyoda Yusuke Member Dr. Rodger Doran Member Dr. Charlie Thame Member Dr. Michael O’leary Member Dr. Shekh Mohammad Altafur Rahman Member Dr. Arthur E. Brown, Jr., M.D. Member Dr. Andrew Corwin Member Dr. Stanley Fenwick Member Dr. Uma Langkulsen Member/Secretary Mr. Desire Tarwireyi Rwodzi Member/Assistant Secretary

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Conference Agenda 4 March 2016 Thailand Science Park Convention Center, Pathumthani, Thailand Time

Topic

Presenter

8:30

Registration

9:00

Introduction to the Agenda

Dr. Stephen J. Atwood, Conference Chairperson Associate Professor, School of Global Studies Thammasat University

Welcome Address: How Global Health Fits into Global Wellbeing

Dr. Chaiyuth Chavalitnitikul Dean, Faculty of Public Health Thammasat University

Welcome Address: Inter-cultural Education of Global Health Students: Sharing North-South Experience

Associate Professor Dr. Nitaya Vajanapoom Dean, School of Global Studies Thammasat University

Key Note Address: Equity at Risk in a Changing World

Professor Dr. Somkit Lertpaithoon Rector, Thammasat University

Location Auditorium, 2nd Floor

Oral Presentations

Session 1: Issues of Cultural Violence

9:30

1. Women’s perception about spousal violence: Unheard voices in rural Bangladesh (O-1)

Dr. Halima Sultana Haque Lecturer Centre for Medical Education, Ministry of Health and Family Welfare, Bangladesh

2. Community Violence and state accountability in Indonesia: The Indonesian comfort women in Post-WWII Era (O-2)

Ms. Maya Dania Ph.D. student RegNet Ph.D. Program, School of Regulation and Global Governance (College of Asia Pacific), Australian National University, Australia

3. Sexual violence in conflict settings: A health-system response to victims from hosting and refugee communities (O-3)

Ms. Christelle Moussallem Exchange student Maastricht University, Netherlands

4. Stigmatizing attitude and knowledge about HIV transmission among nurses in Indonesia (O-4)

Ms. Siti Urifah Master student BCNNV (Boromarajonani College of Nursing Nopparat Vajira) affiliated with Kasetsart University

10:30

Panel Discussion:

10:45

COFFEE BREAK

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Auditorium, 2nd Floor

Chair: Assoc. Prof. Dr. Stephen J. Atwood School of Global Studies, Thammasat University

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In front of the conference room

Time 11:00

Topic

Presenter

Location

Session 2: Issues of Gender Inequity and Gender Empowerment 5. Gender Awareness and Women’s Muhammed Ashraful Alam, M.D. Auditorium, Empowerment in Rural Bangladesh: A DrPH student 2nd Floor Silent Crisis (O-5) Faculty of Public Health, Mahidol University 6. Maternal and Neonatal complications of teenage pregnancy at Justice Jose Abad Santos General Hospital, Manila, Philippines (O-6)

Ms. Lorelina Viana Licensing Officer III Department of Health, National Capital Regional Office, Philippines

11:20

Panel Discussion:

Chair: Assoc. Prof. Dr. Oranut Pacheun Lecturer, Faculty of Public Health, Thammasat University

11:30

Session 3: Issues of Food, Food Security and Nutrition 7. Factors enhancing food insecurity in East African countries: a case study of Somalia (O-7)

Ms. Sharon Chipo Manzvera MPH-GH student School of Global Studies, Thammasat University

8. The underlying determinates of food insecurity in Southern Africa: a case study of Zimbabwe (O-8)

Mr. Tapiwa Murevanemwe MPH-GH student School of Global Studies, Thammasat University

9. The Relationship between Perceived Self-Efficacy, BMI and Physical Activity among Adolescents in Kudus, Central Java, Indonesia (O-9)

Ms. Umi Faridah Master student BCNNV (Boromarajonani College of Nursing Nopparat Vajira) affiliated with Kasetsart University

12:00

Panel Discussion:

Chair: Mr. Desire Tarwireyi Rwodzi, UNAIDS

12:15

LUNCH BREAK

Poster Review, TECHNICAL AND AWARDS COMMITTEE MEET

1:15

Session 4: Issues of Work Environments and Occupational Safety

2:00

Auditorium, 2nd Floor

10. Health literacy, safety behaviors, organizational safety culture affecting accident at work among industrial international migrant workers in Thailand (O-10)

Ms. Wassanan Namthep Auditorium, Master student 2nd Floor Department of Public Health Nursing, Faculty of Public Health, Mahidol University

11. Psychosocial work environment and work ability among agricultural Cambodian migrant workers in Buriram Province, Thailand (O-11)

Mr. Akkaradet Awatsadarak Auditorium, Master student 2nd Floor Department of Public Health Nursing, Faculty of Public Health, Mahidol University

Panel Discussion:

Chair: Dr. Twisuk Punpeng Lecturer, Faculty of Public Health, Thammasat University

Auditorium, 2nd Floor

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Time 2:15

Topic

Presenter

Session 5: Aging 12. Impact of social support networks on loneliness among the elderly in Myanmar (O-12)

Ms. Khin Myo Wai Ph.D. student College of Population Studies, Chulalongkorn University

13. The relationships between social determinants and quality of life among older adults in nursing homes, East Java Province, Indonesia (O-13)

Ms. Fatma Sayekti Ruffaida Master student BCNNV (Boromarajonani College of Nursing Nopparat Vajira) affiliated with Kasetsart University

14. Effect of self-management support program on knowledge and self-care behaviors of community-dwelling older adults with congestive heart failure (O-14)

Ms. Ketchayanee Waenkaew Master student Department of Public Health Nursing, Faculty of Public Health, Mahidol University

2:45

Panel Discussion:

Chair: Asst. Prof. Dr. Kwanjai Amnatsatsue Lecturer, FPH, Mahidol University

3:00

COFFEE BREAK & POSTER PRESENTATION SESSION

4:30

Closing Panel Discussion: How can we protect and enhance equity in a changing world, based on the presentations today?

Panelists: Dr. S.J. Atwood (Chair) Prof. Marc Van der Putten Asst. Prof. Dr. Kwanjai Amnatsatsue Dr. Istvan Rado Dr. Shekh Md. Altafur Rahman Dr. Arthur Brown Dr. Andrew Corwin Ajarn William E. Brady

5:00

Presentation of Awards

Assoc. Prof. Dr. Nitaya Vajanapoom Dean, School of Global Studies, Thammasat University

5:30

Closing

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Location

Auditorium, 2nd Floor

Corridor outside the conference room

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Auditorium, 2nd Floor

Poster Sessions Poster Presentations and Review Poster Presenters available on line from 15:00 – 16:30 to answer chat questions.

Poster Presentations Number

Author

Title

Affiliation

P-1

Mr. Hari Jung Rayamazi

Early marriage and adolescent pregnancies in Nepal: Promoting Gender Equity

Nepal / School of Global Studies, Thammasat University

P-2

Ms. Samittra Pornwattanavate

Nutrition transition and the prevalence of overweight and obesity in Asean countries during the age of rapid globalization: A documentary review

School of Global Studies, Thammasat University

P-3

Mr. Pramesh Koju

Impact of promotions of antibiotics for Nepal / School of Global upper respiratory infections by pharmaceuti- Studies, Thammasat cal companies on equity in Nepal University

P-4

Mr. Elias Teages Adgoy

Comparative study on prevalence and modifiable risk factors for Diabetes Mellitus in Eritrea

Eritrea / School of Global Studies, Thammasat University

P-5

Mr. Keith Mukondwa

Barriers to accessing adolescent sexual and reproductive health services among undocumented migrants in South Africa-a documentary review

Zimbabwe / School of Global Studies, Thammasat University

P-6

Ms. Annette d’ Arqom

Medical cost on the early implementation of national health insurance in a top referral hospital, Indonesia

Lecturer, Department of Pharmacology and Therapy, Airlangga University, Indonesia

P-7

Mr. Pattakorn Buppan

Relationship between hygiene behaviors with Lecturer, Faculty of protozoa and intestinal parasitic infections Health Science, Srinaof the student in Wat Santithamratbamrung kharinwirot University School, Nakhornnayok

P-8

Ms. Chanakarn Charoenphan, Ms. Patticha Boonyanet, and Ms. Paphassara Borngern

Food preferences, taste preferences and physical activities in relation to body mass index of students in Srinakharinwirot University, Ongkharak Campus

Undergraduate Student, Department of Health Promotion, Faculty of Health Science, Srinakharinwirot University

P-9

Dr. Nang Sam Si Phong

A review on barriers to HIV care and treatment center of HIV infected mother and child in Indonesia and India

UNAIDS, Yangon, Myanmar / School of Global Studies, Thammasat University

P-10

Dr. Hlwan Moe Paing

Women’s autonomy in family planning among Myanmar migrant women in Pathum Thani, Thailand

Myanmar / School of Global Studies, Thammasat University

P-11

Ms. Judith Sprunken

Exploring business models at the bottom of Bangalore´s pyramid

Maastricht University, Netherlands

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Number

X

Author

Title

Affiliation

P-12

Ms. Anne van Driessche

Stakeholder perceptions in challenges of the Ghanaian mental healthcare system and implementation of the New Mental Health Act

P-13

Ms. Erin Kuipers

Food security on St. Eustatius: Perceptions of Maastricht University, agricultural development Netherlands

P-14

Ms. Kritika Dixit

The role of strengthening primary health care service provider’s accountability in improving maternal health in Nepal

P-15

Dr. Khine Su Win

Policy reform for sex work: Criminalization Myanmar / School of and decriminalization in the context of femi- Global Studies, nist ideologies, social determinants of health Thammasat University and human rights

P-16

Dr. Wai Phyo Thant

An approach to assessing disease surveillance in Myanmar

Myanmar / School of Global Studies, Thammasat University

P-17

Dr. Istvan Rado

Sustainable change through socially responsive design

Lecturer, School of Global Studies, Thammasat University

P-18

Ms. Elin Longard

Case studies from Ethiopia and Nepal - What variants in social determinants make girls vulnerable to trafficking for sexual exploitation?

MPH-GH student, School of Global Studies, Thammasat University

P-19

Ms. Amanda Pierz

The role of traditional life and colonial authority in the formulation of post-colonial identity for women in Cameroon

Maastricht University, Netherlands

P-20

Ms. Amanda Mowry, Ms. Therese Caouette

Hidden in plain sight: Community-based research on undocumented children living along the Thai-Myanmar Border

Researcher, Lecturer, School of Global Studies, Thammasat University

P-21

Ms. Lina Katharina Brandt

The inclusiveness of society for children with Maastricht University, disability in Nepal Netherlands

P-22

Mr. Ritzmond Loa

Effects of motivational interviewing on treatment adherence of tuberculosis patients in the Philippines

Ph.D. student, College of Nursing, University of Santo Tomas, Philippines (Faculty of Nursing, TU)

P-23

Ms. Helmi Rumbo

Mothers’ behaviors in preventing diarrhea to children aged 1 - 5 years and its related factors in rural district of Buol, Indonesia: A cross sectional study

Master student, BCNNV (Boromarajonani College of Nursing Nopparat Vajira) affiliated with Kasetsart University

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Maastricht University, Netherlands

Nepal / School of Global Studies, Thammasat University

Welcome Address:

How Global Health Fits into Global Wellbeing Dr. Chaiyuth Chavalitnitikul Dean Faculty of Public Health Thammasat University

Professor Dr. Somkit Lertpaithoon, Dean Nitaya Vajanapoom, Distinguished faculty from Thammasat University, and from Mahidol University, colleagues, researchers, students and friends. I am pleased to welcome you to this International Conference New Voices in Global Studies and Wellbeing 2016. As in previous years, this is a conference aimed at giving new investigators and students of Global Studies and Global Public Health a wider audience where their ideas can be heard, and their research can be given a critical review before an audience of their peers and colleagues. This annual conference is now in its 4th year and I am pleased to have been involved with it each of those years. It has grown and developed as its reputation has spread. There are more abstracts submitted for review, more participants selected, and, not unexpectedly, a growing audience that reflects the expanding interest nationally and internationally in the topic of global health and wellbeing. The addition of the term “wellbeing” was made last year, but it went unmentioned. So this year, as a public health professional, I decided to look up the term so that I understood why the addition was made, and why well-being was so important. What did it add to our understanding of global health. It is not an easy word to define. As I’m sure most of you know, the World Health Organization in 1948 used the term in its definition of “Health”: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” “Health” is defined by Wellbeing, but well-being seems to be larger than health. I found another definition of well-being: the point of balance an individual achieves when forced to adapt his or her psychological, social and physical resources to meet a particular challenge or stress. Well-being is achieved by an individual’s constant return to that set-point for balance. It represents an ability by the individual to reset his or her equilibrium in the face of stress or challenge. It is somewhat the same as homeostasis: “the tendency of the body to seek and maintain a condition of balance or equilibrium within its internal environment, even when faced with external changes.” This was a useful but complicated definition. And, I was sure that Well-being went beyond the physical and internal environment referred to in the definition of homeostasis. Where were the mental and social resources necessary for a balanced life? Didn’t the social determinants of physical and mental health contribute to well-being? And what about our emotional lives – our relationships, happiness, wellness, quality

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of life? I almost stopped there, but then found one more definition – quoted in an article from The International Journal of Well-being: “Well-being is freedom of choice, made up of positive emotion (of which happiness and life satisfaction are all aspects), engagement, relationships, meaning and purpose; the state of being happy, healthy or successful.1” This entry added significant emotional elements to the previous definitions of wellbeing. Taken with the others, It seemed more complete. If we accept these definitions, how do they fit with global health and with today’s conference? I suggest that well-being is our ultimate goal – beyond health alone, beyond the absence of disease. We seek to balance the stresses of life by drawing on our inner physical and psychological resources in a positive social environment. That balance allows us to cope with all sorts of diseases and disorders, and to continue to contribute to society in a positive way. As an extension of this concept in the realm of global health, doesn’t equity itself – the other theme of this conference – represent a balance within the society? Equity includes concepts of fairness and justice in the distribution of gains and losses; a notion that burdens and rewards should not be spread unevenly across the community. When the unevenness is too great, we strive for equity to reset the balance, to pull families out of poverty, to reduce the gap between the haves and the have-nots. We use our social, political, economic, and medical resources to counter the challenges of disease, of hunger, of fear. To bring our society back from inequity. Presented this way, equity is the well-being of global society. Thank you, and welcome to the Conference.

-----------------------------------------------------------------1

Dodge, R., A. P. Daly, J. Huyton and L. D. Sanders (2012). “The challenge of defining wellbeing.”

International Journal of Wellbeing 2(3).

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Welcome Address:

Inter-cultural Education of Global Health Students: Sharing North-South Experience Associate Professor Dr. Nitaya Vajanapoom Dean School of Global Studies Thammasat University Professor Dr. Somkit Lertpaithoon, Distinguished faculty from Thammasat University, Faculty from Mahidol University, colleagues from other academic institutions, students and friends. It gives me great pleasure to add my welcome as Dean of the School of Global Studies, to the Fourth Annual International Conference New Voices in Global Studies and Wellbeing, 2016. Over the last four years, this conference has grown in both the number of abstracts received and the diversity of the authors of those abstracts. The first and second conferences had roughly 9 oral presentations and 14-15 poster presentations. The students submitting abstracts in those years were from Thammasat and Maastricht University. Today we have 14 oral presentations, and 23 poster presentations; we have abstracts from Thammasat, Mahidol, Kasetsart, Srinakharinwirot and Chulalongkorn Universities in Thailand, Maastricht University in the Netherlands, University of Santo Tomas and the Department of Health in the Philippines, Airlangga University in Indonesia, Australia National University in Australia, and the Ministry of Health and Family Welfare in Bangladesh. Those presenters affiliated with our Thammasat University Global Health program, which includes Exchange students from Maastricht University, have participated in classes surrounded by fellow students from other continents, countries and cultures, taught by an international faculty. This year we have 18 students enrolled at the School of Global Studies coming from Bangladesh, Eritrea, Fiji, Lesotho, Malawi, Myanmar, Nepal, Sweden, and Zimbabwe. The 18 Maastricht students who join us for the second trimester of the year add Belgium, Canada, Germany, Lebanon, the Netherlands, and the UK to the group. I go back to this detailed list in order to briefly illustrate our experience at Thammasat and examine the value of bringing this highly varied cross-cultural group together. I hope to promote the benefits of an inter-cultural environment for education of students of global health. The obvious benefit is that peer learning is powerful, and students learn from each other through observation, conversation and, to some extent, role modeling. Though the situation of a single trimester of interaction between the Maastricht and Thammasat students is very short, both groups have at least a year together to develop their own internal integration. In addition, class discussions and extracurricular activities spontaneously organized and participated in by members of each group, can accelerate the process of understanding of different beliefs, cultural practices and even language.

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The situation at Thammasat is somewhat unique as it engages two groups of students with distinctly different educational backgrounds both between and within each group. Neither group is homogeneous. While these differences are the basis of learning by both groups, they could also create an intimidating environment that interferes with some students’ willingness to participate. In our experience, networking and strengthening of the social capital that bonds members within each separate group is of even greater importance than faculty interventions, and can provide the initial support for students to effectively engage with others who are different in background, age, and experience. The challenge of finding your voice in this inter-cultural educational environment is a valuable skill for a global health professional. Beyond learning how to make a good presentation, or express oneself in writing, the capacity to engage confidently in conversation with other colleagues from any country or culture clearly confers a huge advantage to the person intent on bringing people together. Advocacy begins with the ability to establish trust, and conversation and interpersonal exchange are key steps toward that end. We believe that the inter-cultural environment facilitates that achievement. Today’s Conference offers another inter-cultural experience. We will be hearing from students of highly varied personal, cultural, and educational backgrounds – exchanging information and ideas. I leave it to you to critically examine the strengths of this process, and to let us know areas where improvements could be made. Please don’t hesitate to communicate your views and experiences on this form of intercultural learning. It is our hope that with your input, we can expand this forum and continue it for another four years at least. I look forward to your participation and thank you for your support in attending this New Voices conference. Thank you.

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Rector’s Keynote Address:

Equity at Risk in a Changing World Professor Dr. Somkit Lertpaithoon Rector Thammasat University Thank you, Dr. Atwood. Dean Chaiyuth Chavalitnitikul, Dean Nitaya Vajanapoom, Distinguished faculty and colleagues from Thammasat University, Faculty from Mahidol University, investigators, Ladies and gentlemen: Thank you for inviting me to deliver the Keynote address for the 4th annual international conference of New Voices in Global Health and Wellbeing on the theme Equity in a Changing World. It is the theme that aims to draw attention of ours and of the young professionals to realize how important it is for every member of our society – including the most vulnerable: women, children, lower income groups and minorities, to be given the chance to utilize their full potential and have their right to health and wellbeing. Human Rights, Equity, Health and Wellbeing are all important. They speak to the deep truths that define who we are as a people, as a culture, and as a civilization. They define our highest ideals as fairness, justice and the freedom to make choices that protect the best interests of our children and our families. They place these ideals higher than the lesser human traits of greed, selfishness and hatred. Unfortunately, as we scan the global horizon, we can see too many images of the latter: an endless exodus of people forced to flee from their homes to escape conflict; infants and young children, victims of drought and famine, starving as their families struggle to find food that can save their lives; children and adult disabled by war: being trafficked for child labor or sex; girls forced into marriage and early pregnancy, deprived of their childhood when they should have been going to school There is one particularly sad image that stands out, symbolizing the injustice and inequity that is the theme of our times: the devastating image of a small refugee child, drowned, alone, washed up on the shores of Greece – ironically, the country known as the “cradle of Western civilization”. These are haunting images of a harsh world; images we wish we had never seen – images made even more painful when screened along with others of people living in unimaginable wealth: private jets and personal helicopters, private skyscrapers, multiple homes with multiple vehicles parked outside, extravagant banquets and expensive ornaments. This, we are told, is an era where banks are too big to fail, and where some individuals too rich and powerful to tax. These images offer a jarring contrast of lavish living and privilege against the background of unimaginable poverty and deprivation. Can Equity find a place in this changing world? Is there still a role for social and distributive justice? Is it realistic to believe that our society can answer the fair claim of its citizens to realize their human rights, to overcome unjust disparities in today’s ever-changing world?

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Let us make no mistake: we must accept the fact that inequity is not going away any time soon. Economists will tell us that between countries, equity is decreasing. This is true. In our globalized world today, even poorer countries they have a rich class that raises their national GDP. But, inside boundaries of each country, the income gap between the rich and the poor is increasing. Along with it, the social gap is widening, depriving the poorer members out of their education, health, and security. Social justice is impaired. As a result, their capability to choose the life they want for their children is decreased; and, without social justice, their freedom to be able to do or say what they want is less. It is hard not to become pessimistic. Anyway, and I refuse to be pessimistic. Many of these issues are the topics of today’s presentations -- chosen by young investigators who believe that something can be done. Dear young professionals, Your New Voices which will be presented today are not naïve. Ladies and Gentlemen I encourage you all to learn from these New Voices. They recognize that equity is not constant in this changing world, but they refuse to accept that injustice and inequity are inevitable and unstoppable. They have applied their skills and knowledge to analyze each problem for its causes; they look for points on the causal framework where strategic intervention can lead to sustainable change. They turn critical analysis into prevention and mitigation. And, they apply an academic and scientific approach to break down large and seemingly insurmountable problems into small manageable components. Change will not happen overnight, but gradually, one step at a time. I invite you to join them in this endeavor, to listen carefully to what they say, and respond thoughtfully to their presentations. Perhaps, today we can start to work together towards a more equitable world, step by step. Thank you and wish you all the success.

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Oral Presentations

Women’s Perception about Spousal Violence: Unheard Voices in Rural Bangladesh Halima Sultana Haque1, Ashraful Alam2, Shaila Hossain3, Tania Islam3, Mostafa Kamal Pasha3, Shuvashis Saha3, Abdullah Al Mamun4 1 Centre for Medical Education (CME), Bangladesh 2 Mahidol University, Thailand 3 NIPSOM, Bangladesh 4 Sapporo Dental College, Bangladesh Contact address: [email protected]

ABSTRACT Rural women of Bangladesh are extremely vulnerable to experiencing spousal violence. This cross sectional study was done among 195 married rural women of reproductive age in Trishal sub-district of Bangladesh in 2014 to assess the level of perception of rural women about spousal violence. Respondents were selected by purposive sampling and data were collected through a concurrent mixed method approach. Almost all of the respondents were Muslims and housewives living with rural characteristics. More than half (52.3%) of them were screened as victims of spousal violence using the HITS (Hurt, Insult, Threaten and Scream) scale. Among the victims, 73.5% had experienced physical violence and more than 90% gave a history of psychological violence. Almost 37% had an average perception and a similar percentage had poor perception about spousal violence; the remaining respondents had well perception. Illiteracy, lower income, early marriage and undervaluation showed a correlation with a poor perception against spousal violence (p<0.05). Patriarchal structures and male dominance were common barriers to raising voices against the vulnerability. Women were silent about spousal violence to avoid further familial disharmony. Social motivation with increased awareness among rural women about spousal violence can be effective to help women raise their voices against spousal violence.

INTRODUCTION Spousal violence, a common form of violence against women (VAW), is a persistent threat to the dignity of women. Gender discrimination makes women more vulnerable in third world countries like Bangladesh and rural women have to face it in an epidemic level (Ahmed, 2005 & Bhuyia et al., 2003). A 2013 report by the World Health Organization (WHO) found that intimate partner violence affects 30% of women worldwide and is the most prevalent type of violence against women (WHO, 2013). Spousal violence against women, especially violence perpetrated by a woman’s husband, is found as a serious problem in Bangladesh (Bhuiya et al.,2003). It is one of the easiest ways to express male dominance and to exercise control over the family; unfortunately many rural women silently accept this form of violence as a routine phenomenon (Heise et al., 1994). Undervaluation of women allows men to dominate and control, not only their families and resources (Schuler et al., 1998 & Hossain, 2007), but also the lives of women. Consequently, societal norms and traditional values associated with gender roles are in favor of men which increases the possibility of spousal violence against women (Koenig et al., 2003).

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Although Bangladesh has attained remarkable success in increasing literacy rates for women, and decreasing the maternal and child mortality rate, violence against women is still very high in this society. Among the different forms of violence against women, domestic violence is widely prevalent in both urban and rural areas of Bangladesh, and has become an every-day matter in many women’s lives. A study by the International Center for Diarrhoeal Disease Research-Bangladesh (ICDDR,B ) in 2006, indicated that 60% of violence suffered by women occurs within their home. Being vulnerable in a patriarchal society, women face various types of domestic violence in Bangladesh. In a recent study (CPD, 2009) it was observed that mainly four types of domestic violence occur with great prevalence in Bangladesh: physical, psychological, economic, and sexual abuse and violence. Most of the victims (93%) reported in the study that they had experienced physical violence; only 13 percent reported having experienced sexual violence, 91 percent of the victims reported economic violence and 84 percent reported psychological violence committed by their husbands (Doza, 2013). Spousal violence is in epidemic form among Bangladeshi rural women, but it is widely unheard of due to under reporting and the silence of rural women. Rural women are in a crisis of empowerment and they are often denied any decision making power (OECD, 2012). They are not well aware about gender equity and not aware that they can raise their voice against violence, nor do they know how to. Spousal violence in rural areas is treated as a family matter traditionally, and women have adapted to this societal norm since their childhood.

MATERIALS AND METHODS This cross sectional study was conducted among 195 married rural women of reproductive age in Trishal sub-district of Bangladesh in 2014 to assess the levels of women’s perceptions about spousal violence with its determinants. Respondents were selected purposively and data were collected through a concurrent mixed method approach. Qualitative data were collected through Focus group discussions and in-depth interviews; face-to-face interviews were done using pretested questionnaires to quantify data. The status of domestic violence was initially identified by the Hurt, Insult, Threaten and Scream (HITS) scale previously used by Sherin et al. and women’s perceptions about spousal violence were measured through nine items. Neither any intervention nor any invasive procedures were undertaken. Prior to initiation of the study ethical clearance was taken from the Ethical Committee of National Institute of Preventive and Social Medicine (NIPSOM). Data processing and analyses were done using SPSS (Statistical Package for Social Sciences) version 19. Qualitative information was narrated according to the themes.

RESULTS The socioeconomic status of the respondents showed an expected picture of rural Bangladesh. The average age of the respondents was 25.9 years with a standard deviation (SD) of ±5.3years. The average age gap with their husbands was 7.0 years with SD 3.7 years. Among the respondents 79% had a history of early marriage and 60% had a history of adolescent pregnancy. The average number of children was 2.12 with SD of 1.6. Average monthly family income was 13,751 taka and only about 9% had a history of personal income. More than one-third (38.5%) of the respondents were illiterate. Males had a poorer history of literacy than their female counterparts. Almost half of the husbands (48.7%) were illiterate. More than 90% of the respondents were housewives and among the husbands more than one-third (36.9%) were in business and 22.6% were farmers. More than half (59.0) lived in a single family. Two-thirds of them (65.7%) lived in tin-shed houses. Less than 10% of the respondents had land or houses in their own names and only 8.7% had a history of

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personal income. In more than 9% of the cases, respondents were taken as a wife by the second marriage of their husbands. Spousal violence was initially screened through use of the HITS scale - a four itemed domestic violence screening tool for use in the community. Four questions were in that scale about hurt, insult, threat and screaming at the women. Frequency of the items was categorized from ‘almost daily’ to ‘never’ in the last year. In between ‘daily’ to ‘never’ there were weekly, monthly and yearly frequencies available. Each item scored from 1 to 5. A score of greater than 10 was considered positive for spousal violence. Minimum score was 4 and maximum was 15. Average score was 9.6 with SD of 2.3. More than half of them (52.3%) were screened as cases of domestic violence. Among the respondents with a history of domestic violence, 73.5% had experienced physical violence and the rest of them had no history of physical violence. Around 91% of the respondents with domestic violence also had a history of psychological violence. Among the respondents with a history of domestic violence, approximately 62% agreed to answer the question related to sexual violence and 12.7% of them had a history of sexual violence with forceful sex or sex against their will. All of the respondents with a history of domestic violence participated in the question related to economic violence and around 39% of them had a history of economic violence. Although spousal violence was highly prevalent in rural areas, in only approximately 15% of the spousal violence cases did the women say they wanted help locally against violence and only 2% reported that they informed local police to protest against violence. Table 1: Distribution of different forms of spousal violence Spousal violence in Frequency Category different forms (Incidents / past year) Yes 102 Spousal violence (n=195) No 93 Yes 75 Physical violence (n=102) No 27 Yes 93 Psychological violence (n=102) No 9 Yes 40 Economic violence (n=102) No 62 Yes 8 Sexual violence (n=61) No 53

Percentage (%) 52.3 47.7 73.5 26.5 91.2 8.8 39.2 60.8 12.7 87.3

The perception of domestic violence was measured on the basis of nine items. This scale was based on the tool used in the previous BDHS Survey and the Cronbach’s alpha score of the present scale in this study was more than 0.80. The level of perception against violence was increased with the increasing number of the total score. After calculating the total score, perception was categorized through using cut off points for three equal groups. Almost 37% had average perception and a similar percentage had poor perception against spousal violence; only 27.2% were in the well perception group.

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Perception about spousal violence

Figure1: Distribution of women’s perception level about spousal violence The average perception score was only around 2 in illiterate, whereas it was 7 in above primary level. Educational status was in highly significant state with perception against violence (F=13.96, p<0.001). The illiterate group differed significantly from other educational groups (p<0.05) although the average perception score was gradually increased with the higher level of educational status.

Figure2: Educational status with women’s perception about spousal violence The average perception score was only around 4 in the lowest income group of ≤ 10000 taka whereas it was more than 7 in the highest income group of >20000 taka. Family income was also significantly associated with perception against violence (F=3.15, p<0.05). The lowest income group differed significantly only from the highest income group (p<0.05) although average perception scores were gradually increased with the higher level of income status. Perception against violence showed highly significant association with the status of spousal violence (p<0.001). Among the respondents with poor perception, more than 84% had experienced spousal violence and only about 16% of them did not have a history of spousal violence. In the average perception group, the chance of spousal violence was almost 50%. Among the respondents with well perception about 85% had no experience of spousal violence and only around 15% had a history of spousal violence. Perception of rural women against violence had an important role in domestic violence in rural area. The chance of spousal violence gradually increased with the decreased level of perception against violence. Figure3: Women’s perception about spousal violence and the reality Qualitative findings were also in favor of socioeconomic disparity in women’s perception about spousal violence. Social mechanisms were not in favor of rural women to raise their voices against violence. Spousal violence victims lived in silence domestically. In conjunction with socio economic disparity, the attitudinal problems of both men and women were common in most of the cases of spousal violence. Gender inequity was undoubtedly worsening the problem of spousal violence.

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DISCUSSION This study found spousal violence to be a silently accepted gender issue in rural areas. It was very difficult for women to raise their voices against violence under such strong patriarchal structures. Some findings regarding age, income, religion, family size, parity, etc., showed similarities to findings of the recent Bangladesh Demographic and Health Survey (BDHS, 2011), but in a few cases differed due to regional variations or due to the study process. Early marriage is a common scenario in rural communities, and it was slightly higher in this study in comparison to the BDHS of 2011.The differences with the present study might have been due to the difference in study process or selection of study site. Social security was a major concern in marriage before maturity. It was also explained in a previous study by Shanaj Parveen done in the same upazila (Parveen & Leonh¨auser, 2004). More than half of the respondents experienced domestic violence, which was similar to the findings of Taslima et al. in 2012. Women were silent in most of the cases and it was very hard to raise their voices in their husbands’ house. Although percentages of physical violence differed with other study findings, the proportion of psychological violence was similar to the findings of the Centre for Policy Dialogue and others (CPD, 2009 & Naved et al., 2006). Socioeconomic disparity was not only common in findings concerning the vulnerability to spousal violence but also significantly related to women’s perception against violence. These issues were similarly described in spousal violence studies on other occasions ((CPD, 2009 & icddr,b, 2006). Literacy and better economic status were in favor of well perception against spousal violence. Early marriage was in favor of domestic violence and it was really difficult for an immature girl to fight against violence. Although higher parity was in favor of spousal violence in other studies, it was not in favor in this study (Ahmed, 2005 & Hadi, 2009). Women kept silent about violence domestically to avoid further familial disharmony. Social structures did not work to the advantage of women and made it more difficult for them to raise their voices. Males were in advantageous positions to express their muscle power over their spouses. Similar findings have been reported in many national and international papers (Rani et al., 2004, WHO, 2013). Education and better economy share a positive role to reduce the vulnerability, but psychological violence was common in all educational and income status. Dowry was still a major concern for domestic violence in rural areas. Overall, women had to adjust or compromise in almost every case of domestic violence.

CONCLUSION Spousal violence remains domestically in Bangladesh’s male dominant rural society and women’s silence makes them more vulnerable. Socio economic disparity should be minimized to reduce the vulnerability of violence against women. Education can be the most powerful weapon to raise awareness among women about gender equity, and male engagement should be encouraged to reduce the vulnerability of spousal violence. Planners should ensure social security to break the silence of rural women in raising their voices about spousal violence to improve their life status.

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REFERENCES Ahmed, S.M. 2005. Intimate Partner Violence against Women: Experiences from a Woman-focused Development Programme in Matlab, Bangladesh, J Health PopulNutr, 23(1): 95-101 Bangladesh Demographic and Health Survey Report, 2011 Bhuyia, A., Sharmin, T. & Hanifi, S.M.A. 2003. Nature of Domestic Violence against Women in a Rural Area of Bangladesh: Implication for Preventive Interventions, J Health PopulNutr, 21(1): 48-54 Centre for Policy Dialogue. 2009. Domestic Violence in Bangladesh: Cost Estimates and Measures to Address the Attendant Problems, Report no 97 Doza, A.B.M.S. 2013. Domestic violence still pervasive. The Daily Star; Wednesday, May29, 2013 Hadi, S.T. 2009 “It’s OK to beat my wife?” – Patriarchal Perceptions of Bangladeshi Respondents and Factors Associated,Bangladesh e-Journal of Sociology, 6(2):4-14 Heise, L., Pitanguy, H.& Germain, A. 1994. Violence against Women: The Hidden Health Burden, World Bank Discussion Papers No. 255, Washington DC: The World bank, 1994 International Center for Diarrhoeal Disease Research-Bangladesh (icddr,b). 2006. Domestic Violence against Women in Bangladesh. Available at: https://centre.icddrb.org/pub/publication.jsp (Accessed on 7/9/2014) Khatun, M.T. &Rahman, K.F. 2012. Domestic Violence against Women in Bangladesh: Analysis from a Socio-legal Perspective. Bangladesh e-Journal of Sociology.Volume 9, Number 2. 19-30 Naved, R. T., Azim, S., Bhuiya, A.& Persson, L. A. 2006. Physical violence by husbands: Magnitude, disclosure and help-seeking behavior of women in Bangladesh. Social Science & Medicine, 62, 2917– 2929. Naved, R.T. & Persson, L.A. 2005. Factors Associated with Spousal Physical Violence against Women in Bangladesh, Studies in Family Planning, 36(4): 289-300 Organisation for Economic Co-operation and Development (OECD). 2012. SIGI: Social Institutions and Gender Index. Understanding the Drivers of Gender Inequality. (Paris: OECD Development Centre), p 4. Available at: http://www.oecd.org/dev/50288699.pdf. (Access on 10/11/14) Parveen, S. & Leonh¨auser, I. 2004. Empowerment of Rural Women in Bangladesh - A Household Level Analysis. Conference on Rural Poverty Reduction through Research for Development and Transformation. 5-7 October 2004, Berlin: DeutscherTropentag. Rani, M., Bonu, S., & Diop-Sidibe, N. 2004. An Empirical Investigation of Attitudes towards Wife- Beatingamong Men and Women in Seven Sub-Saharan African Countries.African Journal of Re productive Health, 8(3), 116-136. Sherin, K.M., Sinacore, J.M., Li, X.Q., Zitter, R.E., Shakil, A. 1998. HITS: a short domestic violence screening tool for use in a family practice setting.Fam Med.; Volume 30 (7):508-12. World Health Organization. 2013. Global and Regional Estimates of Violence Against Women: Prevalence and Health Effects of Intimate Partner Violence and Non-Partner Sexual Violence. Available at: http://apps.who.int/iris/bitstream/1/9789241564625_eng. (Accessed on 7/11/14)

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War Crimes and State Accountability in Indonesia: The Indonesian Comfort Women in Post-World War II Era Maya Dania1 1 RegNet Ph.D Program, School of Regulation and Global Governance (College of Asia Pacific), Australian National University, Fellows Rd., Canberra ACT 0200 Australia, [email protected]

ABSTRACT Background: Rape and torture of women for the purpose of enforced prostitution are included as war crimes under the 1907 Hague Convention IV and 1949 Geneva Convention. Japan established a forced prostitution system in the Dutch East Indies (DEI) during World War II. Through manipulation and coercion, Japanese soldiers recruited native women to provide sexual services on a daily basis in their military brothels. However, in Indonesia, there has been no recognition of war crimes by Japanese soldiers against native Indonesian women. Objectives: The purpose of this study is to explain and explore the claims from the postwar period that the Japanese military created a comfort women system that forced native Indonesian women into sexual servitude. Additionally, this paper aims to highlight the fact that the Indonesian government has failed to do enough to get recognition and redress for the survivors of the comfort women system. Methods: The study is based on qualitative documentary research done by collecting documented evidence from the Tokyo People Tribunal 2000 and the Indonesian-Japanese government war reparation agreements and treaties. Results: Indonesia has failed to reflect state accountability to protect human rights and justice for former comfort women by claiming impunity and concluding a peace treaty and war reparations with Japan, without addressing the voices of former comfort women. In 1958, Indonesia concluded the Japan and Indonesian Peace Treaty and Reparation agreements. Through the agreements, Japan insisted that all compensation for war reparation had been completed. Subsequently, in 1997, an MoU was also signed between the government of the Republic of Indonesia and the government of Japan, represented by the Asian Women’s Fund (AWF). Both the agreements and the MoU provided financial aid, which implied that the Japanese government had met its promise to compensate for war casualties and damage. The Indonesian government did not use the compensation for individual claims, however, and instead used it to develop the Indonesian economy in the post-war era. Similarly, in the Ministry of Social Affairs of the Republic of Indonesia report to AWF in 2006, the government continued to refer to the survivors of the comfort women system as prostitutes (perempuan penghibur). Being considered prostitutes meant that the survivors of the comfort women system had never been considered victims of war crimes deserving of protection or retribution. Conclusion: Indonesia and Japan have made agreements that limit Indonesia’s legal and reparation-based claims on Japan’s accountability for establishing a comfort women system. At the same time, those agreements have not yet been finalized beyond amendment. Some demands could be delivered to the current Japanese and Indonesian governments that frame the comfort women survivors as war victims and, as a result, urge both governments to take action to restore their social dignity and provide them with due recognition and redress. Keywords: Comfort Women, War Crimes, State Accountability, Indonesia.

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BACKGROUND On the advice of its military leaders, Japan established a system of military brothels throughout Asia, including in Indonesia (Tanaka, 1996). The term comfort stations refers to military-controlled brothels, organized by the Japanese government to serve members of the Japanese armed forces stationed abroad. More than 200,000 civilian women were forced to work as comfort women under Japanese military occupation during World War II (Tanaka, 1996). The first comfort station was set up in Shanghai in 1932. However, it was not until 1937 that Japan expanded its closely regulated “comfort women system” for the sexual gratification of Japanese soldiers (Ahmed, 2004). The system was developed in response to four perceived needs: (1) the Japanese military leaders were very concerned about the rape of civilians by members of the Japanese armed forces during the Nanjing Massacre (the Rape of Nanjing). They believed that a ready supply of women for the armed forces would help reduce the incidence of rape of civilians; (2) the military leaders believed that the provision of comfort women was a good means of providing their men with leisure; (3) the military leaders were also concerned about the incidence of venereal diseases and believed that these diseases undermined the strength of their men (and hence their fighting ability) and that this could potentially create massive public health problems back in Japan once the war was over; and (4) the military leaders were concerned with security, believing that private brothels could be easily infiltrated by spies (Yuki, 1996). A small number of comfort women were actually Japanese professional prostitutes before the war who voluntarily worked in military brothels as a system of legalized prostitution in Japan at that time (Dolgopol and Paranjape, 1994). However, the number of those professional prostitutes was very small. In Indonesia, from 1942 to 1945, the Japanese-established comfort stations were known as ianjo. The Japanese military fraudulently recruited women aged between eleven to early twenties to work in the ianjo. After the war, the Japanese abandoned the ianjo; their existence was mostly hidden in contemporary Indonesia. Furthermore, almost immediately after its surrender, the Japanese military ordered the destruction of many documents relating to the comfort women issue (Ahmed, 2004).

METHODOLOGY This study was undertaken through qualitative research focused on documentation of evidence that reveals the involvement of the Japanese military in fraudulently recruiting and treating civilian women as comfort women in the DEI during its annexation from 1942 to 1945. Primarily, there are 22 documentary files with three types of evidence examined in this paper: 12 official documents from the Japanese Army to establish comfort stations in the DEI from 1942 to 1945, eight official memoirs from the Japanese Army regarding the establishment of comfort stations in the DEI from 1942 to 1945, and two recorded testimonies of Indonesian comfort women survivors from the Tokyo People Tribunal 2000. All documents were obtained from the material evidence series of Indonesian comfort women kept in a Japanese museum called Women’s Active Museum on War and Peace (WAM) in Waseda University, Tokyo. Furthermore, material evidence about Indonesian comfort women issued by the Ministry of Social Welfare of the Republic of Indonesia was also included as primary data during the research for this study. This paper will use the evidence collected and also compare it with the international laws on women in war and post-conflict.

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RESULTS Post World War II, on behalf of 17 allied nations, the United Nations War Crimes Commission was set up in October 1945 to ensure the detection, apprehension, trial, and punishment of those accused of war crimes during the Japanese aggression in Asia (Henry, 2013). Rape and the abduction of girls and women for the purpose of enforced prostitution was explicitly included as a war crime in the Tokyo Indictment under the 1907 Hague Convention IV and 1929 Geneva Convention (IMTFE Judgment, 1948) (Sandoz, 2009). Japan built a forced comfort women system in the DEI during the Second World War. However, the Indonesian government has never addressed the issue as a war crime. Until now, Indonesian society regards the comfort women survivors as prostitutes, despite the tragic sexual violence done to them during the war. More specifically, the Indonesian government has not considered hosting public trials concerning the sexual internment of its local women. Indeed, the story of the comfort women has been omitted from Indonesian National History books. In Indonesia, there were three types of Japanese comfort stations. The first were those directly run by Japanese military authorities. The second were run by civilians but essentially set up and controlled by Japanese military authorities. Finally the third types of facility were mainly private facilities but with some priority for military use. Despite these differences, there were common characteristics among the three types of facilities. First, all facilities were under the strict control of the Japanese military, which helped to establish and manage them, including assisting in the recruitment of girls and women. Second, the facilities were used exclusively by Japanese soldiers and army civilian employees. Third, each facility had to obtain a permit from the army and accept its support and control in all procedures. Lastly, all facilities followed written regulations created by the Japanese Army (Parker & Chew, 1999). A permit would only be issued if the women signed a statement that they provided their services voluntarily. However, most girls eligible to work in the military brothels were very young and frequently could not read the volunteer statement, written in Japanese and Malay language (Van Poelgeest, 1994). The Japanese military employed three systematic methods of recruitment in its efforts to recruit girls to fill the brothels: (1) coercion through physical violence including sexual violence, such as rape; (2) coercion by frightening the women through threats as well as terror including psychological violence; (3) coercion by dishonestly promising to give girls or women a job and/or education such as waitressing, washing and cooking, or acting. The third method used intermediaries or brokers to recruit Indonesian women and girls (Dewi, 2014). After the war, the comfort women issues were hidden. Almost immediately after its surrender to the Allied Powers in the Pacific War, the Japanese military ordered the destruction of many documents relating to the establishment of comfort stations. However, the Japanese were not able to hide the system completely. For the DEI comfort women, several documents revealed the involvement of the Japanese military in fraudulently recruiting civilian women and their treatment. For example, documentary evidence mentioned that the Japanese deliberately organized procedures and regulations for the ianjo mentioned as follow: “... the comfort station to be opened tomorrow and the following points are to be kept: 1. The South barrack to the East of the 47th regiment’s officers must pay 2 yen/hour; 2. Commissioned officers must pay 15 yen/hour; 3. Condoms absolutely have to be paid; 4. Hygienic condition of

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the comfort women is indicated by cloths and they must pay for health checking; 5. The usage of comfort station is from 9 a.m. to 4 p.m. and for commissioned officers from 4 p.m. to 9 p.m.” Two documents give evidence that the Japanese military recruited girls to work in the military brothels through manipulation and abduction, and treated the women inhumanly inside ianjo: 1. Recorded testimonies of Mardiyem (#23), and 2. Recorded testimonies of Suhanah (#24), The stories are as follow: 1. #23 - Mardiyem (a local DEI woman from an ianjo in Borneo Island) “I departed from Yogyakarta by train with some other girls to leave for Surabaya port before taking a ship to Banjarmasin. I decided to go to Borneo Island as I was offered to be a singer by some Japanese officers. As I arrived in Borneo Island, a Japanese man named Chikada put me in a small room. I remembered that Chikada was the manager of a place that later I knew it was a comfort station (ianjo). Chikada was the first man who took my virginity by raping and beating me numerous times. In this place, I had to suffer from sexual exploitations until I was forced to have an abortion. I still carry a vivid memory of the rape I had suffered even after the doctor’s ordered not to have any sexual intercourse following my abortion.” 2. #24 - Suhanah (a local DEI woman from an ianjo in Java Island) “I was abducted by Japanese military personnel in my hometown when I was playing in the yard at her house. At that time, my father was pleading to the military police to get his daughter back but the police killed my father. Then, I was transported by car and some officers raped me several times before reaching the comfort station in Simpang Street. In that place, I had to undergo sexual violence every day without having enough time to have a rest and eat”.

DISCUSSION Rape and sexual assault are explicitly identified as being unlawful in the 1949 Geneva Convention IV, which aims to protect civilian women from alleged rape and sexual assault. Under this Law, the International Tribunal shall have the power to prosecute persons committing or ordering to commit grave breaches under the provisions of the 1949 Geneva Convention, in the provision that reads as follow: 1. Wilful killing; 2. Torture or inhuman treatment, including biological experiments; 3. Wilfully causing great suffering or serious injury to body or health; 4. Extensive destruction and appropriation of property, not justified by military necessity and carried out unlawfully and wantonly; 5. Compelling a prisoner of war or a civilian to serve in the forces of a hostile power; 6. Wilfully depriving a prisoner of war or a civilian of the rights of fair and regular trial; 7. Unlawful deportation or transfer or unlawful confinement of a civilian; 8. Taking civilians as hostages. Japan established a forced prostitution system in the Dutch East Indies (DEI) during World War II. Through manipulation and coercion, Japanese soldiers recruited native women to provide sexual services on a daily basis in their military brothels. However, in Indonesia, there has been no recognition of the war crimes committed by Japanese soldiers against native women at the time. Even in the postwar period, the Indone-

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sian government has not done anything to punish those responsible for these atrocities nor to compensate the women who were victimized by this system. Moreover, the manner in which Indonesian society has regarded the comfort women survivors as female prostitutes has devastated the lives of these survivors. Unlike South Korea in the post-war period, the Indonesian government has never made claims to hold Japan accountable for establishing systematic forced prostitution during World War II. No military tribunal has ever been convened by the Indonesian government to prosecute Japanese war criminals who forced Indonesian native women into sexual servitude. Among the fifty military tribunals convened in Asia between 1945 and 1951, there was only one in Indonesia which executed strict sentences; this tribunal was held by the Dutch government in 1948 in Batavia and passed sentences against Japanese soldiers who had forced thirty-five Dutch women into prostitution. In 1958, Indonesia concluded the Japan and Indonesian Peace Treaty and Reparation agreement. Through the agreement, Japan insisted that compensation for war reparations had been completed (Ishida, 2005). Indonesia, with the signing of the 1958 agreement, agreed not to ask for further compensation and only expected that the Japanese government would make a great effort to seek the best solution for the comfort women issue in return for the Indonesian government’s willingness to maintain its national dignity. On March 25, 1997, Japan put forth its best solution for handling the comfort women issue by formalizing its indirect apology through a Memo of Understanding (MoU). The MoU was signed between the government of the Republic of Indonesia, represented by the Ministry of Social Affairs, and the government of Japan, represented by the Asian Women’s Fund (AWF). The AWF principally implied that by providing funds through the MoU, the Japanese government had met its promise to compensate for the casualties of war caused by Japanese soldiers during the Japanese occupation. Indonesia has failed to reflect state accountability to protect human rights and justice for former comfort women by claiming impunity and concluding a peace treaty and war reparations with Japan, without addressing the voices of former comfort women. Japan has also never openly apologized nor personally compensated the former comfort women in Indonesia. The treaties that have been signed have ignored the actions of a nation-state that has violated human rights and women’s dignity for a significant number of native comfort women in Indonesia. Likewise, in the Ministry of Social Affairs of the Republic of Indonesia Report to the AWF in 2006, the government still referred to the survivors of the comfort women system as prostitutes (perempuan penghibur). Being considered prostitutes meant that the survivors of the comfort women system had never been considered victims of war crimes deserving of protection or retribution.

CONCLUSION During its occupation of the Dutch East Indies from 1942 to 1945, the Japanese military deliberately built military brothels. In organizing these brothels, the Japanese applied systematized fraudulent recruitment to get girls and young women to work as sexual slaves. Forced prostitution and rape occurred regularly during this period. The girls and young women who worked as comfort women were forced to sexually service the Japanese military army personnel whenever the military so desired. Under the 1907 Hague Convention and 1949 Geneva Convention, rape and the abduction of girls and women for the purpose of enforced prostitution is explicitly included as a war crime. The Indonesian comfort women survivors must be considered as war crime victims if the Hague and Geneva Conventions are upheld and respected. First, the establishment of a comfort women system was deliberately organized and

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managed by the Army (point 3 of 1949 Geneva Convention IV). Second, the Japanese armies fraudulently recruited and transported DEI civilian women to work in ianjo (point 7 of 1949 Geneva Convention IV). Third, the DEI women had to undergo torture or inhuman treatment as comfort women (point 2 of 1949 Geneva Convention IV). Despite the clear correlation between the war crimes pointed out in the Hague Convention and Geneva Convention and the experiences endured by the comfort women under Japanese occupation in Indonesia, the Indonesia comfort women survivors were never given the status of war crime survivors because they were stigmatized as female prostitutes. Moreover, few survivors were willing to come forward because of the cultural shame attached to their sexual experiences in a society that prized chastity. This paper argues that demands could still be delivered to the current Japanese and Indonesian governments that suggest they re-frame the comfort women survivors as war crime survivors and install policies to restore their social dignity and provide them with due compensation and recognition. Primarily, the Japanese government should formally recognize and apologize for their historic involvement in creating and maintaining the comfort women system and acknowledge that it was, in practice, a mechanism of sexual slavery that was deliberately implemented in the DEI from 1942 to 1945. Secondly, the dark history of comfort women should be put into the school curriculum in both Indonesia and Japan, so that younger generations are made aware of the oppressive sexual violence used against women during war and have a fuller appreciation of their shared history. Lastly, the comfort women survivors should be compensated as the victims of war and provided with personal support. In this way, the implementation of laws related to women and war crime issues in Indonesia could be strengthened and enforced more fairly.

REFERENCES Ahmed, A. R. (2004). The Shame of Hwang V, Japan: How the International Community Has Failed Asia’s “Comfort Women”. Texas Journal of Women & the Law 14(1): 121-149. Alana, Fangrad. (2013). Wartime Rape and Sexual Violence. Bloomington: Author Publisher. Bassiouni, M. Cherif. (1999). Crimes Against Humanity in International Criminal Law. The Hague: Kluwer International. Brooks, R. L. (1999). When Sorry Isn’t Enough: The Controversy over Apologies and Reparations for Human Injustice. New York: New York University Press. De Brouwer, Anne-Marie, 2005. Supranational Criminal Prosecution of Sexual Violence. Tilburg: INTERSENTIA. Dewi, I. H. M. (2014). Gender and the Triangle of Violence : Who was the Indonesian Jugun Ianfu (Comfort Women). Retrieved February 17, 2014, from http://www.internationalpeaceandconflict. org/profiles/blogs/gender-and-the-triangle-violence-who-was-the-indonesian-jugun#.UxHpzXZ 22PU. Dolgopol, U. P., Snehal (1994). Comfort Women: An Unfinished Ordeal. Int’l Communication of Jurists 11. Ekahindra, Koichi Kimura. (2007). Momoye Mereka Memanggilku (Momoye They Called Me). Indonesia: Esensi. Eboe-Osuji, Chile. (2011). Grave Breaches as War Crimes: Much Ado About Serious Violation. Retrieved from: MUCHADOABOUTSERIOUSVIOLATIONS.pdf Henry, N. (2013). Memory of an Injustice: The Comfort Women and the Legacy of the Tokyo Trial. Asian Studies Review 37.

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International Committee of the Red Cross (ICRC). (2015). Rape and Other Forms of Sexual Violence. Retrieved from: https://www.icrc.org/customary-ihl/eng/docs/v1_rul_rule93 Judgment of the International Military Tribunal for the Far East (1948). International Military Tribunal for the Far East (IMTFE) (1948a) with Justice Erima Harvey North Croft Tokyo War Crimes Trial Collection. New Zealand: University of Canterbury Press. Khushalani, Yougindra. (1982). Dignity and Honour of Women as Basic and Fundamental Human Rights. The Hague: Martinus Nijhoff Publishers. Ministry of Social Affairs of Republic of Indonesia (2006). Document of Report on the Handle of Ex Jugun Ianfu by Indonesian Government in Cooperation with Asian Women’s Fund (AWF). D. G. f. S. S. a. R. Directorate of Social Service for Elderly. Indonesia: Jakarta. Park, Erica. (2011). The Trials of a Comfort Woman. CMC Senior Theses. Paper 113. Retrieved from: http://scholarship.claremont.edu/cmc_theses/113 Pictet, Jean. S. (ed.). (1958). International Committee of the Red Cross, Commentary: IV Geneva Convention 598. Poesponegoro, M. D. N., Nugroho (1992). Sejarah Nasional Indonesia: Zaman Jepang dan Zaman Republik Indonesia (National History of Indonesia: the Japanese Period and Republic Period). Jakarta: Balai Pustaka. Sandoz, Y. (2009). The History of the Grave Breaches Regime. Journal of International Criminal Justice 7. Schaffer, Kay & Sidonie, Smith. (2004). Human Rights and Narrated Lives: The Ethics of Recognition. New York: Palgrave MacMillan. Tanaka, Yuki. (1996). Hidden Horrors: Japanese War Crimes in World War II. Colorado: Westview Press.

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Sexual Violence in Conflict Settings: A Health-System Response in Lebanon Christelle Moussallem1 1 Maastricht University, Netherland

ABSTRACT One in five women will experience sexual violence during their lifetime. Figures are exacerbated in conflicts where sexual violence is used as a weapon of war. Being the site of initial contact for victims, the health-system has a vital role to play. To understand the core elements of a health-system response, this paper looked at published literature on the health burden of sexual violence and existing health-system standards. This paper also covered the experience of Lebanon in initiating a response. There are many guidelines for a health-response to conflict-related sexual violence. Victims should receive medical care within the 72 hours following the incident to avoid life-threatening complications like HIV. In humanitarian settings, a higher occurrence of sexual violence makes it crucial to ensure a timely response, yet building a response under such circumstances was shown to be slow due to many barriers. The case of Lebanon, having the highest per-capita number of refugees, serves as an illustrative example. At the onset of the Syrian crisis, the health-system was unable to treat victims. This was accompanied by reluctance to provide care on the part of aid organizations and providers due to stigma associated with victims of sexual violence. Initiatives undertaken, predominantly by international and local organizations, were faced with harsh criticism and challenges but served as a starting point nonetheless. Establishing a “partial” response in Lebanon has taken years. With the ongoing refugee influx, funding shortfalls and hundreds of rape cases in Syria, a multi-sectoral health-system approach is needed that builds on existing guidelines. Keywords: Sexual violence, women and girls, refugees, conflict settings, health-system response, international standards, Lebanon.

INTRODUCTION Every day millions of women and girls suffer violence worldwide. It is estimated that one in five women will experience sexual violence during their lifetime. These figures are exacerbated in emergency and conflict settings. Studies refer to the staggering prevalence of sexual violence in conflict settings as it continues to be a hidden epidemic (WHO, 2002). If left untreated, sexual violence has an impact on victims at multiple levels encompassing physical and psycho-social complications. It can also impact societies and lead to high socio-economical and medical expenditures. Being usually the site of initial contact for victims, the health care system has a crucial role to play in providing adequate care to victims (WHO & LSHTM, 2010).

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METHODOLOGY To understand the core elements of a comprehensive health-system response to conflict-related sexual violence, the paper looked at evidence describing the health complications associated with sexual violence, and the existing norms defining required interventions in emergency settings. Electronic databases were searched using the key words: conflict, emergency, sexual violence, rape, health, guidelines, response, treatment. International guidelines were prioritized in the search. To highlight procedures and challenges in instituting a health system response to sexual violence, this paper also explored the country experience of Lebanon (which has been hosting a large number of Syrian refugees) through a study of implemented interventions and local assessments in that context.

Sexual violence in conflict settings In crisis and forced migration, women and girls become more vulnerable to sexual violence. Generally speaking, conflict environments, where traditional norms and community support systems are disrupted, put women and girls at risk of sexual violence. It has been documented that women and girls may be forced to perform sexual favors in exchange for basic services and survival goods (IASC, 2005). Sexual violence may also be used as a tactic of war (WHO et al., 2004). Today, inside the ongoing Syrian war, sexual violence is employed as a potent weapon. Militant groups employ sexual violence, based on a justified “theology of rape” for ethnic cleansing, lands’ domination and punishment (McRobie, 2015). Most incidents are perpetrated against female victims and involve males as perpetrators (Marsh et al., 2006).

The health consequences of sexual violence Sexual violence is considered as a “serious public health problem with short- and long-term consequences on women’s physical, mental, and sexual and reproductive health whether it occurs in the context of an intimate partnership or during times of conflict” (WHO, 2016). The true scale of sexual violence’s health burden in conflict settings is still relatively unknown due to significant under-reporting. If left untreated, sexual violence may lead to broad health repercussions for victims including: • Physical: injuries, bruises, abrasions, disability, etc. • Mental: depression, suicide attempts, poor self-esteem, etc. • Behavioral: lack of fertility control, substance use, etc. • Sexual and reproductive: unwanted pregnancies, unsafe abortions, vaginal bleeding, sexually transmitted infections (STIs) including HIV, etc. (Paras et al., 2009; WHO & LSHTM, 2010).

Conflict, displacement and sexual violence intersect to create a high risk environment for STIs and HIV transmission. In Rwanda, a post-genocide study revealed higher incidence of HIV- up to 80% - among women who had been raped, compared to an incidence of 13% among the general population (El-Bushra, 2010). Though Syria had a low-prevalence of HIV among its general population prior to the crisis, the ongoing sexual violence could become a driving force for future HIV transmissions (Public Health Watch, 2015).

The role of the health-care system in responding to sexual violence The health-care system has a vital role to play in preventing, identifying and responding to sexual violence. Comprehensive clinical management of rape (CMR) is one of the key and time-sensitive actions to be implemented from the earliest onset of an emergency. Victims of rape should receive post-rape medical care

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as soon as possible following the incident (i.e., within a maximum of 72 hours) in order to avoid medical complications. Preventive treatment comprises post-exposure prophylaxis (PEP) to prevent HIV infection, antibiotic prophylaxis for STIs and emergency contraception to prevent pregnancy. Victims reporting 72 hours after the incident do not benefit from the prophylactic treatments. CMR has been recognized as a life-saving treatment since the mid-1990s within the Minimum Initial Service Package (MISP) for Reproductive Health (RH) in Humanitarian Settings (IAWG, 2006). Additionally, the health system has a key role in guaranteeing effective preventive measures and forensic evidence collection and documentation. This requires different health system interventions and elements including: coordination between sectors, involvement of different national and international actors, establishment of referral pathways for further services (psycho-social, legal, shelter etc.), evidence generation, providing basic infrastructure and medical supplies, and training of health-care professionals in a multi-disciplinary way and victim-centered approach (WHO et al., 2015). Despite the availability of a wide range of international standards to guide the implementation of a health system response, sexual violence health services are still lagging behind in many emergencies due to a variety of socio-cultural and institutional barriers like stigma, absence of national policies, scarcity of funds, lack of trained health care providers, lack of proper infrastructure, poor inter-sectoral coordination, and insufficient data generation (García-Moreno et al., 2015). Case example of Lebanon Context Though Lebanon is not a signatory state of the 1951 Refugee Convention1, the country has been hosting a massive influx of refugees for decades. At the beginning of the Syrian crisis and influx of refugees in 2011, Lebanon had no national protocols, nor adequate clinical services for sexual violence in place. The Lebanese health system was clearly unable to treat victims from local or refugee communities: health care providers were not trained and clinics were not equipped (Ouyang, 2013). This situation was compounded by unwillingness among providers to support victims due to the stigma that accompanied victims of sexual violence and rape. 85% of local clinicians interviewed in 2012 by the International Rescue Committee (IRC) reported never treating or identifying a victim of sexual violence during their lifetime; some even denied the occurrence of sexual violence in communities of Lebanon and Syria (IRC, 2012). Statements from interviewed providers included: “If a rape victim came here, I would call the rapist himself and tell him to come here to the hospital. Then I would lock her alone with him in a room and I would call the police immediately and tell them to take her away.” Additionally, there have been some governmental institutions and humanitarian aid agencies that regard sexual violence as a non-pressing issue when compared to other basic needs like food and shelter. Some such groups even accused agencies of concocting a non-existent myth of sexual violence (Ouyang, 2013). In contrast to this, reports have confirmed the occurrence of gender-based-violence (GBV) among refugees. 30% of refugee women interviewed in 2012 in Lebanon reported being victims of one or more forms of conflict-related violence while in Syria, including sexual violence, without reporting the incident or seeking medical care (Reese-Masterson et al., 2014). There were also reports of sexual violence incidents perpetrated against refugee women residing in Lebanon (UNFPA, 2013).

-----------------------------------------------------------------1

This convention, signed by 144 State parties, is the basis of the work of UNHCR. It defines the rights of the displaced and the legal

obligations that States have to protect them. See, UNHCR at http://www.unhcr.org/1951-refugee-convention.html

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Institutional capacity building and coordination efforts As of 2012, the United Nations Population Fund (UNFPA) took the lead in initiating half-day trainings for health care providers from primary and secondary health care centers. Following that, different UN agencies, and international and national organizations embarked on providing training programs. An inter-agency committee was established to synchronize activities among involved agencies. The content and the duration of trainings were revised and adjusted by the committee to ensure a more comprehensive capacity building approach. Capacity building was extended to three-day trainings based on international protocols and training manuals from the IRC and the World Health Organization (WHO) translated into the local language. Trainings introduced participants to basic gender-based-violence concepts, post-rape clinical treatment and existing national laws and regulations. Despite extensive capacity-building efforts, some health care providers and facilities’ management staff remained reluctant to treat victims - considering sexual violence an issue for the criminal justice system and not the health system. To overcome this challenge, pre- and post-assessments of facilities were initiated and were used to advocate among providers and to guarantee willingness of clinics and providers to assist victims in a confidential and secure environment. By 2014, around 150 health care providers were trained country-wide. Since facilities in Lebanon are characterized by a large rotating roster of health care providers, it was noticed that only one or two trained providers were available for limited shifts to respond to victims (IRC, 2012). Consequently, in 2014, health facility based trainings were adopted where more providers were trained per facility including para-medical staff. Follow-up and on-the job coaching were also initiated in 2015 after the committee identified the need to support facilities in integrating services through systematic action plans. However, due to restricted funds, this process has been limited to only four onthe-job trainings per facility. Pre-packed post-rape treatment kits were provided to facilities where training had occurred (UNFPA, 2013). The above-mentioned interventions implemented from 2012 till 2014 were mostly piloted by local and international non-governmental organizations with a relatively limited role being played by the Ministry of Public Health (MOPH), which was avoiding political involvement in the response to the problematic civil war in Syria. Progress and policy-level response While these initiatives served as valuable initial steps, they remained insufficient. More involvement from the government was required. Standardized national guidelines on CMR and revision of laws were seen as necessities to ensure a more comprehensive integration of services within primary and secondary clinics. The committee took the lead in advocating for such matters with the government. In early 2015, the first national CMR protocol was introduced. Later that year, some laws and regulations related to the reporting of victims to official authorities were also revised to ensure that reporting to legal authorities was only upon the request and the written approval of the victim (UNFPA, 2014). By 2015, around 60 health facilities and more than 300 health professionals were trained and equipped to manage the medical consequences of rape in Lebanon (UN Lebanon & MOSA, 2015). Persisting challenges Many challenges still stand in the way of achieving a comprehensive response to sexual violence. With more than one million registered refugees and tens of thousands of refugees who are unregistered or awaiting registration, Lebanon currently has the highest per capita concentration of refugees in the world (UNHCR, 2016). With an over-extended health system and high risks of epidemic-prone diseases like cholera, sexual violence is still seen of a less pressing priority (Buchanan, 2015). Subsidized services and forensic evidence collection are financially covered by aid organizations for refugees; however, this is not the case

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for Lebanese victims who are not fully covered and have to pay out-of-pocket. Lebanon’s restrictive law on abortion that considers abortion to be illegal even in the case of pregnancy resulting from rape, is another barrier to ensuring a comprehensive health approach (UN, 2012). Lack of awareness, stigma and attitudes of health service providers all remain some of the difficulties for victims to disclose and seek medical services (McRobie, 2015).

CONCLUSION AND RECOMMENDATIONS In peacetime and stable environments, instituting a comprehensive multi-sectoral health response to sexual violence can be challenging. In humanitarian crises, a higher incidence of sexual violence makes it crucial to ensure a timely response. In Lebanon, establishing an “unfulfilled” response has been ongoing for more than five years; meanwhile 24% of reported GBV cases since 2014 have been associated with sexual violence and rape. With the ongoing influx of refugees to Lebanon, funding shortfalls and hundreds of accounts of rape and sexual slavery in Syria, immediate actions are needed to address remaining gaps (UN Lebanon & MOSA, 2015). Adequate resource allocation is needed in close collaboration with the international community that should be committed to provide continuous financial and technical support. More involvement of the MOPH is needed to start a national action plan and a legal framework in close collaboration with other sectors. National interventions should include the integration of sexual violence responses in the curricula of medical schools, expansion of capacity building efforts to cover private and public hospitals in high-population refugee areas but also other regions, full health coverage for national victims, and the establishment of a sustainable strategy for the supply of post-rape treatment. The law on abortion should be revised to include a new indication for abortion: pregnancy from rape or incest. More efforts must also be made to raise awareness, and generate data and research to identify the magnitude of sexual violence among national and refugee communities so that stronger evidence-based responses can be implemented.

REFERENCES El-Bushra, J. (2010). Understanding sexual violence, HIV/AIDS and conflict. Retrieved January 23, 2016, from http://www.fmreview.org/AIDS/El-Bushra.html García-Moreno, C., Hegarty, K., d’Oliveira, A. F. L., Koziol-McLain, J., Colombini, M., & Feder, G. (2015). The health-systems response to violence against women. The Lancet, 385(9977), 1567–1579. IASC. (2005). Guidelines for Gender-based Violence Interventions in Humanitarian Settings. Retrieved January 23, 2016, from http://www.unhcr.org/453492294.pdf IAWG. (2006). Minimum Initial Service Package (MISP) for Reproductive Health in Crisis Situations. Retrieved January 23, 2016, from http://www.iawg.net/resources/MISP2011.pdf IRC. (2012). The Syrian Refugee Crisis in Lebanon: Emergency Rapid Assessment of Health Services for Survivors of Gender-Based Violence. Marsh, M., Purdin, S., & Navani, S. (2006). Addressing sexual violence in humanitarian emergencies. Global Public Health, 1(2), 133–146. McRobie, H. (2015). Sexual violence is a central weapon of war. Retrieved January 23, 2016, from http://www.alaraby.co.uk/english/comment/2015/8/20/sexual-violence-is-a-central-weapon- of-war Ouyang, H. (2013). No Aid for Syrian Refugee Survivors of Rape. Retrieved January 23,2016 from http://www.theglobalist.com/no-aid-for-syrian-refugee-survivors-of-rape/

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Paras, M. L., Murad, M. H., Chen, L. P., Goranson, E. N., Sattler, A. L., Colbenson, K. M.,Zirakzadeh, A. (2009). Sexual Abuse and Lifetime Diagnosis of Somatic Disorders: A Systematic Review and Meta-analysis. JAMA, 302(5), 550. Public Health Watch. (2015). UN: Extremist Groups Using Rape As Weapon Of War In “Shocking Trend Of Sexual Violence”. Retrieved from https://publichealthwatch.wordpress.com/2015/04/ 14/un-extremist-groups-using-rape-as-weapon-of-war-in-shocking-trend-of-sexual-violence/ Reese-Masterson, A., Usta, J., Gupta, J., & Ettinger, A. S. (2014). Assessment of reproductive health and violence against women among displaced Syrians in Lebanon. BMC Women’s Health, 14, 25. UN. (2012). Abortion policies country profiles: Lebanon. Retrieved February 29, 2016, from http://www.un.org/esa/population/publications/abortion/ UNFPA. (2013). Haunting Stories. Retrieved January 23, 2016, from http://www.unfpa.org.lb/News/ Haunting-Stories.aspx UNFPA. (2014). Regional Situation Report for Syria Crisis July 2014. Retrieved March 16, 2016, from https://www.unfpa.org/sites/default/files/jahia-news/documents/Emergencies/UNFPA RegionalSitRep1-31July2014_23.pdf UNHCR. (2016). UNHCR Syria Regional Refugee Response. Retrieved January 23, 2016, from http://data.unhcr.org/syrianrefugees/country.php?id=122 UN Lebanon, & MOSA. (2015). Lebanon Crisis Response Plan 2015-16. Retrieved March 16, 2016, from http://www.un.org.lb/english/lcrp WHO. (2002). World report on violence and health. Retrieved January 23, 2016, from http://www.who.int/violence_injury_prevention/violence/world_report/en/full_en.pdf WHO. (2016). Sexual violence. Retrieved January 23, 2016, from http://www.who.int/entity/ reproductivehealth/topics/violence/sexual_violence/en/index.html WHO, & LSHTM. (2010). Preventing intimate partner and sexual violence against women: taking action and generating evidence. Retrieved January 23, 2016, from http://www.who.int/ violence_injury_prevention/violence/activities/intimate/en/ WHO, SRN, & UNODC. (2015). Strengthening the medico-legal response to sexual violence. Retrieved February 21, 2016, from http://apps.who.int/iris/bitstream/10665/197498/1/ WHO_RHR_15.24_eng.pdf WHO, UNHCR, & UNFPA. (2004). Clinical management of rape survivors: Developing protocols for use with refugees and internally displaced persons. Retrieved January 19, 2016, from http://www.who.int/reproductivehealth/publications/emergencies/924159263X/en/

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Stigmatizing Attitude and Knowledge about HIV Transmission among Nurses in Indonesia Siti Urifah1, Monthana Hemchayat2, Boosaba Sanguanprasit2 1 Kasetsart University, Bangkok-Thailand, [email protected] 2 Boromarajonani College of Nursing Nopparat Vajira, Bangkok 10230, Thailand

ABSTRACT Background: Lack of knowledge and misunderstanding about HIV transmission can influence the attitude toward patients with HIV or AIDS among health care providers. Negative attitude or stigmatizing attitude toward HIV or AIDS patients can create barriers to the provision of quality care. In healthcare settings in Indonesia, nurses are the majority group of health personnel. Thus, lack of knowledge about HIV transmission and poor attitudes of nurses may result in poor health care services for these patients. Objectives: To examine the stigmatizing attitude and knowledge about HIV transmission among nurses in Indonesia Methods: A cross sectional study was conducted with 400 nurses providing care to patients with HIV or AIDS in eight public hospitals in Jakarta selected by using convenience sampling method. Knowledge about HIV transmission was measured by using Knowledge of HIV/AIDS questionnaire, and Provider Attitude Toward PLHIV questionnaire was used to assess nurses’ stigmatizing attitude toward patients with HIV or AIDS. Data were analyzed by frequency, percentage, mean, standard deviation, and Pearson correlation. Results: The results of this study showed that approximately 17.5 % of nurses had poor knowledge about HIV transmission. Among all nurses in this study, 27.7 % and 40.0 % of them answered that sweat and urine can transmit HIV, respectively. It was found that only 24.3 % of the nurses had a good attitude toward patients with HIV or AIDS. More than half of the nurses agreed and strongly agreed that patients with HIV or AIDS should be isolated and that hospital facilities for these patients must be kept separate from other facilities. Moreover, 28.8% of the nurses believed that HIV and AIDS was punishment from God. In addition, this study also revealed that there was a significantly negative correlation between knowledge about HIV transmission and stigmatizing attitude toward patients with HIV and AIDS patients (r = -.171, p < .01). This finding revealed that the nurses who had poor knowledge about HIV transmission were more likely to have stigmatizing attitude toward HIV/AIDS patients. Conclusion: It is important for nurses to have accurate information about care for patients with HIV or AIDS patients and knowledge about HIV transmission. The results of this study suggested that knowledge about HIV transmission is still needed for nurses in Jakarta. Therefore, continuing education and training related to HIV and AIDS should be implemented in hospitals to enhance nurses’ HIV and AIDS knowledge, so that they can provide quality nursing care to patients with HIV or AIDS in the hospitals. Keywords: Knowledge, Stigmatizing Attitude, HIV/AIDS Patients, Nurses, Indonesia

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BACKGROUND Human Immunodeficiency Virus (HIV) is one of the world’s leading killer diseases that attacks the body’s immune system, while Acquired Immunodeficiency Syndrome (AIDS) is a chronic health condition caused by the HIV. Globally, in 2013, an estimated 35 million people were living with HIV and 1.5 million of them died due to AIDS-related illnesses. In 2013 in the Asia and Pacific region, an estimated 4.8 million people were living with HIV and 250,000 people died due to AIDS-related illnesses. In Indonesia, in 2013, an estimated 610,000 people were living with HIV and 27,000 of them died due to AIDS-related illnesses (UNAIDS, 2014; MoH, 2014). In order to handle the epidemic, which started in the last decade, the United Nations has issued global health policies and preventive actions to reduce the burden of HIV/AIDS. The global preventive actions are covered in the “Getting to Zero” strategy. The three targets of this program are reaching zero number for: 1) new HIV infection cases, 2) deaths due to AIDS-related illness, and 3) stigma and discrimination toward people living with HIV (UNAIDS, 2010). Stigmatizing attitude toward HIV patients is still predominant in Indonesia. In 2007, a survey in Indonesia found that 40% of patients with HIV and AIDS patients had experienced stigma and discrimination in their community, usually in HIV testing (Ford, et al, 2004 cited UNAIDS, 2007). In Jakarta, a study found that 77% of the HIV/AIDS patients had experienced stigma from their community (Weaver, 2014). Moreover, some previous studies documented a strong relationship between stigma and failures to refill ARV medication prescriptions among patients with HIV/AIDS (Mills et.al, 2009; Nachega et al, 2006)). Previous studies in Indonesia found that stigmatizing attitude toward HIV patients was high among nurses (Waluyo, 2011; Paryati, 2011; Harapan, 2013). Despite the fact that the Indonesian government has a policy that did not allow any health care providers to refuse or reject patients with HIV/AIDS patients whenever they want to have test and treatments. The policy also forbids any stigmatization and discrimination toward patients with HIV/AIDS from health care workers at any level of health care service (MoH, 2014). However, in Jakarta, HIV-infected patients reported violations committed by nurses, including physical isolation and medical neglect (Waluyo, Nurachmah, & Rosakawati, 2006). In Bali, people living with HIV experienced rejection by healthcare workers and were refused treatment by nurses (Merati et al, 2005 cited Waluyo, 2011)). To better understand this evidence many studies had been conducted and found that lack of knowledge among healthcare providers including nurses about cause, treatment, prevention of HIV, knowledge of stigma and discrimination would result in higher stigmatizing attitude (USAID, 2007; Harapan, et al,. 2013; Ebied, 2014; Feyissa, et al,. 2012, Platten, 2013). Since several attempts have been made during the past ten years to reduce stigmatizing attitude toward HIV/AIDS patients in Indonesia, it was valuable to investigate the current situation. Therefore this study was conducted to assess the relationship between knowledge about HIV transmission and stigmatizing attitude toward patients with HIV or AIDS among nurses in Jakarta, Indonesia. The results of this study may provide useful information to prevent stigmatizing attitude among nurses.

METHODOLOGY A cross sectional study was conducted among 400 nurses working in eight public hospitals in Jakarta, Indonesia during 21 October – 25 November 2015. The samples were selected by using a multistage sampling technique combined with proportion sampling method. The inclusion criteria included nurses who at the time had provided HIV/AIDS care for at least 6 months and were working in a government hospital in Ja-

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karta, Indonesia. The research instrument used was a self-administrative questionnaire. The questionnaire consisted of three main parts: individual information, knowledge about HIV transmission, and stigmatizing attitude toward HIV/AIDS patients. The Provider Attitude toward PLHIV questionnaire was used to assess nurses’ stigmatizing attitude toward HIV/AIDS patients. Validity and reliability The validity of the questionnaire was checked and approved by three experts including two experts in HIV and AIDS in Thailand and one in research methodology. The reliability test with targeted samples was conducted among 30 nurses in Jakarta having similar characteristics. The reliability of the questionnaires was examined by utilizing Crombach’s alpha for the scale items and Kuder-Richardson Formula 20 to examine dichotomous items. The reliability results of the knowledge about HIV transmission was 0.84 and the attitude was 0.82. The data were collected by the researcher and one trained assistant, following the steps of data collection approved by the Research Ethics Committee at Boromarajonani College of Nursing Nopparat Vajira, Thailand. Data analysis Data were analyzed by frequency, percentage, mean, and the standard deviation which were applied for describing general characteristics of participants. Pearson’s correlation was used to test the correlation between knowledge about HIV transmission and stigmatizing attitude.

RESULTS The nurses’ ages ranged from 21-56 years old with the mean of 31.2 years and standard deviation of 6.6 years. More than half (68.0%) of the nurses were females, 77.0% were Muslims, and 66.0% of the nurses had a diploma as their highest education. Work duration at the hospital of the nurses ranged from 6 months to 29 years with the mean of 70.38 months or more than 5 years and the standard deviation of 66.4 months. Only 13.0 % of the nurses received training related to stigma and discrimination toward patients with HIV and AIDS, 39.0% of the nurses had training related to antiretroviral treatment (ART) and HIV care and they had been trained more than one year previously (Table 1). The results of this study showed that approximately 17.5 % of nurses had poor knowledge about HIV transmission. More than a quarter of them answered that sweat (27.7%) and urine (40.0%) transmitted HIV (Table 2). It was found that only 24.3 % of the nurses had a good attitude toward patients with HIV or AIDS patients. In detail, more than half of the nurses agreed and strongly agreed that patients with HIV or AIDS patients should be isolated and the hospital’s facilities for their patients must be separated from other patients. 28.8% of the nurses believed that HIV and AIDS was a punishment from God (Table 3). The study also revealed that there was a significant negative correlation between knowledge about HIV transmission and attitude toward patients with HIV or AIDS (r = -.171, p < .01). This finding suggested that the nurses who had poor knowledge about HIV transmission were more likely to have stigmatizing attitude toward patients with HIV/AIDS.

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Table 1: Number and percentage of individual information (n=400) Characteristics Age in years 20 – 29 30 – 39 ≥ 40 Mean ± S.D = 31.2±6.6 years Min-Max = 21-56 years Gender Male Female Level of Education Diploma Bachelor degree and Higher Religion Islam Christian and Catholic Work duration* Novice Advance beginner Competent Specialist Mean ± S.D = 70.3±66.4 months Min-Max = 6-348 months (0.5-29 years) Training relating to stigma and discrimination Yes No Time since being trained 1 year or less More than 1 year Training relating to ART and HIV care Yes No Time since being trained 1 year or less More than 1 year

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Number

Percent

184 176

46 44

40

10

130 270

32 68

266 134

66 34

309 91

77 23

205 82 80 33

51 21 20 8

51 349

13 87

13 38

25 75

157 243

39 61

28 129

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Table 2: Number and percentage of nurses’ knowledge about HIV transmission by items (n= 400). No

Statements

1 2 3

Blood can transmit HIV Needle prick/ sharps injuries can transmit HIV Standard sterilization are sufficient when sterilizing instruments used HIV patients Breast milk can transmit HIV Vaginal secretion can transmit HIV Tears can transmit HIV Sweat can transmit HIV Feces can transmit HIV Saliva can transmit HIV Urine can transmit HIV

4 5 6 7 8 9 10

Correct answer Number Percent 380 95 379 94.8 360 90 346 345 297 289 273 264 240

86.5 86.3 74.3 72.3 68.3 66 60

Table 3: Number and percentage of participants’ attitude toward HIV/AIDS patients by items (n=400)

No

Attitude

1 2 3 4

HIV spread by female sex workers HIV spread by promiscuous men HIV spread by injection drug users HIV/AIDS children are more deserve of treatment HIV/AIDS is the result of bad behaviors HIV/AIDS patients must feel ashamed of their disease HIV/AIDS patients should be isolated Hospitals facilities must be separated from other patients Use gloves in noninvasive exams HIV women should not have children HIV/AIDS is punishment from God

5 6 7 8 9 10 11

Strongly Disagree and Disagree N % 3 0.8 3 0.8 11 2.8 82 20.6

Uncertain N 12 8 40 13

% 3 2 10 3.3

Agree and Strongly Agree N % 385 96.2 389 97.2 349 87.2 305 76.2

47 62

11.8 15.5

55 70

13.8 17.5

298 268

74.4 67

117 84

29.3 21

80 77

20 19.3

203 239

50.7 59.7

100 112 238

25.1 28 59.5

61 92 47

15.3 23 11.8

239 196 115

59.7 49 28.7

DISCUSSION The aim of this study was to assess the relationship between knowledge about HIV transmission and the stigmatizing attitude toward patients with HIV or AIDS. This study found less than a quarter of the nurses had poor knowledge about HIV transmission. This finding is consistent with previous study that found 33.8% of Jordanian nurses had a weak level of HIV knowledge, especially about HIV transmission (Hassan, 2011). However, this result was in contrast with a survey among health care workers in Nigeria that showed most of the health care workers (87%) had a good understanding of cause and mode of transmission of

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HIV and AIDS. In particular, this study found more than a quarter of the nurses incorrectly answered that sweat, tears, urine, saliva and feces transmitted HIV. This finding is consistent a study from Marranzano et al (2013) found 35% of the nurses had incorrectly answered regarding HIV modes of transmission. Consequently, the nurses need to enhance both accuracy and adequacy of their knowledge about HIV transmission to safely perform their roles in caring for patients with HIV/AIDS (Hassan, 2011). Concerning stigmatizing attitude, only 24.3% of the nurses had a good attitude toward patients with HIV/ AIDS. This study shows almost half of the nurses agreed that women with HIV should not have children but 23% of them were still uncertain about this statement. Primarily, HIV could be transmitted between mother and her infant during pregnancy, childbirth and breastfeeding (WHO, 2014). Furthermore, most of the nurses were in agreement and strong agreement that children with HIV or AIDS were more deserving of treatment. This finding was consistent with a study in South Africa that found that nurses experienced sadness when there was no progress and when the children with HIV got worse. Nurses also felt it was unfair that the children died because they were so ill at the final stage of AIDS, as that is not the way it should be (Enerholm and Fagrell, 2012). Moreover, this study also found more than half of the nurses agreed and strongly agreed that HIV patients should be ashamed with their disease, be isolated in hospital, and that HIV patients’ facilities in hospital should be separated. This finding is in line with a previous study that reported that 27% of the health care workers believed that patients with AIDS should be isolated from other patients (Umar et al, 2012). Results of this study support the statement that lack of knowledge and misunderstanding about HIV transmission were among the possible reasons for why some healthcare workers are not comfortable in dealing with patients with HIV and AIDS. And as a consequence, they expressed negative attitudes toward these patients (Famoroti et al, 2013).

CONCLUSION The results of this study suggest the nurses’ attitude toward patients with HIV or AIDS still need improvement, especially their beliefs that patients with HIV and AIDS should be isolated from other patients. This discrimination coming from health care providers can be a barrier to prevention and treatment of HIV and AIDS. Also better knowledge about HIV transmission is still needed for some nurses in Jakarta. It is important to enhance accurate knowledge regarding HIV transmission to nurses. Therefore, continuing education and training related to HIV and AIDS should be implemented in hospitals to enhance nurses’ knowledge so that they can provide quality nursing care to patients with HIV or AIDS in the hospitals.

REFERENCES Ebied, Ebtesam Mo’awad El-Sayed. 2014. Factors Contributing to HIV/AIDS – Related Stigma and Discrimination Attitude in Egypt: Suggested Stigma Reduction Guide for Nurses in Family Health Centers. Journal of Education and Practice, Vol. 5, No. 24. Enerholm, Elin and Lisa Fagrell. 2012. Registered Nurses’ experiences of caring for children with HIV/ AIDS in South Africa. University of Orebro in Sweden Famoroti et al. 2013. Stigmatization of people living with HIV/AIDS by healthcare workers at a tertiary hospital in KwaZulu-Natal, South Africa: a cross-sectional descriptive study. BioMed Central Ltd. Feyissa, Garumma T., Abebe L, Girma E, Woldie M. 2012. Stigma and Discrimination against People Living with HIV by Healthcare Providers, Southwest Ethiopia. BMC Public Health. 12:522.

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Harapan, H., Syarifah F, Hendra K, Mohd. Andalas, M.Bella H. 2011. Factors Affecting the Level of Healthcare Workers’ Stigmatized and Discriminatory Attitude toward People Living with HIV: a Study at the Dr. Zainoel Abidin General Hospital, Banda Aceh- Indonesia. Proceeding of The Annual international conference Syiah Kuala University. Volume 1 number 230-233. 2011. Hassan, Zeinab M. 2011.Knowledge and Attitudes of Jordanian Nurses towards HIV/AIDS: Findings from a nationwide survey. Informa Health care. Khorvash et al. 2014. The relationship between knowledge, attitude and tendency to care of HIV/AIDS patients among nurses and midwives, working in general hospitals and health care centers of Istahan-Iran. Journal of Midwifery and Reproductive Health. Marranzano et al. 2013. Knowledge, Attitudes and practices towards patient with HIV/AIDS in staf nurses in one university hospital in Sicily. Epidemiology Biostatistics and Public Health. Volume 10. Mills et al. 2009. Adherence to Antiretroviral Therapy in Sub Saharan Africa and North America: A Meta-Analysis. JAMA Ministry of Health of the Republic of Indonesia (MoH). 2014. Cases of HIV/AIDS in Indonesia Reported through September. Jakarta: Ministry of Health. Paryati, Tri. 2011. Faktor-Faktor yang Mempengaruhi Stigma dan Diskriminasi kepada ODHA (Orang dengan HIV/AIDS) oleh Petugas Kesehatan: Kajian Literatur (Factors Influencing Healthcare Workers’ Stigma and Discrimination toward PLHIV: A Literature Review). Bandung: Padjajaran University. Platten, Mechael et al. 2014. Knowledge of HIV and factors associated with attitudes towards HIV among final-year medical students at Hanoi medical university in Vietnam. BMC Public Health. Umar, A.S. et al. 2012. Discriminatory practices of health care workers toward people living with HIV/ AIDS in Sokoto, Nigeria. Journal of AIDS and HIV Research. UNAIDS. 2014. HIV/AIDS Fact Sheets. Joint United Nations Programme on HIV/AIDS (UNAIDS): WHO Library Cataloguing in Publication Data. UNAIDS. 2010. Getting to Zero: 2011 – 2015 Strategies. Bangkok: United Nations Publications. USAID. 2007. Evaluation of Knowledge, Attitudes, and Practices of Health Care Providers toward HIV positive Patients in Tanzania. USAID. Waluyo, Agung. 2011. Indonesian Nurses’ HIV Knowledge, Religiosity, Individual Stigma Attitude and Workplace HIV Stigma, a Dissertation from University of Illinois, Chicago, the United States. Waluyo, A., Nurachmah, E. & Rosakawati. 2006. Patient and their family perception on HIV/AIDS and stigma on HIV/AIDS. Indonesian Nursing Journal. Vol. 9 (1): 5-9. Weaver, Emma Rosamond Nony et al. 2014. Factors that Influence Adherence to Antiretroviral Treatment in an Urban Population, Jakarta, Indonesia. PLOS one. WHO. 2014. MDG: Combat HIV/AIDS, Malaria, and Other Diseases. Available Source: http://www.who. int/topics/millennium_development_goals/diseases/en/. April 02, 2015

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Gender Awareness and Women’s Empowerment in Rural Bangladesh: A Silent Crisis Md Ashraful Alam1, Halima Sultana Haque2, Md Rizwanul karim3, Shahana Sultana4, Jahanara Ferdous Khan5, Tithi Das6, Shahina Haque7 1 Mahidol University, Thailand 2 Centre for Medical Education (CME), Bangladesh 3 DG Health, Bangladesh 4 Saphena Women’s Dental College and Hospital, Bangladesh 5 Laser Medical Center, Bangladesh 6 Bangladesh University of Health Sciences 7 BRAC, Bangladesh Contact: [email protected]

ABSTRACT Women of developing countries like Bangladesh are no doubt in empowerment crisis and this vulnerability is more rooted in rural areas. This cross-sectional study was conducted in 2014 in Trishal, a rural Mymensingh sub-district, in Bangladesh among 396 married women of reproductive age to assess gender awareness and women’s empowerment. Cluster sampling was done in multi-stage form and data were collected through a concurrent mixed method approach. All participants were Muslims having typical rural characteristics. Almost all of them were housewives; poverty, illiteracy and early marriage were endemic. Over one-third (39.1%) were poorly aware of gender issues and approximately 32% were well aware. More than one-third (37.1%) scored poorly for empowerment and approximately 32% were well empowered. Only age and educational status of respondents were statistically significant in multiple regression to predict women’s empowerment (p<0.05). Household decision making, economic access and mobility were strongly correlated with women’s empowerment in different income as well as educational status (p<0.05). Patriarchal structures and male dominancy were common barriers in women’s empowerment. Empowerment remained challenged and was not uncommon in gender aware women. Access to education could provide the leverage to raise awareness among rural women about gender disparity and to foster empowerment.

INTRODUCTION Gender equity is an urgent issue to be addressed in third world countries like Bangladesh where women are deprived of their basic rights (Kabeer, 1999; Jejeebhoy, 2002; Malhotra & Schuler, 2005; Mosedale, 2005; Mahmud et al., 2012). Gender awareness is important, but it is only the awareness about gender equity and does not ensure women’s empowerment. Women’s empowerment can be treated as a process by which women can enjoy greater autonomy in decision making with control over their resources to express their own identity in both the social and cultural context. Women’s empowerment is a multidimensional issue that should be ensured for the sake of women’s dignity as well as for national development (Sultana & Hossen, 2013; Kundu & Chakraborty, 2012).

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When it comes to gender equality in many parts of this region, societies still culturally favor males. Boys still outnumber girls in primary school enrolment in Afghanistan, India, Nepal and Pakistan. Patriarchal norms isolate women in their homes by placing restrictions on their mobility and prohibiting contact with the opposite sex, especially in rural areas in Afghanistan and Pakistan (IFAD, 2013). Women in Bangladesh are treated significantly worse than men through the implementation of the countries’ rules, regulations, customs and societal norms. This irrational behavior gives women a lower status than men socially, culturally, religiously, economically and legally. They are deprived of education, decision-making power in the family, control of their own assets, and decision making power regarding domestic changes such as household properties (Sultana & Hossen, 2012; Schuler & Rottach, 2010; Goetz et al., 1996). The empowerment situation of rural women is an even more vulnerable process than of urban-based women. For example, it is common for rural based women to prepare the meals for their husbands and family, but they are often deprived of eating these meals themselves, or they are often made to wait to eat until the end of the session. Women in rural areas are raised, from childhood, with disempowering gender roles and mind sets to prepare them for the role they will play in their future families. The women who are engaged in any self-earning activities are more empowered. The women who are entrepreneurs or engaged in the development of entrepreneurship activities in Bangladesh are more socially, politically and economically empowered (Al-Hossienie, 2011; Chen & Mahmud, 1995; Kabeer, 2001). Gender awareness is increasing day by day but women’s empowerment is still very difficult to describe especially in rural Bangladesh (Haque et al., 2011).

MATERIALS AND METHODS This cross sectional study was conducted among 396 married rural women of reproductive age in Trishal Upazila in 2014 with the intention of discovering the socioeconomic disparity in gender awareness and women’s empowerment in rural area. Respondents were selected through cluster sampling and data were collected through a concurrent mixed method approach. Focus group discussions (FGDs) and In-depth Interviews (IDIs) were done for qualitative data and face to face interviews were conducted with pre-tested semi-structured questionnaires for quantitative data. Neither interventions nor invasive procedures were undertaken. However, prior to the initiation of the study ethical clearance was taken from the Ethical Committee of NIPSOM. The empowerment status of rural women was measured by the empowerment scale used by Kundu SK and Chakraborty A in 2012 in rural India using several indicators. The gender awareness scale was based on ten items, which were previously used by Parveen & Leonhäuser in 2004 to measure gender awareness of rural women in Bangladesh. Data processing and analyses were done using SPSS (Statistical Package for Social Sciences) version 19.

RESULTS Gender awareness and women’s empowerment were described in the rural context with their socio economic disparity. More than half (53%) of the respondents were in the age group of 20-29 years and the average age of the respondents was 26.6 years with a standard deviation (SD) of ± 5.6 years. The average age gap was 5.8 years with the maximum being 23 years. The mean of the family members was just 5.0 with ±2.2 SD. Average monthly family income was 12,688 taka. Almost 31% of the respondents were illiterate. Males had a poorer history of literacy than their female counterparts.

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All respondents were Muslims and almost all of them were housewives. Among the husbands, more than one-third (34.1%) were in business and almost 18% were farmers. The majority of them (79.2%) lived in tin-shed houses. Only about 7% had a history of personal income. Almost two thirds of the respondents (63.9%) had a history of watching television. Almost 25% had a history of exposure to micro credit. More than 6% of the cases revealed respondents that were taken as a wife for the second time at the house of their husbands. Among the respondents more than 82% had a history of early marriage. Almost 63% had experienced adolescent pregnancy and the average parity was 2.4 with a SD of 1.8. Gender awareness was measured on the basis of ten items that were previously used by Shahnaj Parveen in 2004 in her study to assess the level of gender awareness of women in rural Bangladesh and the Cronbach’s alpha score of the present scale in this study was more than 0.80. The majority of them (39.1%) were in the poor awareness group and only about 32% were well aware; the remaining respondents showed average awareness about gender equity. Women’s empowerment was measured on the basis of 4 dimensions through using 22 items which was previously used by Kundu and Chakraborty in 2012 in their study in Murshidabad. Economic access had 6 items and household decision making was measured through 7 items. Mobility was calculated through 6 items and lastly political awareness was described through 3 items. The Cronbach’s alpha score of the present scale in this study was more than 0.90. Majority of them (37.1%) were in poor empowerment group and only around 32% were well empowered and rest of them were in average empowered group.

Figure1: Distribution of status of gender awareness Although age did not show a significant relationship to gender awareness, the age of the respondents was found to have a significant association with women’s empowerment (F=3.54, p < 0.05) and the middle age group actually made the difference with others. Mean empowerment score was highest (43.1yrs) in the 25-29 years group and lowest in the adolescent group with a mean age of 36.1 years. Educational status showed significant association with gender awareness and women’s empowerment (p<0.05). Although gender awareness and women’s empowerment had a significant relationship with Figure2: Distribution of women’s educational status, they were significant only for empowerment status the average empowerment score of higher educational levels. Economic status did not have a significant association with awareness on gender equity. Although the relationship was not significant, there was a gradual increase in empowerment levels among those with the higher income status. The mean empowerment score was 40.5 in the lower income group,

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whereas it was 42.5 in the higher income group. Early marriage was a significant factor in women’s empowerment. Only around 29% of the respondents were well empowered in the early marriage group whereas more than 44% were well empowered in the marital age group of ≥18 years. Even in the gender aware group, women were not well empowered. These factors were not in a significant state of correlation. Almost 50% of the women accepted dowry for the wellbeing of women. Almost 39% of them were in favor of under valuation of themselves. Even regarding equal rights in paternal property, gender awareness was not in relation. A multiple regression was run to predict empowerment from five independent variables, and only the age and educational status of respondents were statistically significant in individual relation to the prediction (p<0.05). Figure 3: Gender awareness with women’s empowerment Table 1: Independent factors to predict women’s empowerment Model Constant Family income of respondents Marital age of respondents Personal income of respondents Age of respondents Educational status of respondents

Beta 35.77 0.73 1.47 3.76 4.14 2.76

t 27.07 0.43 1.08 1.86 3.03 2.57

Sig. 0 0.67 0.28 0.06 0 0.01

F

P

4.745

0

Household decision-making, economic access and mobility were strongly correlated with women’s empowerment at different income levels and with educational status (p<0.05). Economic access was improved with increased levels of empowerment. Decision-making and mobility were also gradually increased with higher levels of empowerment. Qualitative findings were also in favor of socioeconomic disparity in gender awareness and women’s empowerment in rural area. Women were confused about some issues of gender equity. Women accepted their empowerment crisis in silence to avoid familial disharmony. Although women were showing progress in relation to gender awareness, women’s empowerment was too hard to describe in the rural context. Gender awareness alone was not enough to empower rural women. The social configuration was another major concern in women’s empowerment along with male dominancy.

DISCUSSION This research was conducted to explore the socioeconomic disparity in women’s empowerment and gender awareness in rural areas of Bangladesh. Through this research it was discovered that women’s empowerment remained challenging in patriarchal structures. Age, income, religion, family size, parity etc. showed

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occasional similarities to the national findings in the Bangladesh Health and Demographic Survey (BDHS) of 2011, and, in a few cases, differed due to regional variation or due to the study process. Early marriage was a common scenario in rural communities and it was slightly higher in this study in comparison to the BDHS of 2011. Among the respondents, more than 82% had a history of early marriage and even in the 20-24 years age group the percentage of early marriage was 78.4 which was little bit high in comparison to the recent BDHS. Social security was a major concern in marriage before maturity. Early marriage was not uncommon even in educated and economically stable families in rural areas. It was also explained in a previous study by Parveen & Leonhäuser (2004) done in the same Upazila. Bangladesh is progressing day by day in women’s education. Despite this progress, women’s empowerment is still hard for most rural women to grasp and put belief in. Among the respondents of this study, only approximately 32% were well empowered, with the majority being in the poor empowerment group. These results were slightly better than the previous study findings of Parveen. Like many other studies have found, education was in a significant state with women’s empowerment. Early marriage was also a major concern with regards to women’s empowerment. Personal income showed a significant relation and provided a strong argument for creating more work opportunities for rural women to empower themselves as in other studies. Role of employment was found to be significant in a recent study by Sultana & Hossen (2013) done in Khulna division of Bangladesh. Economic access, household decision-making and mobility were in strong correlation with women’s empowerment but mobility was still restricted in the study of Parveen & Leonhäuser. Even in the cases where women were aware of gender equality, they were not necessarily in an empowered position, and it was complicated to describe empowerment to them in a way that was accessible, which was similar to findings in the study of Jejeebhoy, et al. in 2002. Rural women were confused about their empowerment in most of the cases. Sometimes they were happy with their current statuses, and, in a few cases, they were demanding more empowerment. Acceptance of dowry, undervaluation and gender inequity were still accepted silently to avoid familial disharmony; this result mirrored findings from a recent study in the Muslim community of Murshidabad (Kundu & Chakraborty, 2012). Social security was an added issue with male dominancy in the crisis of women’s empowerment, and it was commonly found to be an issue in many studies related to women’s status in the Indian sub-continent (Kishor & Gupta 2004, Roy & Tisdell, 2002)

CONCLUSIONS Women living in rural locations are without a doubt the most common victims of gender discrimination, and socioeconomic disparity makes the gap more prominent and highlights the women’s empowerment crisis. Rural women are not well aware about their empowerment, which allows the already male-dominant society greater ability to control and disempower these women, making them even more vulnerable. Gender equity has the ability to upgrade women’s situations in both their familial and social lives, especially in third world countries like Bangladesh. Without improving their socioeconomic status, rural women will not be able to fully realize actual empowerment. The Bangladeshi government should take urgent actions to minimize the gap of socioeconomic disparity to empower rural women to improve their current status and make them more participatory in the development.

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REFERENCES Al-Hossienie, C. A. 2011. Socio-Economic Impact of Women Entrepreneurship in Sylhet City, Bangladesh. Bangladesh Development Research Working Paper Series (BDRWPS). Bangladesh Demographic and Health Survey Report, 2011. Ministry of Health and Family Welfare, Bangladesh Chen, M., Mahmud, S. 1995. BRAC-ICDDR,B Joint Research Project Working Paper No 2. Dhaka, Bangladesh: Assessing change in women’s lives: A conceptual framework. Goetz, A.M. & Gupta, R.S. 1996.Who takes the credit? Gender, power, and control over loan use in rural credit programs in Bangladesh. World Development; 24(1):45–63. Haque, M.M., Islam, T.M., Tareque, M.I.&Mostofa, M.G..2011. Women Empowerment or Autonomy: A Comparative View in Bangladesh Context. Bangladesh e-Journal of Sociology, 8-17. The International Fund for Agricultural Development (IFAD). 2013. Annual Report on Results and Impact of IFAD Operations (ARRI). IFAD, United Nations, 2014. Available at: http://www.ifad.org/evaluation/arri/2013/index.htm (Accessed on 18/11/2015) Jejeebhoy, S.J. 2002. Women’s autonomy in rural India: Its dimensions, determinants, and the influence of context. In: Presser, HB.;Sen, G., editors. Women’s Empowerment and Demographic Processes: Moving Beyond Cairo. Vol. Chapter 9. New York: Oxford University Press; p. 204-238. Kabeer, N. 1999. Resources, Agency, Achievements: Reflections on the Measurement of Women’s empowerment. Development and Change, 30:35–464. Kabeer, N. 2001. Conflicts over credit: Re-evaluating the empowerment potential of loans to women in rural Bangladesh. World Development, 29(1):63–84. Kishor, S. & Gupta, K. 2004. Women’s empowerment in India and its States: Evidence from the NFHS. Economic and Political Weekly. 39(7):694–712. Kundu K. & Chakraborty, A. 2012.An Empirical Analysis of Women Empowerment within Muslim Community in Murshidabad District of West Bengal, India. Research on Humanities and Social Sciences. ISSN 2224-5766(Paper) ISSN 2225-0484(Online) Vol.2, No.6 Mahmud, S., Shah, N.M. & Becker, S. 2012. Measurement of Women’s Empowerment in Rural Bangladesh. World Dev. 2012 March 1; 40(3): 610–619. Malhotra, A. & Schuler, S. 2005. Women’s empowerment as a variable in international development. In: Narayan-Parker, D., editor. Measuring empowerment: Cross-disciplinary perspectives. Vol. Chapter 3. Washington, DC: World Bank; p. 71-88. Mosedale, S. 2005. Assessing women’s empowerment: towards a conceptual framework. Journal of International Development.; 17(2): 243 – 257. Parveen, S. & Leonhäuser, I. 2004.Empowerment of Rural Women in Bangladesh - A Household Level Analysis. Conference on Rural Poverty Reduction through Research for Development and Transformation. 5-7 October 2004, Berlin: Deutscher Tropentag. Roy, K.C. & Tisdell C.A. 2002 Property rights in women’s empowerment in rural India: a review. International journal of social economic, 29 (4): 315-334. Schuler, S.R & Rottach, E. 2010. Women’s Empowerment across Generations in Bangladesh. J Dev Stud, 46(3): 379–396. Sultana, A. and S. S. Hossen (2013). Role of employment in women empowerment: Evidence from Khulna City of Bangladesh. International Journal of Social Science and Interdisciplinary Research 2(7): 117-125. 4th International Conference on New Voices, 4 March 2016 |

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Maternal and Neonatalcomplications of Teenage Pregnancy at Justice Jose Abad Santos General Hospital, Manila, Philippines Lorelina F. Viana1, Vandita Rajesh1, Nitaya Vajanapoom1 1

School Of Global Studies, Thammasat University, Pathumthani, Thailand

ABSTRACT Background: Globally, adolescent pregnancy is an important social and public health issue. It is a symptom of dire economic and social conditions that perpetuates the cycle of poverty and inequality. Fifteen percent of the Global Burden of Disease is the result of maternal conditions and 13% results from maternal deaths. There are 17.4 million adolescent mothers aged 15 to 19 years in the South East Asian Region (SEAR). The Philippines has the highest rate of adolescent pregnancies in the ASEAN Region. This study focused on births in a free, public access tertiary care Hospital that serves referral patients, and walk-ins with a similar socioeconomic background from a small geographical catchment area. Objective: To determine if there are more maternal and neonatal complications associated with adolescent pregnancies than in adult primigravida mothers. Method: A cross-sectional study was conducted at the Department of Obstetrics and Gynecology of Justice Jose Abad Santos General Hospital (JJASGH). A sample size of 615 out of 945 deliveries was drawn from primigravida women aged 15-35; 307 were aged 15-19 years (adolescents) and 308 aged 20-35 years (adult) mothers with complete data from January 1 to December31, 2013. The convenience sampling strategy was used for data collection. Results: The prevalence of adolescent pregnancy in this study was 49.9%, which is five times higher than the National Prevalence. There was a significant difference in marital status between adolescent and adult mothers (p<0.001) that creates a large problem for social support for adolescent pregnancies and has a significant impact on management of more common complications among adolescent than adult pregnancies. There was a significant difference in educational status between the two groups (p<0.001). Among all maternal complications, preterm deliveries (p=0.03) and preeclampsia (p=0.02) have significant associations with the age of the pregnant woman. In addition, fetal distress (p=0.041) was significantly more common among adolescent mothers as compared to adult mothers. Adolescent pregnancies were also significantly associated with a higher prevalence of low birth weight (LBW) babies (p<0.05). The prevalence of stillbirth was significantly higher among adolescent mothers (p=0.007); observed to be five times higher in adolescent pregnancies as compared with adult pregnancies. Conclusion and recommendations: The results of this study reinforced the fact that a good outcome is rarely the result of adolescent pregnancy. However, adolescent pregnancy can always be prevented. Primary and secondary prevention strategies that are gender sensitive and adolescent friendly could be adopted to lower the prevalence of adolescent pregnancy.

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INTRODUCTION Adolescent pregnancy is one of the most important social and public health challenges globally. According to Demographic and Health Surveys (DHS) and Multiple Indicators Cluster Surveys (MICS) conducted in 2010 published in a UNFPA report, 17.4 million teenage mothers live in South Asia (Loaiza, 2013, p. 14) and complications from pregnancy and child birth are the leading cause of death among adolescent girls in this age group (WHO, 2013). Nearly one third of deaths among adolescent girls in South Asia are due to complications from pregnancy and child birth (WHO, 2014). Fifteen percent of the Global Burden of Disease is the result of maternal conditions and 13% results from maternal deaths (WHO, 2006). Amongst the six major economies in the Association of Southeast Asian Nations (ASEAN), the Philippines ranks as the third highest rate of adolescent pregnancies and the only country where the rate is increasing as per UNFPA report (Van der Hor, 2014). The rising prevalence of adolescent pregnancy is now a serious public health issue that confronts the Philippine Department of Health. Adolescents who are pregnant represent a high risk group because of the double burden of reproduction and growth on the adolescent girl, wherein the adolescent mother is still developing physically and mentally while pregnant with a baby (Talawar, 2013). Although it is well-known that adolescent pregnancy is associated with an increase in obstetric and neonatal complications (Mahfouz, 1995), there is a dearth of scientific research in the Philippines that compares the maternal and neonatal complications between the adolescent and adult pregnant mothers. This study aims to determine if there are more maternal and neonatal complications in adolescent than in adult primigravida mothers. This study focused only on one hospital in a small geographical area with people with the same social and economic background. The study examined the prevalence of adolescent pregnancy among 15-19 years old among hospital admissions and compared the maternal and neonatal outcomes of adolescent pregnancies with that of adult pregnancies at a tertiary care hospital in Manila, Philippines.

METHODOLOGY A cross-sectional study was conducted at the Department of Obstetrics and Gynecology, JJASGH, a Government referral free health care facility that caters to people from low socio-economic background and high risk groups. The data was obtained from the hospital’s patient records and labor room database. The study populations are the 15-35 years old primigravida women of which 15-19 years old are adolescent mothers and 20-35 years old are adult mothers. The study participants included all primigravida women ages 15- 35 with complete data from January 1 to December 31, 2013 and excluded those primigravida older than 35 y/o, primigravida 15-35 y/o with chronic illnesses and primigravida 15-35 y/o maternal deaths during deliveries at JJASGH. The study sample size was 615 out of 945 deliveries from primigravida women of which 307 were adolescent and 308 were adult pregnant mothers. All statistical analysis was performed using the SPSS computer software (SPSS Version 16 for Microsoft Windows, SPSS Inc., Chicago, USA). Prevalence of adolescent pregnancy was presented using frequency tables along with the percentage. The association between the independent variables and the dependent variables were examined using bivariate analysis. Hypothesis testing using T-test and chi-square were carried out to compare the maternal and neonatal complications between adolescent and adult pregnancy. Prevalence odds ratio and 95% Confidence Interval (CI) was calculated to examine the links between teenage pregnancy with maternal and neonatal complications. Independent variables that indicated a significant bivariate association were included in the analysis and results were considered to be statistically significant at p-value ≤ 0.05 or confidence limits which did not embrace unity.

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RESULTS Demographic characteristics Table 1 shows the demographic characteristics of both adolescent and adult primigravida mothers. Among the eligible 615 deliveries, 49.9% were adolescent pregnancies and 50.1% were adult pregnancies who are primigravidas recorded in the labor registry. There was a significant difference in marital status between adolescent and adult mothers (p<0.001); more adolescent mothers were single 245(79.8%), and a significant number were ‘unmarried’ (4.2%). There was a significant difference (p<0.001) in the educational status between the two groups. Adult mothers had better educational status as compared to adolescent mothers. A total of 129(42%) adolescent mothers visited antenatal care less than 4 times, antenatal uptake was marginally higher among adolescent mothers compared to adult mothers [227(74%) versus 223(72%)] (p=0.048). Normal spontaneous delivery was significantly higher among adult mothers than among adolescent mothers [159(51.8%) versus 127(41.4%)] (p=0.012). Table 1: Summary of demographic characteristics and descriptive statistics (N=615) Variables Age Marital status Single Married Live in Educational Status No formal education Primary education Secondary education College graduate Antenatal visits No antennal visit Visit < 4 times Visit ≥ 4 times Method of delivery Normal spontaneous delivery Operative vaginal delivery Caesarian delivery Other method of deliveries

Teenage pregnancy n (%) 307(49.9)

Adult pregnancy n (%) 308 (50.1)

245(79.8) 13(4.2) 49(16. 0)

186(60.4) 99(32.1) 23(7.5)

15(4.9) 74(24.1) 218 (71. 0) 0 (0. 0)

3(1. 0) 38(12.3) 229(74.4) 38(12.3)

80(26.1) 129(42. 0) 98(31.9)

85(27.6) 104(33.8) 119(38.6)

127(41.4) 123(40.1) 53 (17.3) 4(1.3)

159(51.8) 106(34.5) 41(13.4) 1(0. 3)

P-value

<0.001**

<0.001**

0.048*

0.012*

*Association significant at <0.05 **Association is statistically significant at <0.01

Table 2 presents the average gestational age of teenage and adult mothers. The average gestational ages for teenage and adult mothers were 38.0 (± 2.8) and 38.4 (±1.9) weeks respectively and there was a significant difference between mean gestational ages of teenage mothers when compared to that of the adult mother (p=0.04).

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Table 2: Average gestational age using T-test

Gestational age

Age in years

N

Mean

Teenage Adult

307 308

38.046 38.425

Std. Deviation 2.80951 1.91453

Std. Error Mean 0.160 0.109

P-value 0.04*

*Association significant at <0.05 **Association is statistically significant at <0.01

Comparison of maternal complications among adolescent and adult pregnancies Table 3 shows the summary of obstetric complications of both adolescent and adult primigravida mothers. Among all maternal complications preterm labor, preeclampsia and fetal distress were significantly higher among adolescent primigravida mothers compared to adult primigravida mothers. The prevalence of preterm labor was found to be significantly higher among adolescent pregnancy as compared to adult pregnancy [55 (17.9%) versus 36 (11.7%)]; [OR, 1.65; 95% CI, 1.05-2.59; p=0.03]. Adolescent mothers were found to be almost two times more likely to suffer from preterm labor as compared to adult mothers. The prevalence of preeclampsia among adolescent pregnancy was significantly higher [29(9.4%)] as compared to the prevalence of preeclampsia among adult pregnancy [14(4.5%)], [OR, 2.19; 95% CI, 1.13-4.23; p=0.02]. Adolescent mothers were found to be almost two times more likely to suffer from preeclampsia as compared to adult mothers. Only a few mothers reported fetal distress but fetal distress was significantly more common among adolescent mothers as compared to adult mothers [41(13.4%) versus 26(8.4); OR, 1.67; 95% CI, 0.99-2.81; p=0.041]. Adolescent pregnant mothers are vulnerable to have fetal distress as a pregnancy complication. The proportion of cephalo-pelvic disproportion (CPD), premature rupture of the membrane (PROM) and multiple gestations are found to be higher among adolescent mothers than among adult mothers; however, the prevalence of these last mentioned maternal complications was not significantly different between the two groups. There was no significant difference in the proportion of breech presentation among adolescent [16 (5.2)] and adult mothers [44(14.3%)], [OR, 1.16; 95% CI, 0.55-2.41; p=0.07]. Very few mothers were anemic and the difference in the proportion of anemia among adolescent and adult mothers was not statistically significant [OR, 1.14; 95% CI, 0.57-2.27; p=0.72], though the number of anemic adolescents (18 [5.9%]) was slightly higher than anemic adult women (16 [5.2%]). The prevalence of other pregnancy complications (placenta previa, post-partum hemorrhage, multiple gestation, gestational hypertension and post-partum depression) for an adolescent mother is 41 (13.3%) compared to adult mothers 24 (7.8%). The other pregnancy complications did not significantly differ between the two groups [OR, 1.96; 95% CI, 0.56-9.15; p=0.85], though, again, teenage mothers have greater chance of developing other maternal complications compared to adult pregnant mothers.

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Table 3: Comparison of maternal complications among adolescent and adult pregnancies (N=615) Complications Preterm labor CPD Anemia Fetal Distress PROM Breech Presentation Preeclampsia Other maternal complications

*Association significant at <0.05

Teenage n=307 (%) 55(17.9) 20(6.5) 18(5.9) 41(13.4) 49(16.0) 16 (5.2) 29(9.4) 41(13.3)

Adult n=308 (%) 36(11.7) 18(5.8) 16(5.2) 26(8.4) 44(14.3) 14(4.5) 14(4.5) 24(7.8)

OR

95% CI

P-value

1.65 1.12 1.14 1.67 1.14 1.16 2.19 1.96

1.05 – 2.59 0.58 – 2.17 0.57 – 2.27 0.99 – 2.81 0.73 – 1.77 0.55 – 2.41 1.13 – 4.23 0.56 – 9.15

0.03* 0.73 0.72 0.041* 0.56 0.07 0. 02* 0. 85

**Association is statistically significant at <0.01

Comparison of neonatal complications between adolescent and adult mothers Table 4 summarizes the comparison of neonatal complications between adolescent and adult mothers. The proportion of LBW babies was higher in adolescent mothers [88(28.7%)] as compared to adult mothers [67(21.8%)]. The prevalence of LBW babies was found to be nearly two times higher in adolescent pregnancies than in adult pregnancies [OR, 1.45; 95% CI, 1.00-2.09; p<0.05). The prevalence of stillbirth was significantly higher among adolescent mothers 14(4.6%) than among adult mothers 3(0.9%), [OR, 4.86; 95% CI, 1.38-17.08; p=0.007]. Moreover, the proportion of stillbirth was observed to be over five times higher in adolescent pregnancies as compared with adult pregnancies. An Apgar score less than 7 at one minute was not statistically significant [OR, 1.27; 95% CI, 0.86-1.87; p=0.22] between adolescent and adult mothers; the same was true of the difference between the two groups for the five minute Apgar score less than 7 [OR, 1.46; 95% CI, 0.91-2.34; p=0.12]. The prevalence of low Apgar scores at both 1 and 5 minutes was observed to be higher in adolescent pregnancies as compared to adult pregnancies. Table 4: Comparison of neonatal complications among teenage and adult mothers (N=615) Neonatal complications Low Birth weight Stillbirth Apgar score 1 min < 7 Apgar score 5 min < 7

Teenage n=307 (%) 88(28.7) 14(4.6) 71(23.1) 47(15.3)

*Association significant at <0.05 **Association is statistically significant at <0.01

Adult n=308 (%) 67(21.8) 3(0.9) 59(19.2) 34(11.0)

OR

95% CI

P-value

1.45 4.86 1.27 1.46

1.00 – 2.09 1.38 – 17.08 0.86 – 1.87 0.91 – 2.34

0.04** 0. 007** 0.228 0.124

DISCUSSION The prevalence of adolescent pregnancy from this study was found to be 49.9% which is more than the prevalence reported in other regions of the Philippines, e.g., Caraga (38%) and Cagayan Valley (37%), and more than the recent National Demographic and Health survey that reported the prevalence of adolescent pregnancy as 10% in Philippines (Philippine Statistics authority, 2014). One reason for the higher prevalence of adolescent pregnancy in this study is the fact that the study was conducted in a tertiary care

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community hospital that accepts both referrals and walk-ins from the coummunity. The high proportion of people served by this hospital are poor and with no formal education. This is a possible reason for poor access of adolescents to sexual and reproductive health service and as mothers, to maternal health services (Raj, 2010). A higher prevalence of adolescent patients, either from the community or referred because of complications, may have a significant effect on measures of early pregnancy and unintended pregnancy in this region. The majority of the mothers were single with more adolescent mothers unmarried than adult mothers. This may create a problem for social support for adolescent pregnancies with a significant impact on maternal complications, more than for adult pregnancies. This has previously been noted by other researchers (Harden et al., 2009; Turner et al., 1990) and is noted in other studies (Chen et al., 2007; Feldman et al., 2000; Omar et al., 2010), which found a significant difference in marital status between the two groups. Significantly, more adolescent mothers reported no formal schooling as compared to adult mothers. The significant impact of no formal education is that it can lead to more adolescent pregnancies and maternal complications. These results were consistent with other studies (Anjum, 2011; Dangal, 2006; Isaranurug, 2006; Mukhopadhyay et al., 2010; Watcharaseranee, 2006) which found lower literacy levels among adolescent mothers than adult mothers. However, contrary to the study findings, a study in India and Pakistan (Mahavarkar et al., 2008; Shah et al., 2011) showed no significant difference between educational level and age of pregnancy. A study in the United States (Stanger-Hall & Hall, 2011) found that adolescents who had been taught sex education and abstinence at the school achieved higher educational attainment than their counterparts. Low socio-economic status is one of the reasons of adolescent mothers do not have access to formal education (Boden et al., 2008). The uptake of antenatal care services was slightly lower among pregnant adolescents as compared to adult pregnancies; less social support and no formal education have contributed to this finding. Similar views were echoed in other studies done in Asia (Anjum, 2011; Conde-Agudelo et al., 2005; Mukhopadhyay et al., 2010; Omar et al., 2010; Reynolds, 2006), which reported poor levels of antenatal visits among pregnant adolescents as opposed to adult pregnancies. These results were expected since pregnant adolescents often have less education and have limited information on how and where to seek help regarding antenatal care. Thus antenatal care is often delayed or inadequate (Gharoro, 2002). In addition, adolescent mothers may lack the intellectual and emotional maturity needed to provide for another life, consequently pregnancies are often hidden from others for months, resulting in a lack of adequate prenatal care and dangerous outcomes for the babies (Saba, 2013). Generally, adolescent girls have limited knowledge about their own physical development and they often delay or are afriad to reveal their pregnancy to others, even those who may be able to provide assistance and guidance (Dangal, 2006). In addition, reproductive health services are mostly designed for adults and often deter adolescent from getting the services vital to their health and well-being of their child. To exacerbate the situation, most health workers are inadequately trained in dealing with adolescents. However, in developing countries other studies have not found significant differences in the uptake of antenatal care services between adolescent and adult mothers (Simkhada et al., 2008). The greatest driving force for this inconstency may be attributed to the unenforced, unclear, and contradictory sexual and reproductive policies. Moreover, lack of social support among adolescent mothers may have contributed to the inconsistenty of study findings (Saba, 2013).

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There are significant differences in the method of delivery between the adolescent and adult mothers. The study found a higher prevalence rate of operative vaginal delivery and a slightly lower prevalence rate of normal spontaneous delivery among adolescent mothers. A study done in Jordan and India (Mahavarkar, et al., 2008; Ziadeh, 2001) echoed the same results as the findings from the present study. In this study, among all maternal complications, preterm labor, preeclampsia and fetal distress was found to be the most common obstetric complications of adolescent pregnancy. The study finding was consistent with other studies, which found that adolescent mothers were significantly more likely to develop the above mentioned common obstetric complications. (Kovavisarach et al., 2010; Talawar, 2013; Whitworth & Cockerill, 2010). The reason for higher prevalence of these common complications of adolescent pregnancy may be explained by poor quality of antenatal care and delay in identification of obstetric complications. In addition, the lack of formal education is associated in some studies with poor nutrition of adolescent mothers, less knowledge on where and how to seek help and low socio-economic status. However, while this study finding is comparable with other studies (Mahavarkar et al., 2008; Paranjothy et al., 2009; Thaithae & Thato, 2011), it is contrasted with the findings of a study in Pakistan (Shah et al., 2011), which found no significant difference between the two groups. In addition, the higher prevalence of fetal distress can be attributed to higher proportion of CPD among teenage mothers (Yasmin et al., 2014). However, a few studies contradict the afore-mentioned studies (Chan et al., 2007; Rasheed et al., 2011; Watcharaseranee, 2006). Although there was no significant difference, the study found that CPD was more prevalent in adolescent mothers than in adult mothers. This was not unexpected since young adolescent mothers have underdeveloped pelvises because of their physical immaturity. The pelvis develops fully only when a girl has attained her full stature. If an adolescent girl gets pregnant, she may develop CPD during labor and subsequently obstructed labor. This may lead to fetal and maternal death if appropriate health service intervention is not rendered in a timely manner. This similar theory has been echoed with other studies (Jolly et al., 2000; Watcharaseranee, 2006) and they reported two-fold increase in CPD among adolescent mothers compared to adult mothers. There was no significant difference in prevalence of anemia and the age of pregnancy, however adolescent pregnances had a slightly higher proportion of anemia when compared to adult pregnancies. This may be anticipated since their physical immaturity may be over-burdened by the demands of pregnancy. Adolescent mothers who are still growing compete for nutrients with the developing fetus resulting in iron deficiency (Whitworth & Cockerill, 2010). A reason for the inconsistent results on this subject may have been caused by the small sample size which had an effect on the precision of the research findings. The proportion of PROM in this study was found to be slightly higher among adolescent pregnancies than in adult pregnancies though the difference is not statistically significant. Although the cause is unknown, it could be hypothesized that the increase of PROM rate is attributed to lack of pregnancy counselling, especially if expectant mothers have a uterine infection, or infections of the, vagina and cervix, too much stretching of the amniotic sac, smoking, and nutritional deficiency (especially vitamins, iron and zinc). There was no significant difference between breech presentation and age of pregnancy. This was replicated by other studies (Dye et al., 1995; Gould et al., 1990; Jadoon et al., 2008). However, there are some studies that disagreed with these findings (Jolly et al., 2000; Kovavisarach et al., 2010), which reported a significant difference in breech presentation between adolescent pregnancies compared to adult pregnancies. The prevalence of other maternal complications such as post-partum hemorrhage (PPH), multiple gestation, gestational hypertension, post-partum depression, and placenta previa were not significantly different be-

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tween adolescent and adult pregnancies. However, other study findings (Usta et al., 2008; Watcharaseranee, 2006) reported higher rates of placenta previa and post-partum hemorrhage (PPH) in adolescent mothers than among adult mothers. Adolescent pregnancies were significantly associated with higher prevalence of low birth weight babies. Adolescent mothers were nearly two times more likely to have low birth weight babies. This was contradictory and debated in various studies. Some studies reported low birth weight babies as a result of adolescent pregnancy (Chen et al., 2007; Liabsuetrakul, 2012; Watcharaseranee, 2006). Yet, other studies (Smith, 2001; Talawar, 2013) found no significant difference in prevalence of low birth weight between adolescent and adult mothers. The reason for this conflicting and inconsistent finding can be possibly explained by the observed higher prevalence of pre-term labor and poor nutrition. The age and physical development of the pregnant adolescent is likely a factor in the delivery of smaller babies with low birth weight. In this study, stillbirth was significantly associated with age of pregnancy. Adolescent mothers were more than four times more likely to have a stillborn baby compared to adult mothers. Preeclampsia can cause fetal deaths. Pregnant adolescent are prone to develop preeclampsia, which can lead to early labor, which, when the baby is not viable will lead to fetal death (Hutcheon et al., 2011). Generally, adolescent mothers and primigravida are vulnerable to intrauterine fetal death. Similar views were echoed by different studies in different areas (Andersen et al., 2000; Smith & Pell, 2001). A study done in Mozambique and Thailand, (Bacci et al., 1993; Kovavisarach et al., 2010; Mukhopadhyay et al., 2010) found that stillbirth rate is significantly higher among adolescent mothers as compared to adult counterparts. It is necessary to note that stillbirth comes from many causes and adolescent pregnancy is only one of the risk factors.

CONCLUSION AND RECOMMENDATIONS The yielded results support the observation that there are few good outcomes of adolescent pregnancy for the mother or the baby. However, adolescent pregnancy can always be prevented. Primary prevention strategies that could be adopted to lower the prevalence of adolescent pregnancy includes provision of comprehensive sexual education curriculum, increase awareness on policies and laws eliminating child marriage, and keeping girls in school. In addition, secondary prevention strategies that could be adopted to lower the prevalence of adolescent pregnancy and the complications associated with it include awareness of the most common complications of adolescent pregnancy by promoting utilization of antenatal care and family planning services, provide a fair and equal access to quality information on sexual and reproductive health services that are gender-sensitive and adolescent friendly and provide a comprehensive access to birth control.

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Aviram, A., Raban, O., Melamed, N., Hadar, E., Wiznitzer, A., & Yogev, Y. (2013). The association between young maternal age and pregnancy outcome. J Matern Fetal Neonatal Med, 26(15), 1554-1558. do i:10.3109/14767058.2013.794212 Bacci, A., Manhica, G., Machungo, F., Bugalho, A., & Cuttini, M. (1993). Outcome of teenage pregnancy in Maputo, Mozambique. International Journal of Gynecology & Obstetrics, 40(1), 19-23. Boden, J. M., Fergusson, D. M., & John Horwood, L. (2008). Early motherhood and subsequent life outcomes. Journal of Child Psychology and Psychiatry, 49(2), 151-160. Burrows, L. J., Meyn, L. A., & Weber, A. M. (2004). Maternal morbidity associated with vaginal versus cesarean delivery. Obstetrics & Gynecology, 103(5, Part 1), 907-912. Chan, A., Scott, J., Nguyen, A.-M., Sage, L., Unit, P. O., & Branch, E. (2007). Pregnancy Outcome in South Australia. Government of South Australia, editor. Pregnancy Outcome (Statistics) Unit SH. Adelaide: Pregnancy Outcome Unit Epidemiology Branch, Department of Human Services. Chen, X.-K., Wen, S. W., Fleming, N., Demissie, K., Rhoads, G. G., & Walker, M. (2007). Teenage pregnancy and adverse birth outcomes: a large population based retrospective cohort study. Int J Epidemiol, 36(2), 368-373. Conde-Agudelo, A., Belizán, J. M., & Lammers, C. (2005). Maternal-perinatal morbidity and mortality associated with adolescent pregnancy in Latin America: Cross-sectional study. American journal of obstetrics and gynecology, 192(2), 342-349. Dangal, G. (2006). Teenage Pregnancy: Complexities and Challenges. Review Article, Vol. 45 262-272 Dye, T. D., Tolliver, N. J., Lee, R. V., & Kenney, C. J. (1995). Violence, pregnancy and birth outcome in Appalachia. Paediatric and Perinatal Epidemiology, 9(1), 35-47. Feldman, P. J., Dunkel-Schetter, C., Sandman, C. A., & Wadhwa, P. D. (2000). Maternal social support predicts birth weight and fetal growth in human pregnancy. Psychosomatic Medicine, 62(5), 715-725. Gharoro, E., & Igbafe, A. (2002). Maternal Age at First birth and Obstetric Outcome. Nigerian Journal of Clinical Practice, Vol. 5 (1), 20-23. Gould, J. B., Davey, B., & Stafford, R. S. (1990). Socioeconomic differences in rates of cesarean section. Obstetrical & Gynecological Survey, 45(1), 54-55. Harden, A., Brunton, G., Fletcher, A., & Oakley, A. (2009). Teenage pregnancy and social disadvantage: systematic review integrating controlled trials and qualitative studies. BMj, 339, b4254. Hutcheon, J. A., Lisonkova, S., & Joseph, K. S. (2011). Epidemiology of pre-eclampsia and the other hypertensive disorders of pregnancy. Best Practice & Research Clinical Obstetrics & Gynaecology, 25(4), 391-403. doi:10.1016/j.bpobgyn.2011.01.006 Isaranurug, S. M.-s., L., & Choprapawon, C. (2006). Differences in Socio-economic Status, Service Utilization, and Pregnancy Outcomes Between Teenage and Adult Mothers. e-Journal: http://www. medassocthai.org/journal, Vol. 89 (No. 2 2006). Jadoon, S., Khan Jadoon, S., & Shah, R. (2008). Maternal and neonatal complications in term breech delivered vaginally. J Coll Physicians Surg Pak, 18(9), 555-558. Jolly, M., Sebire, N., Harris, J., Robinson, S., & Regan, L. (2000). Obstetric risks of pregnancy in women less than 18 years old. Obstetrics & Gynecology, 96(6), 962-966. Keskinoglu, P., Bilgic, N., Picakciefe, M., Giray, H., Karakus, N., & Gunay, T. (2007). Perinatal outcomes and risk factors of Turkish adolescent mothers. J Pediatr Adolesc Gynecol, 20(1), 19-24. Kovavisarach, E., Chairaj, S., Tosang, K., Asavapiriyanont, S., & Chotigeat, U. (2010). Outcome of teenage pregnancy in Rajavithi Hospital. Medical journal of the Medical Association of Thailand, 93(1), 1.

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Kramer, M. S., Goulet, L., Lydon, J., Séguin, L., McNamara, H., Dassa, C., . . . Genest, J. (2001). Socio‐economic disparities in preterm birth: causal pathways and mechanisms. Paediatric and Perinatal Epidemiology, 15(s2), 104-123. Kramer, K. L., & Lancaster, J. B. (2010). Teen motherhood in cross-cultural perspective. Ann Hum Biol, 37(5), 613-628. doi:10.3109/03014460903563434 Kramer, M. S., Platt, R. W., Wen, S. W., Joseph, K. S., Allen, A., Abrahamowicz, M., . . . Breart, G. (2001). A New and Improved Population-Based Canadian Reference for Birth Weight for Gestational Age. Pediatrics, 108(2), e35-e35. doi:10.1542/peds.108.2.e35 Kumbi, S., & Isehak, A. (1999). Obstetric outcome of teenage pregnancy in northwestern Ethiopia. East African medical journal, 76(3), 138-140. Lao, T. T. H., L. F. (1998). Obstetric outcome of teenage pregnancy. Medical Journal, vol.13 (No. 11), 3228– 3232. Liabsuetrakul, T. (2012). Trends of Teenage Pregnancy and Pregnancy Outcome. Thai Journal of Obstetrics and Gynaecology Vol. 20, pp 162-165. Loaiza, E., & Liang, M. (2013). ADOLESCENT PREGNANCY: A Review of the Evidence. 14. Mahavarkar, S. H., Madhu, C. K., & Mule, V. D. (2008). A comparative study of teenage pregnancy. J Obstet Gynaecol, 28(6), 604-607. doi:10.1080/01443610802281831 Mahfouz, A., El-Said, M., Al-Erian, R., & Hamid, A. (1995). Teenage Pregnancy: are Teenagers a High Risk Group? European Journal of Obstetrics & Gynecology and Reproductive Biology, Vol. 59 17-20 Mukhopadhyay, P., Chaudhuri, R., & Paul, B. (2010). Hospital-based perinatal outcomes and complications in teenage pregnancy in India. Journal of health, population, and nutrition, 28(5), 494. Omar, K., Hasim, S., Muhammad, N. A., Jaffar, A., Hashim, S. M., & Siraj, H. H. (2010). Adolescent pregnancy outcomes and risk factors in Malaysia. International Journal of Gynecology & Obstetrics, 111(3), 220-223. Paranjothy, S., Broughton, H., Adappa, R., & Fone, D. (2009). Teenage pregnancy: who suffers? Archives of disease in childhood, 94(3), 239-245. Philippine Statistics Authority. (2014). One in Ten Young Filipino Women Age 15 to 19 Is Already A Mother or Pregnant With First Child (Final Results from the 2013 National Demographic and Health Survey). Retrieved from Philippines: https://psa.gov.ph/content/one-ten-young-filipino-womenage-15-19-already-mother-or-pregnant-first-child-final-results Raatikainen, K., Heiskanen, N., Verkasalo, P. K., & Heinonen, S. (2006). Good outcome of teenage pregnancies in high-quality maternity care. The European Journal of Public Health, 16(2), 157-161. Raj, A., Rabi, B., Amudha, P., & Glyn, C. (2010). Factors associated with teenage pregnancy in South Asia, a systematic review. Health Science Journal, vol. 4(ISSUE 1 ), 3-14. Rasheed, S., Abdelmonem, A., & Amin, M. (2011). Adolescent pregnancy in upper Egypt. International Journal of Gynecology & Obstetrics, 112(1), 21-24. Reynolds, H., Wong, E., & Tucker, H. (2006). Adolescents Use of Maternal and Child Health Services in Developing Countries. International Family Planning Perspectives, Vol. 32, 6-16. Saba, N., Hamayun, M., & Bilal, M. (2013). Out Come of Teenage Pregnancy. Biomedica, Vol. 29. Shah, N., Rohra, D. K., Shuja, S., Liaqat, N. F., Solangi, N. A., Kumar, K., . . . Khan, N. (2011). Comparision of obstetric outcome among teenage and non-teenage mothers from three tertiary care hospitals of Sindh, Pakistan. JPMA-Journal of the Pakistan Medical Association, 61(10), 963.

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Shrestha, S. (2002). Socio-cultural factors influencing adolescent pregnancy in rural Nepal. International journal of adolescent medicine and health, 14(2), 101-110. Simkhada, B., Teijlingen, E. R. v., Porter, M., & Simkhada, P. (2008). Factors affecting the utilization of antenatal care in developing countries: systematic review of the literature. Journal of advanced nursing, 61(3), 244-260. Smith, G. C., & Pell, J. P. (2001). Teenage pregnancy and risk of adverse perinatal outcomes associated with first and second births: population based retrospective cohort study. BMj, 323(7311), 476. Stanger-Hall, K. F., & Hall, D. W. (2011). Abstinence-only education and teen pregnancy rates: why we need comprehensive sex education in the US. PLoS One, 6(10), e24658. Talawar, S., & Venkatesh, G. (2013). Outcome of Teenage Pregnancy. IOSR Journal of Dental and Medical Science (IOSR-JDMS), Volume 6(Issue 6), 81-83. Thaithae, S., & Thato, R. (2011). Obstetric and perinatal outcomes of teenage pregnancies in Thailand. J Pediatr Adolesc Gynecol, 24(6), 342-346. doi:10.1016/j.jpag.2011.02.009 Turner, R. J., Grindstaff, C. F., & Phillips, N. (1990). Social support and outcome in teenage pregnancy. Journal of Health and Social Behavior, 43-57. Usta, I. M., Zoorob, D., Abu-Musa, A., Naassan, G., & Nassar, A. H. (2008). Obstetric outcome of teenage pregnancies compared with adult pregnancies a. Acta Obstetricia et Gynecologica Scandinavica, 87(2), 178-183. Van der Hor, C. (2014, May 15, 2014, 12:07AM). Teenage pregnancy among today’s Filipino youth.PhilippineDaily Inquirer. Retrieved from http://opinion.inquirer.net/74517/teenage-pregnancy-among-todays-filipino-youth Ventura, S., & Hendershot, G. (1984). Infant Health Consequences of Child Bearing by Teenagers and Older Mother. Vol. 99(No. 2), 138-145. Watcharaseranee, N., Pinchantra, P., Piyaman, S. . (2006). The incidence and complications of teenage pregnancy at Chonburi Hospital. J Med Assoc Thai, Vol. 89(No. 4), 118-123. Whitworth, M., & Cockerill, R. (2010). Antenatal management of teenage pregnancy. Obstetrics, Gynaecology&Reproductive Medicine, 20(11), 323-328. doi:10.1016/j.ogrm.2010.08.003 WHO. (2006). Pregnant Adolescents: Delivering on Global Promises of Hope WHO.(2013).Childmarriages:39,000everyday.Retrievedfromhttp://www.who.int/mediacentre/ news/ releases/2013/child_marriage_20130307/en/ WHO.(2014).Maternalmortality[Pressrelease].Retrievedfrom http://www.who.int/mediacentre/factsheets/ fs348/en/ Yadav, S., Choudhary, D., Narayan K.C., Mandal, R., Sharma, A., Siddharth Singh Chauhan, S., & Agrawal, P. (2008). Adverse Reproductive Outcomes Associated With Teenage Pregnancy. McGill Journal of Medicine. Yasmin, G., Kumar, A., & Parihar, B. (2014). Teenage Pregnancy-Its Impact on Maternal and Fetal Outcome. Ziadeh, S. (2001). Obstetric outcome of teenage pregnancies in North Jordan. Archives of gynecology and obstetrics, 265(1), 26-29.

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Factors Enhancing Food Insecurity in East African Countries: A Case Study of Somalia Sharon Chipo Manzvera1 1 School Of Global Studies, Thammasat University, Pathumthani, Thailand

ACRONYMS AMISOM

African Union Mission in Somalia

FAO

Food and Agriculture Organization

FSNAU

Food Security and Nutrition Analysis Unit for Somalia

ICRC

International Committee of the Red Cross

IDP

Internally Displaced People

IGAD

International Authority on Development

LMIC

Low and Middle Income Countries

MDGs

millennium Development Goals

UN

United Nations

SHS

Sustainable Human Security

TFG

Transitional Federation Government

WFP

World Food Programme

WHO

World Health Organization

ABSTRACT Background: One of the most current significant discussions in public health and development is food security. The major contributing causes include natural and human factors like conflicts, climate changes and famine. Objectives: The purpose of this study is to examine factors that determine food security in Africa with special reference to war-torn Somalia. Both human and natural factors to include political hegemonies and climate change will be discussed at length. Materials and Methods: In analyzing the symbiotic relationship of the factors that enhance food insecurity in Somalia, a systematic review was conducted. Inclusion was used for documentary assessment, which involved journal papers and relevant reports, to explore the underlying causes of the food crisis in Somalia. Discussion: Despite efforts from the international community and donors in helping to alleviate food insecurity in Somalia, conflicts and climate change are critical factors that inhibit food production. An array of strategies has been noted through livelihood diversification, but it has not helped the situation; even remittances from abroad has done less. Results: The data collected from the literature review estimated that 731,000 people were in a state of food crisis with 202,600 children malnourished. Conclusion, governance issues, investment in technology, conflict management and early warning systems to avert climate change impacts should be taken as a priority. 4th International Conference on New Voices, 4 March 2016 |

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INTRODUCTION Food insecurity is increasingly recognized as a serious, worldwide developmental and public health concern that has contributed immensely to the failure to fulfill the Millennium Development Goals (MDGS) . Previous studies has shown that most countries in Africa are not food secure. According to the United States Agency for International Development (2015) food insecurity is a state in which, “regular access to sufficient food is limited due to lack of money, and struggle to avoid hunger as a result of lack of sustainable economic or physical access to nutritious, and socially acceptable food for a productive and healthy life.” Food insecurity may be seasonal, temporary or chronic, leading to malnutrition, which results to catastrophic amounts of human suffering. Taken together, the World Health Organization (2010) noted that more than 60% of childhood deaths in the low and middle-income countries (LMIC) are associated with malnutrition and chronic hunger. The predominant forms of violent conflict evolve from interstate, intra-state or civil wars to other forms of violence such as gangs, and rebels’ organized crime, ranging from civil conflict but also to urban unrest with no ideology (Reno, 2011). The drivers of conflicts include a wide range of factors and these include economic, political, environmental and social issues.

OBJECTIVES The purpose of this paper is to look at the factors that enhance food insecurity in Somalia by interrogating the linkages of underlying factors and the effectiveness of mitigatory and preventative factors.

MATERIALS AND METHODS: In analyzing the symbiotic relationship of the factors that enhance food insecurity in Somalia, a systematic review was conducted. Inclusion was used for documentary assessment, which involved journal papers and relevant reports, to explore the underlying causes of the food crisis in Somalia

RESULTS Regional perspective The Horn of Africa (East Africa) is one of the most food insecure regions globally, with more than 40% of its population undernourished. In Somalia and Eritrea, the percentage of malnourished people rises to 70%. In the seven countries in the region (Ethiopia, Kenya, Djibouti, Sudan, Eritrea, Uganda and Somalia), with a population of around 160 million, nearly half (around 70 million people) were prone to extreme food shortages in 1990s (FAO, 2001 and The Atlantic 2011). Subsequently, in 2011 more than 13.5 million in East Africa were affected by recurrent drought that emerged from the 1990s, reappeared in 2000-2001, in 2005-2006 and in 2008 and 2009. In the Region, Kenyans comprised 3.75 million victims of drought and in the Dollo Ado refugee camps in Ethiopia, 50% of children under 5 years were acutely malnourished (IFRC, 2011 and DeCapua, 2013). Thus, food crises affect children mostly since they are more vulnerable to various diseases due to shortage of adequate, balanced diets that support and enhance their rapid growth. Governance and conflict Somalia has been experiencing two decades of civil unrest since the downfall of the central government in 1991, and this has contributed to threats to livelihoods and food insecurity in the country. The ongoing conflict has severely upset communities’ abilities to manage the unrest and has restricted humanitarian

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access to the affected people. (World Bank, 2005). The capacity of localized systems of governance that have emerged in Somalia (which includes the semi-autonomous region of Puntland and self-declared independent Republic of Somaliland in the northern parts) is limited, which contributes to a tense security situation. This is, mainly in the Sanag and Sool administrative regions in the north because of the continuous border disputes between these two entities. Additionally, in central Somalia, the paramilitary group, Ahlu Sunna Waljama’a (ASWJ) is dominant and has managed to oust the al-Shabaab, Heeb, Galmudug and Himan state administrators from some parts of the country (World Bank, 2005). In southern Somali, al-Shabaab has been in control since 2008. However in August 2011 the group withdrew from Mogadishu because its influence had been diminishing due to the military offensive by the internationally supported Transitional Federation Government (TFG) group,, supported by the African Union Mission in Somalia (AMISOM) and the Ethiopian and Kenyan armies (International Crisis Group, 2011). Thus, the battle to control the state, which brings economic and political power, enhances the source of conflict yearly. In addition, the 2011 withdrawal of al-Shabaab led the TFG to be able to extend its controls to a majority of the capital (WHO, 2012). Such evidence supports the thesis that food insecurity has been enhanced by the absence of good governance, and that the experience with a poorly functioning state has resulted in mistrust towards the government, leading to continued conflicts. In addition, conflicts characterized by both low-intensity fighting over resources and also intense fighting in the south and central part of Somalia, where military conflicts between TFG and al-Shabaab intensified from 2010, have resulted in enormous population displacements as well as restrictions of markets and trade activities in some parts of Somalia (WHO,2012). This has affected markets and also the civil security condition in general. Although food security and nutrition improved due to al-Shabaab’s withdrawal between August 2011 and April 2012, a military TFG or AMISOM intervention to secure and control the Afgoye region in May 2012 resulted in at least 11,000 displaced people who moved towards Mogadishu, making it the largest Internally Displaced People (IDP) concentration in the world (WHO,2012). The escalation of conflicts in various parts of the country did not give farmers adequate time to prepare their land or to harvest their crops. Hence, there was an increase in the food crisis in the country. Tribal or clan conflicts also enhance food insecurity as there are two distinctive groups in Somalia. The Somalis constitute 85% of the nation’s inhabitants, which are organized into diverse clan groupings and sub-clans, whilst 15% constitute a minority of non-Somali ethnic group made up of Bantus, Britons, Italians, Persians, Bajunis, Pakistanis, Eyle, Indians and Ethiopians (Central Intelligence Agency, 2011). These minority groups are more affected by intense food insecurity than the majority group since they face major challenges in gaining access to government infrastructure and public services (WHO, 2012). For this reason, the marginalized groups suffer from multiple effects of food insecurity because of poor and unaccountable governance that continuously exclude them.

Political instability, food prices, famine and humanitarian access The ongoing interstate conflicts and insecurity has impeded humanitarian access in Somalia. In the parts that are controlled by al-Shabaab, mainly in southern Somalia, the ability of World Food Programme (WFP) in particular and humanitarian actors in general to operate is very limited. As a result, since early 2010, WFP has pulled out of southern Somalia and has never been in al-Shabaab controlled areas (WHO, 2012). This is because of direct attacks against the aid community between 1997 to 2012. The attacks were very high in 2008, due to the expansion of the al-Shabaab group in central and southern Somalia despite amplified international efforts to limit the influence of the group by labelling it a terrorist organization

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(WHO, 2012). In 2010 al-Shabaab group subsequently expelled as many as 20 agencies from its controlled areas, including the UN agencies (WHO, 2012). Inadequate humanitarian access thus further magnified the poor nutrition situation and food insecurity in southern Somalia, which was already the worst affected area by the food crisis. Somalia’s famine was a deadly combination of conflict, drought, an uncertain non-state response, and La Niña. Added to this, in 2012 the International Committee of the Red Cross (ICRC), which had not been banned by al-Shabaab, suspended its seed and food distributions to 1.1 million in southern Somalia after alleged reports of being blocked from distributing the commodities (ICRC, 2014). Political upheavals continue to expose marginalized people to food crisis. Consequently, Somalia is a fragile state, which is engulfed by the militant Islamic group al-Shabaab (which mostly targets foreigners),.clan-based violence, a virtually non-existent political structure, and piracy on its southern coast (ICRC, 2014). The political instability in the country enhances food insecurity. The 2011 famine resulted in more than 3.2 million people vulnerable and brought to the brink of starvation in Somalia, with more than 215,000 people displaced and seeking refuge in Kenya due to drought combined with conflict, state failure and insecurity (IFRC, 2011). About 3.7 million people in Somalia face a humanitarian crisis, with one in three children in Southern Somalia malnourished. The food aid coming to Somalia can only meet about 10% of the country’s needs (IFRC, 2011). Thus, the ongoing disputes hinder prospective donors and expose the majority of Somalian people, who are poverty stricken, to starvation due to inadequate food. Another factor that has caused high food insecurity in Somalia is the response failure, in which Somalia’s government and donors are unable to tackle the countries chronic poverty that has continuously increased the marginalization of vulnerable people and diminished their abiliby to cope (OXFAM, 2011). Given such evidence, Somalia will unceasingly face food crises that in-turn greatly affect human security as people do not have freedom from want, lacking a balanced diet of nutritious food due to political instability. In addition, late response by international donors to this humanitarian crisis has exposed many people to starvation and malnutrition. Because of reasons mentioned above, among others, the donors response has been inadequate and too slow, as the UN figured out that to alleviate Somalia’s food crisis US$ 1 billion was required to meet all immediate needs, yet the donors had only committed $200 million, leaving $800 million unfunded (OXFAM, 2011 AND United Nations 2011). For this reason, starvation, undernourishment and high mortality due to inadequate food supplies continue to increase in Somalia. Compared to other parts of the world, Somalia’s famine represents the most serious food insecurity in both severity and scale. Somalia was the first to be officially declared a country with famine in Africa in the 21st century, at a time when famine was eradicated everywhere else (OXFAM, 2011 and Operation USA, 2013).

Climate change and malnutrition During the 1980s there was a high prevalence of chronic malnutrition in Somalia, mainly in the southern part, measured by the frequency of Global Acute Malnutrition (GAM)1 . From 2006 forward, the nutrition catastrophe extended to almost all regions of southern and central Somalia. GAM occurrence surpassed 20% in parts of the Bakool and Gedo regions during the Gu (rainy season) in 2008 and has not receded since then (WHO, 2012). Thus food insecurity enhances malnutrition specifically to marginalized populations who do not have access to adequate health care. Moreover, WHO (2012) asserted that very serious ......................................................................................................... 1

Calculated as the proportion of children between 6-59 months with weight for height less than -2 Z scores.

Lower Juba thus the camel holder pastoralists and also the Shabelle regions (irrigated maize and various cash crops). 48

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levels of the GAM extended to most of the regions, and west of Shabelle river, upsetting both farming and pastoral communities and only short term and less development during the good Gu 2010 season in the Lower Juba thus the camel holder pastoralists and also the Shabelle regions (irrigated maize and various cash crops). For the past five years, there were two phases of increased SAM and GAM prevalence, and between the Gu 2008, 2009 and 2011 season, which was noticeable by declaration of famine in the southern part of Somalia (WHO, 2012). These peaks match with major food security shocks, namely the 2008 food prices increase on the international markets and soaring fuel prices, and severe drought compounded by restrictions of humanitarian access and the ongoing conflict in southern Somalia (WHO, 2015). Therefore, severe food security shocks and famine have effects on the nutrition situation because of synergistic relationship of health, care, and food insecurity. As such, food security influences the social environment and access to basic services and disrupts the social fabric of communities. The prevalence of floods along the Shabelle and Juba Rivers, and flash floods along the intermittent streams in the northern part of the country, also contributed to food insecurity (WHO, 2012). Both riverine and flash floods cause high numbers of casualties with significant economic impact. According to the Food Security and Nutrition Analysis Unit for Somalia (FSNAU), around 731,000 people remain in ‘emergency’ and ‘crisis’. As such these people required urgent lifesaving humanitarian assistance to help them meet food needs, such as critical nutrition and also health support for the acutely malnourished, specifically children (WHO, 2012). Additionally, 2.3 million are classified as ‘stressed’, since they struggle to meet minimum daily needs for their food, hence they remain highly vulnerable to major shocks like floods or drought which easily push people back into a food security crisis (WHO, 2015). Therefore, natural causes of food crisis enhance human insecurity as people are denied freedom from wanting basic needs. Conflicts, insecurity and high food prices continue to increase poor household food security and also the high rate of malnutrition, because gains made in nutrition and food security might be lost in the absence of humanitarian support. The situation is fragile, with communities recovering from recurrent droughts and many seasons of failed rains. For this reason an estimation of 202,600 children under 5 years old were acutely malnourished in 2015, and in some areas of southern Somalia, the Global Acute Malnutrition (GAM) rate was 33%, considerably more than the WHO’s emergency threshold of 15% (WHO, 2015). Therefore, shortage of donors and undemocratic government to eradicate food crisis in Somalia has exposed children to high mortality and morbidity due to malnutrition that is further enhanced by severe food insecurity.

CONCLUSION Food insecurity in Africa remains an open reality. The underlying causes of high levels of food insecurity in Somalia include conflicts that are embedded with various groups like TFG and al-Shabaab, tribalism, and clan conflicts. To alleviate the food crisis there must be awareness, efforts to mitigate drought through improved irrigation systems, and promotion of peace between the al-Shabaab group and the government.

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REFERENCES Central Intelligence Agency. 2011. “Somalia”. The World Factbook. Langley, Virginia: Central Intelligence Agency. DeCapua, J. 2013. 11 million in Sahel face severe food insecurity. Available at http://www.voanews.com/ content/fao-sahel-10sept13/1746852.html. Accessed on 23 January 2016. FAO. 2001. The elimination of food insecurity in the Horn of Africa. Available at http://www.fao.org/docrep/003/x8406e/x8406e00.htm Accessed on 22 January 2016. ICRC. 2014. Somalia: ICRC temporarily suspends distributions of food and seed. Available at https://www. icrc.org/eng/resources/documents/news-release/2012/somalia-news-2011-01-12.htm.Accessed on 27 January 2016. IFRC. 2011. Drought in the horn of Africa. International Federation of Red Cross and Red Crescent Societies; Geneva. International Crisis Group. 2011. Somalia: The Transitional Government on Life Support. Available at http://www.crisisgroup.org/en/regions/africa/horn-of-africa/somalia/170-somalia-the-transitional-government-on-life-support.aspx. Accessed on 24 January 2016. OXFAM. 2011. Famine in Somalia: causes and solutions. Available at https://www.oxfam.org/en/somalia/ famine-somalia-causes-and-solutions. Accessed on 23 January 2016. USDA. 2015. Ranges of Food Security and Food Insecurity. Available at http://www.ers.usda.gov/topics/ food-nutrition-assistance/food-security-in-the-us/definitions-of-food-security.aspx.\.Accessed on 21 January 2016. United Nations. 2011. An overview of vulnerability analysis and mapping. Available at http://www.un.org/ Depts/Cartographic/ungis/meeting/march00/documentation/wfp_recalde2.pdf. Accessed on 25 January 2016. Reno, W. 2011. Warfare in Independent Africa. Cambridge University Press. The Atlantic. 2011. Famine in East Africa. Available at http://www.theatlantic.com/photo/2011/07/famine-in-east-africa/100115/. Accessed on 23 January 2016. World Bank. 2005. Conflict in Somalia: Drivers and Dynamics. Available at http://siteresources.worldbank. org/INTSOMALIA/Resources/conflictinsomalia.pdf. Accessed on 24 January 2016. WHO. 2010. What does FOOD INSECURITY Mean? Available at http://www.dccmaugusta.org/What%20 does%20FOOD%20INSECURITY%20Mean.pdf. Accessed on 21 January 2016. WHO. 2012. Somalia: Trend Analysis of Food and Nutrition Insecurity (2007-2012). Nairobi. Kenya. WHO. 2015. Humanitarian Assistance Remains Vital. Available at https://www.wfp.org/countries/somalia/ food-security. Accessed on 23 January 2015.

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The Underlying Determinants of Food Insecurity in Southern Africa: A Case Study of Zimbabwe Tapiwa Murevanemwe1 1 School Of Global Studies, Thammasat University, Pathumthani, Thailand

ABSTRACT Food insecurity which is the absence, uncertainty and limited availability and accessibility of nutritious, safe and adequate food continues to be a global health challenge. It is estimated that approximately 795 million people in the world do not have enough food. Majority of them are living in developing countries where approximately 12.9 % of the population is undernourished. Zimbabwe is one of the countries in Southern Africa that is being affected by this problem of famine, with an estimated 1.5 million people expected to be facing serious food insecurities at the peak of the 2015-16 lean season. The underlying determinants of this challenge of food insecurity are the social, economic and political factors that cause and enhance this problem. A review and analysis of literature was conducted to identify the underlying determinants of food insecurity. Results shows that poverty, political instability and violence, climate change, lack of investment in agriculture, cash crops dependence, rapid population growth, high food price and food shortages, post-harvest loses are among the most important determinants of food insecurity in Zimbabwe. It was also found that lack of good governance in Zimbabwe was enhancing this problem of food insecurity.

INTRODUCTION The World Food Summit in 1996 defined food security as a situation “when all people at all times have access to sufficient, safe and nutritious food to maintain a healthy and active life” (WHO, 2016). Food insecurity on the other hand is a situation in which people do not have reliable access to nutritious, quantity, sufficient and affordable food to maintain an active and health life. Approximately 795 million people in the world still do not have enough food; the majority of them are living in developing countries where approximately 12.9 % of the population is undernourished. Among all the regions of the world, Sub-Saharan Africa has the highest prevalence of hungry people with about one in four people undernourished (Andrea & Rose, 2015, p. 2). Zimbabwe is one of the countries in this region that is mostly affected by this problem of food insecurity. FAO (2015) estimated that about 1.5 million people (which is roughly 16 % of the Zimbabwean population) are expected to be facing serious food shortages at the peak of the 2015-16 lean season. This is a 164 % increase in food insecurities as compared to the previous season. As a result, less than 28 % of children under the age of 5 in Zimbabwe are receiving the recommended minimum adequate diet for satisfactory nutrition. The rest of the children are not receiving adequate food because of food insecurities. It can be argued that the problem of food insecurity is also overlapping across other pillars of human security such as personal, political and health security. The reasons of food insecurity in Zimbabwe and in other countries in Southern Africa are vast and complex. Some of them include poverty, lack of investment in agriculture, climate and weather, war and displacement, unstable markets, food wastage, corruption and political instability (FAO, 2015). This essay is going to critically analyze the underlying determinants of food insecurity in Southern Africa by focusing on Zimbabwe as a case study. At the end, some recommendations will be proposed to address this problem of food insecurities in Zimbabwe and in other Sub-Sahara Africa countries. 4th International Conference on New Voices, 4 March 2016 |

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METHODOLOGY In order to understand the determinants of food insecurity, a review and analysis of literature was conducted. The Thammasat University online library was the main database that was consulted and also other search engines such as Google Scholar, PubMed, Web of Science and Medscape. Articles published since 2010, which have the key words listed below, were included and those published earlier than 2010 and with no key words were excluded. Keywords: Food insecurity, famine, Southern Africa, Zimbabwe

FINDINGS In Zimbabwe, approximately 56 % of children aged between 6 and 59 months are suffering from malnutrition. Only 17.3 % of children aged between 6 and 23 months are receiving the recommended minimum acceptable and adequate nutrition. Zimbabwe is also ranked number 156 out of 187 developing countries on the Global Hunger Index and this means that it is considered to be one of the worst food-deficit countries (FAO, 2015). The questions are: (i) what are the underlying determinant of the food insecurity and famine in Southern Africa and, more specifically, in Zimbabwe? And (ii) what can be done to overcome this challenge? The underlying determinants of food insecurity in Zimbabwe are very complex and they are interlinked factors. These factors stem from the extreme vulnerability to climatic shocks and man-made crisis of political and economic nature which have negatively affected the agricultural production and eventually the availability of food. The following determinants of food insecurity and famine which are categorized into economic factors, socio-political factors and environmental factors, were identifies and analyzed.

ECONOMIC FACTORS Poverty One of the underlying determinants of food insecurity in Southern Africa is poverty. Crush et al (2012, P. 271) pointed out that people who are living in extreme poverty do not have the capacity to afford nutritious food for their families. In Zimbabwe nearly 75 % of the population in the country is living well below the national poverty line. ZimStats (2013) showed that poverty levels are much higher in rural provinces such as Matabeleland North and Mashonaland Central and this is where majority of people are facing problems of food insecurity. Even the little food available is not accessible to majority of people since they cannot afford it. Peasant farmers in these areas cannot afford basic farming inputs such as seeds and often cultivate crops without fertilizers and tools they require. In short, poverty is trapping people in Zimbabwe preventing their escape from the constraints of food insecurity and famine (Dube, et al, 2014, P. 3).

Lack of investment in agriculture Another determinant of food insecurity in developing countries is lack of investments in agriculture infrastructure such as enough roads, irrigation and warehouses according to FAO (2016). Lack of investment results in high transport costs, unreliable water supplies and lack of storage facilities which eventually results in limited agricultural yields and access to enough food. The government of Zimbabwe is not investing

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enough in these sectors (Watson, 2013). There is an unsatisfactory agricultural infrastructure in resettled farms especially in Zimuto district in Masvingo Province. There is no infrastructure that supports irrigation, transportation, energy and pre- and post-harvest storage. This has resulted in making this province the worst affected province with 28.5 % of households being food insecure in the 2015/2016 consumption year (Dube, 2016).

Cash crops dependence Govereh and Jayne (2013) found out that many African and Third World governments encourage the farming of cash crops rather than food crops; the income from the exportation of the cash crops is used for importing food. They also found out that such countries are at a high risk of food crisis since they do not produce enough food to feed their countries. This is very true in the case of Zimbabwe where the government encourages farmers to grow tobacco -- “The golden leaf ”-- for exportation and this is compromising the production of food crops such as maize, wheat and rice (Alexander, 2013).

High food price and food shortages Another determinant of food insecurity as highlighted by the WFP (2016) is an increase in food prices. For example, the 2007-2008 food price spike resulted in over one billion people (i.e., more than 1/6th of the world’s population) to become hungry. In Zimbabwe in 2010, the price of maize went up by 36% in the capital Harare causing an increase of hungry people from 38 % to 49 %. Many people who were living under the poverty datum line became even hungrier as a result of this increase in food price (Rosin, et al, 2013).

SOCIO-POLITICAL FACTORS Political instability According to Andrea and Rose (2015, p. 2), wars, military conflicts and political instability are worsening the problem of food insecurity in developing countries. Gwarazimba (2011) highlighted that the unplanned, fast track and chaotic land reform program in Zimbabwe resulted in food shortages for both consumption and exportation. Zimbabwe was once called “The Bread basket of Southern Africa” but it is now experiencing the highest food insecurity problems. Farms were taken from white commercial farmers and given to black farmers on a political basis rather than on the ability and qualification to farm and use the land to feed the nation. Some of the Black farmers who took the land did not have enough farming machinery or knowledge. This has caused food to be very scarce, and the little food available is beyond the reach of the majority since 76 % of rural and 38 % urban households are living on less than US $1.25 per day (Cliffe et al, 2011). Rapid population growth According to Thomas Malthus’ theory (1803), unchecked population growth can easily exceed carrying capacity and eventually lead into overpopulation. Over population can in turn cause a strain on the food supply resulting in food insecurity (Weeks, 2014). Zimbabwe is not an exception to the impact of population growth on food security. The population of the country increased from 12,710,589 in 2005 to 16,,283,447 in 2015 with an annual population growth of 35,027. This can be argued to be contributing to the food insecurity in the country since there are no effective measures put in place to increase food production to compensate for the increasing demands of a rapidly growing population (Godber and Wall, 2014).

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Politicized International Aid Another sad reality that is still causing food insecurity, even after the help from the international community, is corruption and politicization of the food aid. The aid, which is intended to benefit the vulnerable and mostly affected members of communities, does not reach them because of corruption and also the political affiliations of those who ultimately benefit from the aid (Vermeulen et at, 2012).

Lack of interest in agriculture Another determinants of food insecurity in Zimbabwe are lack of interest among the youths to venture into farming, and donor dependence. For example, during the 2014/15 cropping season, only 2.8 million hectares out of the 4.3 million hectares of arable land was cultivated due to high fuel costs, lack of interest in farming, and climatic shocks. (Pedzisai et al, 2014).

HIV/AIDS Another determinant of food insecurity in Southern Africa is the problem of HI and /AIDS. AIDS is a disease with a serious public health concerns in Southern Africa and is increasing the problem of food insecurity. This disease not only reduces the work force in agricultural activities but has also put an encumbrance on the poverty at household level (Reddi, Powers & Thyssen, 2012).

ENVIRONMENTAL FACTORS Climate change and weather FAO (2016) described that natural disasters such as, tropical storms, floods and long periods of drought are increasing and these are causing calamitous consequences on food production and hunger in developing countries such as in Sub-Sahara Africa. Zimbabwe is being impacted heavily by climate change which is causing persisting droughts resulting in famine in the country. Productive farmlands are likely to be lost to non-agricultural use thus impacting negatively on crop and livestock production. Many small scale farmers in Zimbabwe entirely depends on rainwater as a source of water for their agricultural activities; only 7 % of the small scale farms are under irrigation. The persistent droughts have contributed to the food insecurity problem in Zimbabwe; there are no adequate drought mitigation strategies introduced by the government to alleviate this problem. (Thierfelder & Wall, 2010)

Agricultural problems There are also a number of livestock diseases, pests and other agricultural problems in Africa impacting on food production. Cattle diseases such as anthrax, and the spreading distribution of, army worm, which destroys huge areas of agricultural land in Zimbabwe is compromising agricultural yields (Dube, et al, 2014).

Post-harvest losses Last but not least, poor past-harvest storage facilities also result in shortages of food in Zimbabwe regardless of having a good harvest. Tefera (2012) pointed out that poor post-harvest management in the country is resulting in between a 14 % to 36 % loss of maize grains. This is increasing the number of people who are becoming hunger.

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MAIN ARGUMENT AND DISCUSSION From all the arguments highlighted above, the main reason why food insecurity remains a very big challenge in developing countries is lack of good governance. It can be seen that all determinants of food insecurity are related to poor governance. For example, the lack of investment in agriculture, cash crops dependence, and political instability and misuse of state funds are all a result of poor governance. Other determinants of food insecurity described above such as climate change are affecting both developing and developed countries, though there is comparatively minimum food insecurity in other countries. It is clear that a lack of mitigation strategies or lack of disaster preparedness to address food insecurity caused by uncertain situations such as drought due to poor governance in Zimbabwe is the main determinant. It was highlighted above that every time there is a droughts in Zimbabwe, the government is caught unprepared and this is why there is a lot of human suffering. Also, corruption and politicization of international food aid is a very sad reality that increases the problem of food insecurity in Zimbabwe. The governments of countries in Southern Africa should strive to have all the characteristics of good governance, namely: rule of law, transparency, responsiveness, consensus orientation, equity and inclusiveness, effectiveness and efficiency, accountability and, lastly, participation. In summary, good governance in developing countries can go a long way to address the problems of food insecurity and famine by implementing some of the recommendations listed below.

CONCLUSION AND RECOMMENDATION The underlying determinants of food insecurity and famine in Southern Africa and specifically in Zimbabwe have been identified and analyzed. It was shown that there is a lot that needs to be done in these developing countries so as to address the problem of food insecurity. This problem is resulting in catastrophic human security violations and suffering. It was argued that poor governance in these developing countries is the main root cause of food insecurity. As a result of that, there are a number of recommendation that can be adopted in Zimbabwe to address the problem of food insecurity and famine. The ultimate goal is to revive both livestock and crop production. First of all, improvement of agricultural skills among small scale farmers are important. These include sustainable water and land management practices to protect the land and natural resources for better agricultural production. Farmers should be encouraged and taught to cultivate drought resistance crops in areas that are more prone to less rainfall and with no drip-irrigation systems. The government should also encourage the growing of food crops over cash crops to address the problem of food insecurity. The government should prioritize investing in agricultural infrastructure such as roads, farming equipment and machinery as well as post-harvest handling facilities to preserve the agricultural yields. Availing farming inputs or subsidizing them will go a long way in alleviating poverty and famine. The government should subsidies commodities such as rice and maize so that it will be affordable to everyone in the country. The Zimbabwean government can delegate that responsibility to the Grain Marketing Board (GNB), which controls the buying and selling of cereal crops in the country. Stopping of corruption especially when distributing food aid from International well-wishers should be taken seriously if the Zimbabwean government wants to address the challenge of food insecurity. The government should focus on achieving the Sustainable Development Goals and more specifically Goal 2 “End hunger, achieve food security and improved nutrition, and promote sustainable agriculture” by 2030.

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REFERENCE LIST Alexander, M. (2013). An Econometric Analysis of the Relationship between Agricultural Production and Economic Growth in Zimbabwe. Russian Journal of Agricultural and Socio-Economic Sciences, 23(11). Andrea, F., & Rose, M. (2015). Food Insecurity and Hunger: A Review of FAO’s Annual Reporton State of Food Insecurity in The World, Issue 2015. Scholedge International Journal of Multidisciplinary & Allied Studies ISSN 2394-336X, 2(5), 1-5. Cliffe, L., Alexander, J., Cousins, B., & Gaidzanwa, R. (2011). An overview of fast track land reform in Zimbabwe: editorial introduction. Journal of Peasant Studies, 38(5), 907-938. Crush, J., Frayne, B., & Pendleton, W. (2012). The crisis of food insecurity in African cities. Journal of Hunger & Environmental Nutrition, 7(2-3), 271-292. Dube, T., Tui, S. H. K., Rooyen, A. V., & Rodriguez, D. (2014). Baseline and Situation Analysis Report: Integrating Crop and Livestock Production for Improved Food Security and Livelihoods in Rural Zimbabwe, Socioeconomics Discussion Series Paper Series 29. FAO (2015). 10 Facts about Hunger in Zimbabwe. Retrieved January 15, 2016 from https://www.wfp.org/ stories/10-facts-about-hunger-zimbabwe Godber, O. F., & Wall, R. (2014). Livestock and food security: vulnerability to population growth and climate change. Global change biology, 20(10), 3092-3102. Govereh, J., & Jayne, T. S. (2013). Cash cropping and food crop productivity: synergies or trade-offs?. Agricultural Economics, 28(1), 39-50. Gwarizamba, V (2011) Strategies for resuscitating Zimbabwe’s Agriculture: Entrepreneurship Africa. Retrived on 20 January 2016 from http://www.entrepreneurshipafrica.com/business-resources/experts/strategies-for-resuscitating-zimbabwe%E2%80%99s-agriculture.html Pedzisai, E., Kowe, P., Matarira, C. H., Katanha, A., & Rutsvara, R. (2014). Enhancing Food Security and Economic Welfare through Urban Agriculture in Zimbabwe. Journal of Food Security, 2(3), 79-86. Reddi, A., Powers, M. A., & Thyssen, A. (2012). HIV/AIDS and food insecurity: deadly syndemic or an opportunity for healthcare synergism in resource-limited settings of sub-Saharan Africa?. Aids, 26(1), 115-117. Rosin, C., Stock, P., & Campbell, H. (Eds.). (2013). Food systems failure: The global food crisis and the future of agriculture. Routledge. Tefera, T. (2012). Post-harvest losses in African maize in the face of increasing food shortage. Food security, 4(2), 267-277. Thierfelder, C., & Wall, P. C. (2010). Investigating conservation agriculture (CA) systems in Zambia and Zimbabwe to mitigate future effects of climate change. Journal of Crop Improvement, 24(2), 113- 121. Vermeulen, S. J., Campbell, B. M., & Ingram, J. S. (2012). Climate change and food systems. Annual Review of Environment and Resources, 37(1), 195. Watson, M. (2013). Agricultural Infrastructure Developmentimperative For Sustainable Food Production: A Zimbabwean Perspective. Russian Journal of Agricultural and Socio-EconomicSciences, 24(12). Weeks, J. R. (2014). Population Theories and Dynamics. Global Population and Reproductive Health, 111

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WFP (2016). What are the current issues in Zimbabwe? Retrieved on January 20, 2016 from https://www. wfp.org/countries/zimbabwe WHO. (2016). Food Security. Trade, foreign policy, diplomacy and health. Retrieved January 15, 2016 from http://www.who.int/trade/glossary/story028/en/

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The Relationship between Perceived Self-Efficacy, BMI and Physical Activity among Adolescents in Kudus, Central Java, Indonesia Umi Faridah1, Sunanta Thongpat2, Yupaporn Tirapaiwong3 1 Kasetsart University, Bangkok 10230, Thailand 2 Boromarajonani College of Nursing Nopparat Vajira, Bangkok 10230, Thailand 3 Boromarajonani College of Nursing Bangkok, 14000, Thailand

ABSTRACT Physical activity is a crucial part of healthy behavior. Insufficient physical activity has been reported as the major cause of obesity, diabetes, cardiovascular disease, osteoporosis, chronic illnesses, disabilities, and even death. The World Health Organization (WHO) has suggested in their guidelines for children and adolescents that they perform at least 60 minutes of moderate to vigorous physical activity (MVPA) per day. Perceived self-efficacy refers to an individual’s confidence in personal ability to maintain and adopt physical activity behavior to overcome obstacles to physical activity. A cross sectional design was used with 273 adolescents aged 14 to 19 years old by multi-stage random sampling in Kudus, Central Java, Indonesia. The research instruments included a self-report questionnaire on Perceived Regulatory Self-Efficacy, and the Physical Activity Questionnaire for Adolescents (PAQ-A). Pearson correlation coefficient was used for analyzing the data. The reliability of physical activity and perceived self-efficacy were obtained (Cronbach’s alpha .853 and .724). The result of this study showed that perceived self-efficacy (r = .279, p < .01) had significant positive correlation with physical activity, and that BMI (r = .042) was not correlated with physical activity. Healthcare providers should provide informative programs to encourage physical activity among adolescents. Keywords: Physical Activity, Adolescents, Self-efficacy, Indonesia

INTRODUCTION Physical activity is a crucial part of healthy behavior. Insufficient physical activity has been reported to be a major contributor to obesity, diabetes, cardiovascular disease, osteoporosis, chronic illnesses, disabilities, and even death (Zanher, et al., 2006). The increased frequency of physical activity for an individual was related to better health outcomes and shown to reduce risks of cardiovascular diseases, stroke, diabetes type 2, and breast cancer. Therefore, physical activity is important for preventing diseases and promoting health in all age groups. For adolescents, physical activity can prevent the development of chronic diseases in adulthood. Physical activity was reported to prevent risks of mental health and injuries effectively (Dambros, et al., 2011). Physical activity among adolescents refers to any body movement produced by skeletal muscles that result in the expenditure of energy and includes occupational, leisure-time, and routine daily activities. Regular physical activity maintenance is based on personal and social motivation in the environment (Pender, et al., 2011). It is recommended that adolescents perform an appropriate type of physical activity to optimize the

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beneficial outcomes for their health, growth and development. The intensity of physical activity was divided into moderate and vigorous, and the duration of physical activity was defined as how long adolescents take to complete a session of that activity. The frequency of physical activity was defined as how often adolescents do physical activity. The World Health Organization (WHO) in 2010 suggested, in their guideline for children and adolescents, that they perform at least 60 minutes of moderate to vigorous physical activity (MVPA) per day (Ling, et al., 2014). The WHO (WHO, 2011) also suggested examples of physical activity for adolescents, such as playing games, sports, transportation, chores, recreation, physical education, or planned exercise, in the environment of family, school, and community. Despite such recommendations, it has been found that there are insufficient physical activity levels among adolescents globally. This issue has also become a public health concern. Perceived self-efficacy was included as one predicting factor of physical activity among adolescents. Perceived self-efficacy refers to an individual’s confidence in personal ability to maintain and adopt physical activity behaviors to overcome obstacles of physical activity (Dewar et al., 2013). Girls and boys who were physically active were identified to have higher self-efficacy (Kelly et al., 2011). However, a previous study showed that perceived self-efficacy and physical activity were not significantly associated. Shokrvash, et al., (2013) stated that perceived self-efficacy might affect adolescents’ physical activity in two ways, direct or indirect support. The number of overweight adolescents found in the Kudus Department of Health showed that overweight cases in adolescents were increasing. In 2013, 426 overweight cases among adolescents were found and in 2014 the cases had increased to 855, representing a significant increase of almost 20% among adolescents age 14 to 19 years old. Therefore, the results of this study would be beneficial for the local health care providers, families and nursing community as it could be used to promote the importance of physical activity among adolescents.

OBJECTIVE The purpose of this study was to examine the relationship between perceived self-efficacy, BMI (Body Mass Index) and physical activity among adolescents in Kudus, Central Java, Indonesia.

METHOD This research was conducted by applying a descriptive cross-sectional approach, which collected data at one point in time (Polit and Beck, 2008). Data was measured once from the participants to identify their physical activity as well as factors relating to physical activities among adolescents. This research was conducted in Kudus District, Central Java, Indonesia. The target population was adolescents in the age range of 14 to 19 years old, studying grade 7 to 12 and who were attending public junior and senior high schools located in Kudus district, Central Java Province, Indonesia, during the academic year 2015. The sample used for this study was comprised of the adolescents enrolled in the September-October 2015 semester at the public junior and senior high schools located in Kudus district. The samples for this study were selected based on inclusion and exclusion criteria. The inclusion criteria included those who were: a) students of public junior high schools and public senior high schools in Kudus District, b) aged from 14 to 19 years old, c) able to understand Indonesian language, d) voluntarily participating in the study and e) had obtained permission from the parent or guardians. Exclusion criteria for the study were students with

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disabilities, hearth disease, epilepsy, kidney disease or those experiencing sickness such as viral infections, diarrhea, influenza and high fever in the last week. The sample size was 273, which used the Daniel Formula (1999). A multistage sampling method was adopted for sample selection due to the concern of condition differences by community area. The research instruments included a self-report questionnaire Perceived Regulatory Self-Efficacy, and the Physical Activity Questionnaire for Adolescents (PAQ-A). BMI was calculated by dividing weight (kg) by height (m) and then squared and categorized as either underweight, normal, overweight or obese using the World Health Organization (WHO) standards. The reliability of physical activity and perceived self-efficacy were obtained using Cronbach’s alpha .853 and .724, respectively. Data were analyzed to identify the relationship between independent variables and dependent variables. The relationship between BMI, perceived self-efficacy, and physical activity among adolescents were analyzed using descriptive statistic and Pearson’s correlation coefficient.

RESULTS AND DISCUSSION Results The majority of participants had a moderate level of physical activity (68.1%) followed by a low level (16.1%). One-third of the participants had a fair level of perceived self-efficacy of physical activity (66.7%), followed by a poor level of perceived self-efficacy of physical activity (16.8%). The majority of the participants’ BMI were normal level (50.9%) followed by underweight (26%) and the remaining were overweight and obese (23.1%). The result of this study showed that perceived self-efficacy had a significant positive correlation with physical activity (r = .279, p < .01) but that BMI (r = .042) was not related with physical activity. Table 1: Number and percentage of physical activity among adolescents (N=273) Physical activity Low (1.13 – 1.64) Moderate (1.65 – 2.61) High (2.62 – 3.52) Mean = 2.13 , SD = .49 Range = 1.13 – 3.52

Number 44 186 43

Percentage (%) 16.1 68.1 15.8

Table 2: Number and percentage of BMI among adolescents (N=273) BMI (Body Mass Index) Underweight Normal Overweight and Obese

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Percentage (%) 26 50.9 23.1

Table 3: Number and percentage of perceived self-efficacy (N = 273) Perceived self-efficacy Poor (1 – 1.92) Fair (1.93 – 3.65) Good (3.66 – 5) Mean = 2.79 , SD = .87 Range = 1 – 5

Number 46 182 45

Percentage (%) 16.8 66.7 16.5

Table 4: Relationship between perceived Self-efficacy, BMI and physical activity among adolescents (N = 273) No 1 2

Variables BMI Perceived Self-Efficacy

r-Value 0.042

P-Value 0.485

0.279

p <.01

DISCUSSION BMI (Body Mass Index) was found to have no significant relationship with physical activity among adolescents in Kudus, Central Java, Indonesia. This finding was similar to a previous study by Hsu et al., (2011), that reported that BMI was not related to physical activity among adolescents. This means that physical activity levels of adolescents who were overweight, normal weight or lower weight were similar. This result can be explained by the idea that both normal and abnormal weight students were give similar opportunities to perform physical activity, particularly during school. Physical activity was a part of the schools’ programs and was required for all students to engage in. Perceived self-efficacy had a significant association with physical activity among adolescents (r = .279; p<0.01). This finding was consistent with Taymoori, et al., (2010) who reported that there was a relationship between perceived self-efficacy and physical activity among adolescents. Perceived self-efficacy of physical activity could influence the confidence and commitment of adolescents to perform physical activity regularly. Furthermore, perceived self-efficacy could influence people to overcome obstacles in their environment. Individuals with low self-efficacy of physical activity were more likely to have negative perceptions of self-efficacy. Individuals with high self-efficacy were more likely to have positive views of their environment (Dewar, et al., 2013; Plotnikoff, et al., 2014). Higher levels of perceived self-efficacy will result in higher levels of physical activity among adolescents as well. Perceived self-efficacy can also increase positive views of one’s environment for engaging in physical activity. A positive perception of environment can help adolescents find easier facilities, time, and places to perform physical activity. Pender, et al., (2011) explained that perceived self-efficacy, particularly regarding perceptions of skill and competence, motivated adolescents to engage in physical activity. Feeling efficacious and skilled is likely to encourage adolescents in the target physical activity more so than feeling unskilled.

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CONCLUSION The results of this study provided important information to support improving physical activity among adolescents in Kudus district. This study showed that perceived self-efficacy had a positive significant relationship with physical activity, but that BMI was not related with physical activity. Moreover, physical activity contributed to maintaining normal weight among adolescents. The findings from this study could be beneficial for the local healthcare providers, families and nursing community, as they could use them to encourage adolescents to increase their physical activity. Additionally, healthcare providers should provide informative programs to encourage physical activity among adolescents. REFERENCES Al-Hazzaa, H.,M, H.I. Al-Sobayel, N.A. Abahussain, D.M.Qahwaji and M.A.Alahmadi. 2013. Association of dietary habits with levels of physical activity and screen time among adolescents living in Saudi Arabia. 27 (Suppl. 2), 204–213. Basic Health Research in Indonesia. 2013. Riset kesehatan dasar. Badan penelitian dan pengembangan kesehatan Kementerian kesehatan RI Tahun 2013. Available sources: www.litbang.depkes.go.id/ sites/.../rkd2013/Laporan_Riskesdas2013.PDF. May 25, 2015. Bervoets, Liene, Caroline Van Noten. Sofie Van Roosbroeck, Dominique Hansen, Kim Van Hoorenbeeck. Els Verheyen, Guido Van Hal and Vanessa Vankerckhoven. 2014. Reliability and Validity of the Dutch Physical Activity Questionnaires for Children (PAQ-C) and Adolescents (PAQ-A). Archives of public health. Burns, N. and S. K. Grove. 2009. The Practice of Nursing Research: Appraisal, Synthesis, and Generation of Evidence. 6th Ed. Saunders Elsevier Inc. United States of America, pp 380-383, 377-378. Butt, Joanne, Robert S. Weinberg, Jeff D. Breckon, and Randal P. Claytor. 2011. Adolescent Physical Activity Participation and Motivational Determinants Across Gender, Age, and Race. Journal of Physical Activity and Health, 2011, 8, 1074 -1083. Carolyn C. Voorhees, Alice F. Yan, Kelly J. Clifton, Min Qi Wang. 2011. Neighborhood Environment, Self-efficacy, and Physical Activity in Urban Adolescents. Am J Health Behaviour. ;35(6):674-688. Dambros, Daniela Dressler, Luis Felipe Dias Lopes and Daniela Lopes dos Santos. 2011. Perceived barriers and physical activity in adolescent students from a Southern Brazilian city. Journal of Physical Activity and Health. 13(6):422-428. Daniel W. W. 1999. Biostatistics: A Foundation for Analysis in the Health Sciences. 7th edition. New York: John Wiley & Sons. Dregval, L. A. Petrauskienė. 2009. Associations between physical activity of primary school first-graders during leisure time and family socioeconomic status. Medicina (Kaunas) 2009; 45(7) Department of Health and Human Services. 2007. Adolescent health in the United States. Available sources: www.cdc.gov/nchs/data/misc/adolescent2007.pdf. May 26, 2015. Department of Health Kudus. 2014. Laporan Data Kesehatan Sekolah. Pemerintahan kabupaten Kudus. http://dinas kesehatankabkudus.go.id. June 20 2015. Department of health and sport of Rupublic of Indonesia. 2014. Ikhtisar Eksekutif LAKIP Tahun 2014 Direktorat Bina Kesehatan Kerja dan Olahraga. Available sources: http://www.gizikia.depkes.go.id/ category/kesjaor/kesehatan-olahraga/. June 22, 2015. 62

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Dewar, Deborah L., David Revalds Lubans, Philip James Morgan, and Ronald C. Plotnikoff. 2013. Development and Evaluation of Social Cognitive Measures Related to Adolescent Physical Activity. Journal of Physical Activity and Health.10, 544-555. Guedes. Nirla Gomes, Rafaella P.M, Tahissa F. C., Thelma L. A, Lorena B. 2009. Students’ physical activity: an analysis according to Pender’s health promotion model. Rev Esc Enferm USP. Hsu, Ya-Wen, Chih-Ping Chou, Selena T. Nguyen-Rodriguez, Arianna D. McClain, Britni R. Belcher, and Donna Spruijt-Metz. 2011. Influences of Social Support, Perceived Barriers, and Negative Meanings of Physical Activity on Physical Activity in Middle School Students. Journal of Physical Activity and Health, 8, 210 -219. Y. Kim H and wang, J.. 2013. Physical Activity and Its Related Motivational Attributes in Adolescents with Different Bmi. Michigan State University 20 (1): 106-113. Inchley, Jo. Jo Kirby, and Candace Currie. 2008. Physical Activity in Scottish Schoolchildren (PASS) Project Physical activity among adolescents in Scotland Final Report of the PASS Study. Child and Adolescent Health Research Unit. Junior, Jose Cazuza de Farias, Adair da Silva Lopes, Rodrigo Siqueira Reis, Juarez Vieira do Nascimento, Adriano Ferreti Borgatto and Pedro Curi Hallal. 2011. Development and validation of a questionnaire measuring factors associated with physical activity in adolescents. Journal of School Health. 11 (3): 301-312 jul. / set. Kelly, S., B.M. Melnyk and M. Belyea. 2011. Predicting Physical Activity and Fruit and Vegetable Intake in Adolescents: A Test of the Information, Motivation, Behavioral Skills Model. Predicting Physical Activity and Fruit and Vegetable Intake in Adolescents: A Test of the Information, Motivation, Behavioral Skills Model 35 (2): Research in Nursing & Health. 146-163. Kelly, S da S, Adair da S L, L Peter H, L Gatto de A C, M F Luchtemberg De Bem, M Virgilio G de Barros, M Vinicius Nahas. 2012. Health risk behaviors Project (COMPAC) in youth of the Santa Catarina State, Brazil: ethics and methodological aspects Projeto COMPAC (comportamentos dos adolescents catarinenses). Brazillian journal of kinanthropometry and human performance. Kelly, Aaron S. Sarah E. Barlow. Goutham Rao. Thomas H. Laura L. Hayman. Julia Steinberger. Elaine M. Urbina. Linda J. Ewing and Stephen R. Daniels. 2015. Severe Obesity in Children and Adolescents: Identification, Associated Health Risks, and Treatment Approaches. A Scientific Statement From the American Heart Association. Kent C Kowalski. Peter RE Crocker and Rachel. 2004. Physical Activity Questionnaire for Older Children (PAQC) and Adolescents (PAQA). University of Saskatchewan, Canada. Pediatric Exercise science. Kimm. Sue Y.S. Nancy W. G Lynn, Andrea M. K Riska, Bruce A. B Arton, S Hari S. K Ronsberg, Stephen R. Daniels, Patricia B. C Rawford, Zak . Sabry, and Kang Liu. 2002. Decline in physical activity in black girls and white girls During adolescence. The New England Journal of Medicine. Kirby, Joanna, Kate A. Levin, and Jo Inchley. 2011. Parental and Peer Influences on Physical Activity Among Scottish Adolescents: A Longitudinal Study. Journal of Physical Activity and Health. 8, 785 -793. Ling, Jiying. L.B. Robbins, K. Resnicow and M. Bakhoya. 2014. Social Support and Peer Norms Scales for Physical Activity in Adolescents. Michigan State University Department of Kinesiology. 38(6):881889/. Mary e. Fournier. S, Bryn Austin, Cathryn. Samples. Goodenow, S H, Corliss mph. 2009. A Comparison of Weight-Related Behaviors Among High School Students Who Are Homeless and Non-Homeless. Journal of School Health American School Health Association.

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Manley, D., P. Cowan, C. Graff, M. Perlow, P. Rice, P. Richey and Z. Sanchez. 2014. Self-Efficacy, Physical Activity, and Aerobic Fitness in Middle School Children: Examination of a Pedometer Intervention Program. Journal of Pediatric Nursing. 29 (3): 228-237. Martin, S.B., D.J. Rhea, C.A. Greenleaf, D.E. Judd and H.O. Chambliss. 2011. Weight Control Beliefs, Body Shape Attitudes, and Physical Activity among Adolescents. Weight Control Beliefs, Body Shape Attitudes, and Physical Activity among Adolescents. Journal of School Health. 81 (5): 244250. Miles, Lisa. 2007. Physical activity and health. Journal compilation © 2007 British Nutrition Foundation Nutrition Bulletin, 32, 314–363. Ministry of Health of Republic Indonesia. 2013. Riset Kesehatan Dasar Indonesia. Source available: www. depkes.go.id/resources/download/Hasil2013Riskesdas. June 4, 2015. Musaiger, Abdulrahman O., Mariam Al-Mannai, Reema Tayyem, Osama Al-Lalla, Essa Y. A. Ali, Faiza Kalam, Mofida M. Benhamed, Sabri Saghir, Ismail Halahleh, Zahra Djoudi, andManel Chirane. 2013. Perceived Barriers to Healthy Eating and Physical Activity among Adolescents in Seven Arab Countries: A Cross-Cultural Study. Nursing and health science. 232164. National Heart, Lung, and Blood Institute. 2011. Physical activity. Available sources: http://www.nhlbi.nih. gov/health/healthtopics/topics/phys. May 24, 2015. Nyberg, Gisela. Eliner Sundblom. Asa Norman. Benjamin Bohman. Jan Hagberg and Liselotte. 2015. Effectiveness of a universal parental support programme to promote healthy dietary habits and physical activity and to prevent overweight and obesity in 6-years old children: the healthy school start study, a cluster-randomised controlled trial. Journal of Physical Activity and Health Olubusola, E. J, Olayinka O. A, and Temitope F. 2013. Physical Activity Levels Of School-Aged Children And Adolescents In Ile-Ife Nigeria. Medicina Sportiva 17 (4): 176-181 Pabayo, R., B.E. Molnar, A. Cradock and K. Ichiro. 2014. The Relationship between Neighborhood Socioeconomic Characteristics and Physical Inactivity among Adolescents Living in Boston, Massachusetts. American Journal of Public Health. 104 (11): e142-149. Park, Hyoungsook and Namhee Kim. 2008. Predicting Factors of Physical Activity in Adolescents: A Systematic Review. Asian Nursing Research. Park, Subin. 2014. Associations of physical activity with sleep satisfaction, perceived stress, and problematic Internet use in Korean adolescents. BioMed Central. Pender, N. J., C. L. Murdaugh, and M. A. Parsons. 2011. Health promotion in nursing practice. Upper Saddle River, N.J. California. Pender, N. J., Garcia, Anne W.; Ronis, David L. 1995. Health Promotion Model - Instruments to Measure HPM Behavioral Determinants: Adolescent Version. Peykari, Niloofar., Monir Baradaran Eftekhari, and Shirin Djalalinia. 2015. Promoting Physical Activity Participation among Adolescents: The Barriers and the Suggestions. Journal of Physical Activity and Health. Polit, D. F. 1996. Statistics and data analysis for nursing research. 2nd edition. New Jersey: Pearson. pp169178, 308-328. Polit, D. F. and C. T. Beck. 2012. Nursing Research: Generating and Assessing Evidence for Nursing Practice. International Edition. 9th Ed. Philadelphia: Lippincott Williams & Wilkins. Plotnikoff, Ronald C., Klaus Gebel, and David Revalds Lubans. 2014. Self-Efficacy, Physical Activity, and Sedentary Behavior in Adolescent Girls: Testing Mediating Effects of the Perceived School and Home Environment. Journal of Physical Activity and Health. 1579 -1586.

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Primacakti, Fitri, Damayanti R. Sjarif and Najib Advani. 2014. Physical activity assessments in obese and non obese adolescents using the Bouchard diary. Nursing and health science. Vol 54 No.3. Sanaeinasab, H., M. Saffari, M. Nazeri, A. Karimi Zarchi and B.J. Cardinal. 2013. Descriptive Analysis of Iranian Adolescents’ Stages of Change for Physical Activity Behavior. Descriptive Analysis of Iranian Adolescents’ Stages of Change for Physical Activity Behavior. Nursing and helath science. 15 (3): 280-285. Shokrvash, Behjat, Fereshteh Majlessi, Ali Montazeri, Saharnaz Nedjat, Abbas Rahimi, Abolgasem Djazayeri and Davoud Shojaeezadeh. 2013. Correlates of physical activity in adolescence: a study from a developing country. Children’s Health Care. 6:20327. Steele, M.M., B. Richardson, K.B. Daratha and R.C. Bindler. 2012. Multiple Behavioral Factors Related to Weight Status in a Sample of Early Adolescents: Relationships of Sleep, Screen Time, and Physical Activity .Children’s Health Care. (4): 269-280. Taymoori, Parvaneh, Shamsaddin Niknami, Tanya Berry, Fazloalha Ghofranipour David Lubans and Anoshirvan Kazemnejad5. 2008. A school-based randomized controlled trial to improve physical activity among Iranian high school girls. International Journal of Behavioral Nutrition and Physical Activity 2008, 5:18. Taymoori, Parvaneh. David Lubans. and Tanya R. Berry. 2010. Evaluation of the Health Promotion Model to Predict Physical Activity in Iranian Adolescent Boys. Health Education & Behavior, Vol. 37(1): 84-96. Thind, Herpreet, TaShauna U. Goldsby, Akilah Dulin-Keita, and Monica L. Baskin. 2015. Cultural Beliefs and Physical Activity among African-American Adolescents. University of Alabama at Birmingham, Birmingham, AL. 39(2):284-293. Todd, Alwyn S. Steven J. Street, and Andrew P. Hills. 2014. Overweight and Obese Adolescent Girls: The Importance of Promoting Sensible Eating and Activity Behaviors from the Start of the Adolescent Period. American Journal Health Behaviour United Nations Children’s Fund, World Health Organization. 2011. Adolescence An Age of Opportunity. UNICEF. New York, NY 10017, USA World Health Organizaztion (WHO). 2011. Global recommendations on physical activity for health. Available sources: www.who.int/dietphysicalactivity/factsheet_recommendations/en/. May 26, 2015. World Health Organizaztion (WHO). 2015. physical activity for health. Available sources: http://www.who. int/mediacentre/factsheets/fs385/en/. May 28, 2015. Zahner, Lukas,. J.J Puder, R. Roth, M. Schmid, R Guldimann, Uwe P, K. Martin, B. Charlotte, B marti and S Kriemler. 2006. A school-based physical activity program to improve health and firness. BMC public health.

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Health Literacy, Safety Behaviors, and Organizational Safety Culture on Worksite Accidents among International Migrant Workers in Thailand Wassanan Namthep1, Pimpan Silpasuwan1, Dusit Sujirarat1 1 Mahidol University, Bangkok, 10400 Thailand, [email protected], [email protected] [email protected]

ABSTRACT Accidents and injuries among international migrant workers (IMWs) in Thailand, especially in the industrial sectors have continuously been reported. This study aims to examine the relationship between health literacy, safety behaviors, organizational safety culture and accidents at work. Methods A descriptive survey was performed with 380 legal IMWs using stratified simple random sampling in Rayong Province in 2015. Data were collected by OHNs through health screenings and structured interviews by IMW translators. Descriptive statistics, and multiple logistic regressions were tested. Results Approximately 10.3% of IMWs surveyed had experienced accidents. Their health literacy was at a moderate level (59.2%), which made it difficult for them to understand safety instructions (63.4%), especially due to poor listening and reading skills. The perception of organizational safety culture among workers in large factories was also higher than among workers in other factories, (F=290.83, P<0.001). Most IMWs had low safety behaviors related to accidents in the workplace. Best predictors for accidents were safety behaviors and health literacy (Wald test = 25.0 and 21.6), respectively. Conclusion Low levels of safety behaviors and health literacy among IMWs could explain most accidents at work. To improve such conditions, safety behaviors, health literacy, and the Thai language skills among the IMWs should be enhanced. Key words: International migrant workers, Accidents and near miss, Health literacy, Safety behaviors.

INTRODUCTION Approximately 50 per cent of the 232 international migrants in the world today are economically active. Industries, including manufacturing and construction, accounted for 26.7 million of the world’s migrant workers (17.8 percent) (ILO, 2015). Similarly, in Thailand, the number of international migrant workers (IMWs) has grown dramatically over the last 10 years. Recently, there are more than 242,000 IMWs in Thailand working in the industrial sector (Office of Foreign Workers Administration, 2014).

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Recently, the prevalence rate of morbidity due to accidents and injuries in the industrial workplace among IMWs has continued to be available because of ongoing reporting. From this, it is reflected that IMWs are still facing not only unsafe acts but also unsafe conditions during the working process. As a consequence, adverse effects impacted individual workers, their families and also company property through the development of a negative image and reputation (Srivirojana, 2014). A few studies showed that because of work-related accidents, injuries occurred to migrants every year (Yang, 2011). Towards understanding and better managing safety and accident prevention among migrant workers, investigations have been made on the potential magnitude of the cause of the problem, and on the identification of potential health risks -- factors that might lead to accidents. The main factors affecting accidents in the workplace, especially in the factory setting, are the various unclear health and safety information materials available to workers that can lead to misunderstandings about hazards related to workers’ health risk and safety behaviors. Workers need to closely follow work instruction guidelines and attend occupational health and safety sessions that are available in companies that promote an organizational safety culture of preventing and promoting health and safety at work. However, in the case of IMWs, there is often a lack of health literacy due to poor education and poor foreign language skills that are inadequate for meeting the minimum requirements of good communication and social interaction in corporate activities for safety practices to be upheld. Companies are interested in the low cost of employing migrant workers but frequently do not do their due diligence in ensuring that proper and accessible safety training and precautions are carried out to reduce accidents in the work place. Moreover, it was found that safety climate (organizational safety culture) is related to unintentional injuries among IMWs in workplaces (Liu et al., 2015). All of these scenarios have reflected the potential hazards and risks that can lead to varying levels of accidents and near-misses among IMWs. The ILO (2011) and WHO (2013) have reported that the number of work related accidents and illnesses continues to increase. According to existing laws, regulations and rules related to accident prevention in the workplace, the ILO noted that there are many cautions outlined for preventable action among industrial organizations and other sectors. With the intention of protecting health and safety among the Thai workforce, as well as the IMWs, the Thai government has been active in strengthening prevention-based approaches through the creation of a mega plan, sub plan and various effective strategies to implement and follow up closely. Nonetheless, the main factors affecting accidents at the work place among industrial IMWs in Thailand is still unclear. For the Myanmar migrant workers working in seafood processing factories in Thailand, the occupational accident prevalence in 2011 was about 48.6% (Khin, 2011). Similarly, through hospital records from 2014 it was shown that IMWs in Rayong province (one of the fastest growing economical industrial areas on the East coast of Thailand) reported accident related injuries that had occurred in a variety of different industries. With these different factors in mind, the study aimed to examine the relationship between health literacy, safety behaviors, organizational safety culture and accidents at work among IMWs in workplaces.

METHOD A cross-sectional study was performed; data was collected from 380 legal IMW who were recruited from large, medium and small factories by stratified simple random sampling in Rayong Province during No-

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vember 2015. The research tool’s validity and reliability was developed before the data collection phase. The questionnaire consisted of information about demographics of participants, nationality, gender, age, marital status, education, Thai language skills, accident/injuries at work within 6 months, health literacy(16-items) applied from Jung Mi and Eunjoo (2013) (reliability =0.90). Organizational safety culture (61-items) applied from Chaichotki (2011) and Flemming (1999) (reliability=0.72). Safety behavior (22-items) applied from Poamuang (2011) (relia- bility=0.80). Health screening among IMWs by Occupational Health Nursing before face-to-face interviews with structured questionnaires translated into Myanmar, Cambodia and Lao languages were performed for data collection purposes.

Data-Analysis The data were analyzed using descriptive statistics, bivariate correlation and multiple logistic regressions. Logistic regression models were used to estimate the odds (ORs) and 95% Confidence Intervals (95% CI) of incurring accidents at work.

RESEARCH RESULTS Demographic characteristic of participants and accidents at work Participants consisted of 380 legal IMWs, the majority of whom were from Myanmar (65.3 %) working in the large factory; the average age of participants was 27.1 years old (SD = 5.19 years), 56.1% were female workers and most of them had completed primary school education (55.8 %); the reported earned income was 9,735 baht/month (59.2%). On average the surveyed IMWs had 2.19 years of Thailand-based work experience (SD=1.23 years). All of the IMWs worked for more than 8 hours a day (Table 1). Table 1: Demographic characteristic of participants Variables Age (in years)

Gender Nationality

Education

Income(Baht)

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Category < 25 25-29 30-34 35-39 ≥ 40 Female Male Myanmar Cambodia Loa Illiterate Primary school Junior high school ≥ High school Less than 7,800 7,800-15,000 More than 15,000

N (%) 133 (35.0) 123 (32.4) 84 (22.1) 35 (9.2) 5 (1.3) 213(56.1) 167 (43.9) 248 (65.3) 127 (33.4) 5 (1.3) 14 (3.7) 212 (55.8) 140 (36.8) 14 (3.7) 20 (5.3) 357 (93.9) 3 (0.8)

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M±SD 27.1±5.2

Range 18-45

9,735.26±1,366.40

7,000-18,000

Table 1: Demographic characteristic of participants (Cont) Variables Working hours/day working experiences

Length of stay in Thailand

Thai language skills Listening

Speaking

Reading

Thai language skills Writing

Category More than 8 hrs. < 1 year 1-2 year 3-4 year ≥ 5 year ≤ 2 year 3-5 year >5 year

N (%) 380 (100) 42 (11.0) 240 (63.2) 75 (19.8) 23 (6.0) 136 (42.9) 171(15.0) 29 (7.6)

Very poor Poor Fair Good Very poor Poor Fair Good Very poor Poor Fair Good

118 (31.1) 148 (38.9) 54 (14.2) 60 (15.8) 155 (40.8) 133 (35.0) 52 (13.7) 40 (10.5) 358 (94.2) 7 (1.8) 11 (2.9) 4 (1.14)

Very poor Poor Fair

360 (94.7) 14 (3.7) 6 (1.6)

M±SD

Range

2.2±1.2

0.6-16

3.4±2.2

0.7-16

The overall health literacy was at a moderate level (59.2%) indicating that respondents on average scored 29-38 out of 48 points on the health literacy scale; the participants reported that they faced difficulties with understanding safety signs (63.4%) due to poor listening and reading skills. Most of them had poor levels of perception regarding organizational safety culture, and low levels of active participation in work safety practices, and representatives of job safety practices 87.4 %. Approximately one third (39.5%) of the surveyed IMWs had low perceptions of safety behaviors particularly regarding the proper use of personal protective equipment (PPE). Approximately 10.3% of them had experienced accidents and injuries at work; the IMWs in small factories self-reported to have higher frequency of accidents during work than the IMWs in medium and large factories (χ2= 12.611, p-value=0.002). By nationality, Cambodian workers experienced higher numbers of accidents than Myanmar and Lao workers; statistically the difference was significant (χ2 = 12.611, p-value=0.002) (Figure 1). A few near-misses were reported also. Moreover the young workers (<25 year old of age) experienced higher numbers of accidents than older workers.

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Figure 1: Comparison prevalence of accidents by size of factories and nationality Size of factories with Accidents

Nationality with Accidents

Perception of organizational safety culture, safety behavior and health literacy by nationality and factory size. The perception of organizational safety culture, safety behaviors and health literacy of Cambodian workers were lower than that of Burmese and Laotian workers. (F=293.426, P<0.001; F=157.596, P<0.001; F=46.006, P<0.001, respectively) (Figure 2). Also the organizational safety cultures perception among the IMWs in large factories were also higher than those in the medium and small factories. (F=290.830, P<0.001), Organizational safety culture (F=290.830,P<0.001), Safety behaviors (F=156.637, P<0.001) and Health literacy (F=36.385, P<0.001); Figure 3) Figure 2: Perception of health literacy, safety behavior and organizational safety culture by nationality. (Units on graph are mean scores as additives of the three ethnic groups)

Figure 3: Perception of health literacy, safety behavior and organizational safety culture by factories size.

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Factors Related to accidents at work among IMWs In the logistic analysis, IMWs who perceived their health literacy to be low were found to be 20.4 times more likely to have accidents in the workplace (OR=20.4 95% CI = 5.72-73.0, p <0.001). Safety behaviors were inversely related to accidents (OR=0.77 95% CI=0.69-0.85, p= <0.001). Age was a factor that was significantly related with accident levels, especially for those < 25 years old (OR=3.96 95% CI=1.742-9.033, p=0.001). Best predictors for accident occurrence were safety behaviors and health literacy (Wald test = 25.0 and 21.6), respectively (Table 2). Table 2: Factors Related with accidents at work by multiple logistic regression analysis Predictors Age Gender Education Health literacy Safety behaviors Constant Cox&Snell R2 = 0.303

B 1.378 -0.492 -0.081 3.017 -0.264 11.151

S.E. 0.42 0.418 0.419 0.65 0.053 3.211

Nagelkerke R2 = 0.543

Wald 10.775 1.385 0.186 21.57 24.922 12.058

Df 1 1 1 1 1 1

Wald = [bi/SE(bi)]2

P-value .001* 0.239 0.666 <.001* <.001* .001

Exp (B) 95%CI 3.967 1.742-9.033 0.611 0.269-1.388 1.198 0.527-2.722 20.43 5.719-72.982 0.768 0.692-0.852 69661.034

*P < 0.05

Noted: Because the organization safety culture variable demonstrated a high multicollinearity with safety beviours (r-0.79) it was cut off from the multiple logistic analysis model.

DISCUSSION Most of the IMWs had accidents that occurred at work (10.3 %), the majority of which resulted in minor injuries 56.4%. Hazards in the industrial sector are primarily experienced by front line workers in each of the factories. The prevalence of accidents could be explained by the absence of appropriate safety measures from the health sector and close safety monitoring combined with the lack of individual safety practices among workers. Young workers who operate power machinery experience injuries due to clamping and trapping from the machines they work with. Consistent with the study of Taiwan IMWs by Cheng & Wu (2013), accidents such as being clamped/trapped by machines had the highest incident rate for workers working in factories. Moreover, health literacy and safety practices of IMWs in Taiwan factories were associated with the accidents reported also. The health literacy; listening, speaking, writing and reading skills of IMWs were poor. It is highly plausible that this could lead to an increase in accidents due to the misunderstanding of safety instructions (Rauscher & Myers, 2014). The results were also similar to previous studies Liu et al., (2015); Rathod (2009,2011); Cheng & Wu (2013); Anastasioua et al.,(2015) which found that international migrant workers generally had lower scores on health literacy (WHO, 2013). Health literacy and safety behaviors were significantly related to the accident levels at work among IMWs in this study. Health literacy of IMWs in this context were reflected in the difficulty experienced with understanding safety signs (63.4%) and included collaborating and coordinating in safety teams due to poor listening and reading skills. Therefore, improving health literacy would involve the employers taking responsibility to empower the migrant workers to educate and manage IMWs health literacy, translate teaching materials, instructions, safety signs and promotional materials or media into the IMWs’ native languages as part of safety organizational culture integration.

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The perception of organizational safety culture in large factories among the IMWs was higher than those workers in the medium and small factories. Because the employer in large factories provided translation support to IMWs for safety training, and translated the documents and safety signs into the language of IMWs. Organizational safety culture may not be an immediate or proximal cause directly of accidents in the workplace among IMWs in this study, however; organizational safety culture did have a high relationship with safety behavior practice ( r= .79), the best predictor being safety behavior as a mediator that could reduce accidents at work (Liu et al., 2015; Cheng & Wu, 2013). The results of this study were derived from a cross-sectional survey, in the further field studies, a longitudinal design or quasi-experimental could be used to clarify these associations. We used a self-reported questionnaire to measure organizational safety culture, safety behaviors and accidents/ injuries at work. This approach had its limitations and the researcher recommends using the companies’ medical records, as well as perception of organizational safety culture; additionally safety behaviors should be monitored by supervisors and managers.

CONCLUSIONS Accident/injuries at work could be explained by safety behaviors and health literacy of IMWs. Therefore, intervention to improve safety behaviors and health literacy should be conducted for IMWs in factories, especially by improving the listening skills in Thai language in order to raise health literacy, and also by increasing safety behavior focus on work practices. Workplace interventions have been shown to help prevent accidents or lower the risk of industrial accidents. Similarly, safety behaviors have been shown to be related to accidents at work, so behavior change for health in the workplace can be effective (WHO, 2013). Since unskilled IMWs are employed in 3D jobs (dirty, dangerous and difficult) they are particularly vulnerable to occupational accidents and injuries. Not many organizations prioritize occupation safety and health (OSH) for IMWs, but a few NGOs have been running OSH programs or training in an effort to raise awareness of safety at work among IMWs and to prevent occupational accidents and injuries.

REFERENCES Anastasioua, S.Siassiakosb, K. Filippidisc, K. & Nathanailidesd, C. 2015. Occupational accidents of immigrant workers in Greece. Procedia Economics and Finance 33, 226 – 233. Chaichotkit, A. 2011. The perception of safety culture of Thai labour in consumerism context (Dissertation). Kasetsart University, Bangkok, Thailand. Cheng, C.-W. & Wu, T.-C. 2013. An investigation and analysis of major accidents involving foreign workers in Taiwan’s manufacture and construction industries. Safety Science 57, 223-235. Fleming, M. 1999. Safety Culture Maturity Model. UK HSE Offshore Technology Report OTO2000/049, HSE Books: Norwich. Her Roral Highness Princess Maha Chakri Siridhorn’s honor Rayong Hospital Hospital. 2015. Access tomedical services of migrant workers (Myanmar, Loa and Cambodia) in Hospital 2014-2015.Department of Medical Record, Rayong Province. Hsiu-Min Tsai, C. C., Shu-Chen C., Yung-Mei Y. & Wang H. 2014. Health literacy and health

promoting behaviors among multiethnic groups of Woman in Taiwan. JOGNN 43, 117-129.

International Labour Office (ILO). 2015. ILO Global estimates of migrant workers and migrant domestic workers: results and methodology/ International Labour Office, Geneva.

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ILO Regional Office for Asia and the Pacific. 2011. Research on occupational safety and health for migrant workers in five Asia and the Pacific countries: Australia, Republic of Korea, Malaysia, Singapore and Thailand. Bangkok. Jung Mi, L. & Eunjoo, L. 2013. Factors influencing level of health literacy of migrant workers in Korea www.koreascience.or.kr [access date: 15 February 2015] Klaeng Hospital. 2015. Access to medical services of migrant workers (Myanmar, Loa and Cambo-dia) in Klaeng Hospital 2014-2015. Department of Quality Assurance, Rayong Provinces Khin, M. M. 2011. A study of factors associated to occupational accident among Myanmar migrant workers in seafood processing factory at Samut Sakorn province, Thailand. Thesis. Mahidol University. Bangkok. Lee, H., Chae, D., Hyung, K., Im, Soye., & Cho, S. H. 2015. Multiple risk factors for work-related injuries and illnesses in Korean-Chinese migrant workers. Workplace Health & Safety 63(1), 18-26. Liu, X. Huang, G., Hung, H., Wang, S. Xiao, Y., & Chen, W. 2015. Safety climate, safety behavior, and worker injuries in the Chinese manufacturing industry. Safety Science 78, 173-178. Office of Foreign Workers Administration. 2014. Statistics for migrant workers are living in Tnailand 2014. http://www.wp.doe.go.th/wp/images/statistic/sy/sy2557.pdf [access date:14 February 2015] Paomuang, S. 2011. Work safety behavior of production employees at CTS electronics corporation(Thailand) (Dissertation).Rajamangala University of Technology Thanyaburi, Pathum Thani, Thailand. Rathod, J. M. 2009. Immigrant labour and the occupational safety and health regime. Employee Right & Employment Policy Journal, 14, 267-294. Rathod, J. M.. 2011. Beyond the “Chilling effect”: Immigrant worker behavior and the regulation of occupational safety &health. Employee Right & Employment Policy Journal 14, 267-294. Rauscher, K. J. & Myers D. J. 2014. Occupational health literacy and work-related injury among US adolescents. International Journal of Injury Control and Safety Promotion 21(1), 81–89. Srivirojanal, N. Punpuing, S. Robinson, C. Sciortino, R. &Vapattanawong, P. 2014. Marginalization, morbidity and mortality: A case study of Myanmar migrants in Ranong Province, Thailand Journal of Population and Social Studies 22(1), 35-52. Yang B. 2011. Life and death away from the golden land: The Plight of Burmese migrant workers in Thailand. http://www.blog.hawaii.edu/aplpj/ files/2011/11/APLPJ_08.2_yang.pdf [access date: 12 December 2015] World Health Organization. 2013. Health literacy: The solid facts. WHO Regional Office for Europe. http:// www.euro.who.int/_data/assets/pdf_file /0008/190655/e96854.pdf [access date: 14 February 2015]

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Psychosocial Work Environment and Work Ability among Agricultural Cambodian Migrant Workers in Buriram Province, Thailand Akkaradet Awatsadarak1, Charnchudhi Chanyasanha2, Orawan Kaewboonchoo1 1 Department of Public Health Nursing, Faculty of Public Health, Mahidol University Bangkok, 10400, Thailand 2 Department of Microbiology, Faculty of Public Health, Mahidol University, Bangkok, 10400, Thailand

ABSTRACT Background Work ability is an important factor to consider for understanding how humans work. Work ability is affected by various factors such as mental health, lifestyle and work environment. Buriram, Thailand is one of the provinces that borders Cambodia, and because of this, the majority of migrant workers (70%) in Buriram province come from Cambodia. Most of them work in the agriculture sector in pig farms, rubber tree farms and sugar tree farms, for example. Their working environment is often poor with restrictions on their freedom, low work control and high work demand which affects their work ability. However, little is known about the psychosocial work environment and work ability among agricultural Cambodian migrant workers in Buriram province. This study aimed to examine the work ability and relationship between the psychosocial work environment and work ability among agricultural Cambodian migrant workers in Buriram province, Thailand. Methods Participants in this study were comprised of 300 legal Cambodian migrant workers who work in the agricultural sector in Buriram province, Thailand. A cross-sectional study was carried out during October and November 2015. Data was collected by self-administered questionnaires with the assistance of Cambodian translators. The psychosocial work environment in terms of job demand, job control and social support at work was assessed by the Job Content Questionnaire. The Work Ability Index (WAI) was used to evaluate work ability. Additional data were also collected on demographics, lifestyle, and work conditions. Multiple regression analyses were used to analyze the relationship between the psychosocial work environment and work ability. Results Approximately half of the participants were male and 85.3% were non-permanent workers. Average age of participants was 29.3±7.2 years old. The average number of years worked in Thailand was 2.8+2.6 years and working hours per day were 8 hours. About 20.3% of participants were smokers, 24.3% drank alcohol and more than 74.3% reportedly did not exercise. More than 77.7% of participants perceived their health as good or excellent. The WAI score was 40.55±5.3 which is in a good category. The multiple regression analysis showed a relationship between the psychosocial work environment and WAI. This model explained 17.3% of variance of work ability as measured by WAI.

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Discussion This study found that the psychosocial work environment was significantly related to WAI. The findings concur with earlier studies showing that a poor psychosocial work environment decreases work ability among industry workers and migrant workers. Improving the psychosocial work environment would be an effective way to increase the work ability of agricultural Cambodian migrant workers in Buriram province.

INTRODUCTION Work ability is a factor that plays an important role in how an individual can achieve their work successfully. Work ability can be divided into two factors: 1) personal factors and 2) work factors. The personal factors encompass a wide range of personal aspects, including health, skills, knowledge, abilities, values, attitudes, and motivation to work. Their health must be perfect, both physical health and mental health in order to be able to work at full capacity. Work factors include work environment, the nature of the work, work load, organization, corporate culture, management, and the characteristic of leadership (Ilmarinen, 2001) There have been extensive studies done on the factors that are associated with the work ability of the working age population especially among labor-intensive workers whose work requires great physical demands. It was found that work ability is correlated with health, lifestyle, quality of life, and work-related factors (Van den Berg TI, 2009; Seitsamo J, 1997; Kaleta D, 2006). It was also found that negative psychosocial factors decrease work ability (Alavinia Sm et al 2007). Since Buriram province borders Cambodia, the majority of migrant workers (70%) in Buriram province come from Cambodia. Most of them work in the agricultural sector. Their working environment is often poor, with restrictions to their freedom, low work control and high work demand which can affect their work ability. However, little is known about the psychosocial work environment and work ability among agricultural Cambodian migrant workers. This study aims to examine work ability and the relationship between the psychosocial work environment and work ability among agricultural Cambodian migrant workers in Buriram province, Thailand.

METHODS This study was a cross-sectional study. Participants were legal migrant workers from Cambodia who work in the agricultural sector in four districts of Burirum province, including Muang district, Nang Rong district, Prakhonchai district, and Ban Gruad district. There were 764 workers in total, and from that, 300 workers were randomly selected as a sample group. The Participants were 18 years and over, and had been working at their current job for at least 1 year. They had the capability to communicate and were willing to participate in this study.

Data Collection This study was approved by the Human Research Ethics Committee, Faculty of Public Health, Mahidol University. After the participants signed a consent form to participate in the study, they were interviewed individually by research assistants who can speak Cambodian. Data were collected from November to December. Psychosocial work environment in terms of job demand, job control and social support at work was assessed by the Job Content Questionnaire. The Work Ability Index (WAI) was used to evaluate work ability. Additional data were also collected on socio-demographics, lifestyle, and work conditions.

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Data analysis Descriptive statistics were used to determine the frequency, percentage, maximum, minimum, average and the standard deviation for the personal characteristics, work characteristics, work environment, and work ability. Multiple regression analysis was used to examine the relationship between study variables and work ability.

RESULTS Sociodemographic of the participants In this study, the participants were comprised of 146 males (48.7%) and 154 females (51.37%). The average age was 29.3 years (SD = 7.2). The age was mostly in the range of 20-29 years (51.0%). Their education, for the most part, was at the primary level (46.7%). More than half were making over 5,000 baht per month. Most participants reported being married. Approximately twenty percent of participants were smokers, 24.4% drank alcohol and 74.3% said they never exercised. Their perception of their own health was mostly good or very good. Participants had been in their current jobs for an average of 2.8 years (SD = 2.57). The most common employment status reported was non-permanent (86.3%). Hours worked per day were surveyed at less than eight hours for 86.7% of the participants, as shown in table 1. Psychosocial work environment and work ability The mean score of job demand ranged from 7 to 20 with a mean of 15.3 and a SD of 2.9. Job control scores ranged from 11 to 30 with a mean of 19.6 and a SD of 3.5. Support from colleagues scores ranged from 4 to 16 with a mean of 12.5 and a SD of 2.1. Support from supervisors scores ranged from 4 to 16 with a mean of 11.2 and a SD of 2.8. Work ability index scores ranged from 29 to 49 with a mean of 40.6 and a SD of 5.3 as shown in table 2 Correlations between study variables and work ability Table 3 shows the correlation for the study variables. Work ability was significantly correlated with working hours, employment status, job demand, supervisors’ support and health perception. However, multiple regression analyses indicated that work ability was significantly correlated with employment status, job demand, supervisors’ support and health perception. These four independent variables have the ability to predict the variability of the work ability which was 17.3 %. Table 1: The number and percentage of the participants classified by sociodemographic characteristics (n = 300). Sociodemographic Sex Male Female Age (Year) < 20 20 – 29 30 – 39 40 – 49

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Number

Percentage

146 154

48.7 51.3

15 153 106 22

5 51 35.3 7.3

Sociodemographic 50 years and over

X

Number 4

Percentage 13

124 140 36

41.3 46.7 12

101 199

33.7 66.3

70 195 35

23.3 65 11.7

239 61

79.7 20.3

227 73

75.7 24.3

223 53 24

74.3 17.7 8.0

233 53 14

77.7 17.6 4.7

133 134 35

43.7 44.6 11.7

259 41

86.3 13.7

260 40

86.7 13.3

= 29.4, S.D. = 7.2, Min = 17, Max = 55

Education None Primary Secondary or higher Income (baht / month) < 5,000 over 5,000

X = 6,137, S.D. = 2,230, Min = 1,000, Max = 10,500 Marital status Single Married Widowed / Divorced / Separated Smoking No/Quit Yes Drinking No Yes Exercise Never Sometimes Regularly Health perception Very good/Good Average Poo Years of work (year) <1 1–5 >5

X = 2.8, S.D. = 2.6, Min = 1, Max = 12 Employment status Non permanence Permanence Working hours per day (hours) <8 >=8

X = 8, S.D. = 2, Min = 5, Max = 13

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Table 2: Mean, standard deviation, maximum and minimum, of psychosocial work environment and work ability index. (n = 300) Psychosocial Environment Job demand Job control Support from colleagues Support from supervisors Work ability index score

X

SD

Range

15.3 19.6 12.5 11.2 40.6

2.9 3.5 2.09 2.79 5.3

20-Jul 11 – 30 4 – 16 4 – 16 29 -49

Table 3: Correlations between sociodemographic, work environment, and work ability.(n = 300) Variable Age Income Working hours Job control Job demand Supervisors support Colleagues Support Educationa Marrieda Emaployment statusa Smokinga Drinkinga Exercisea Health perceptiona *p< 0.05, p<0.001, a= Chi-square test

r -0.014 0.113 0.131 0.103 -0.236 0.191 -0.010 5.983 8.11 17.153 1.71 0.25 0.28 6.54

p-value 0.8 0.05 0.023* 0.073 0.000** 0.001** 0.740 0.425 0.088 0.000** 0.81 0.87 0.59 0.010*

Table 4: Factors related to work ability among Cambodian migrant workers by multiple regression.(N = 300) Variable B Std. Error Beta Employment status -2.76 0.665 -0.218 Working hours 0.063 0.227 0.018 Health perception 3.28 0.815 0.214 Support from supervisors 0.41 0.099 0.219 Job demand -0.38 0.096 -0.214 Constant = 42.107 R2 0.173 F = 6.047 p = <.001 **p-value< 0.05

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p – value <0.001** 0.781 <0.001** <0.001** <0.001**

DISCUSSION In this study, the multivariate analysis showed that work ability of Cambodian migrant workers correlated with employment status, job demand, supervisor’s support and health perception. The Cambodian migrant workers with non – permanent employment status had lower WAI scores. Employment status was significantly related to work ability. Non-permanent employment is able to affect insecurity surrounding job status and income for workers which can lead to higher stress levels and decreases in work ability. These results are similar to earlier studies that found that employment status was closely related to work ability (Wallapa boonrod, 2009). Health is one of the important factors that impact work ability (Ilmarinen, 2001). Poor health leads to poor work ability. This study showed that the migrant workers who perceived themselves to be in better health had better work ability. This result is similar to a study conducted among nurses, which found that perceived health directly related to work ability (Min-Chi Chiu et al, 2007). More than 70% of Cambodian migrant workers perceived their health to be at a good level. The average WAI of the Cambodian migrant worker in this study was found among those in the younger age groups who were still healthy and had good work ability. This study found that supervisors’ support at work seemed to have a strong association with increased work ability among Cambodian migrant workers. This can be explained in part by the fact that migrant workers who work in countries where they are unfamiliar with the language and culture find it more difficult to understand their work. Support from a supervisor could help migrant workers increase their understanding of their work which would result in an increase in work ability. This result corresponds with a previous study that showed that increases in social support at work is associated with improved work ability ( Tuomi K,2004). A high level of support from a worker’s organization has been shown to have correlation with work ability (Feldt T,2009). Other studies also showed that a lack of support from supervisors was strongly associated with WAI (Sugimara H & Theriault G, 2010). Increase job demand was found to be associated with reduced work ability among workers. In this study, it was found that higher job demand resulted in decreases in work ability. Many studies reported that high job demand had a negative impact on the WAI score among industrial workers and nurses (Van den Berg Ti, 2008; Rotenberg I, 2008; Vahid Gharibi, 2015). These result were similar to migrant workers in this study. In conclusion, the results of this study suggest that the work ability of Cambodian migrant workers was significantly related to their employment status, health perception, job demand and supervisors’ support. Increased Job demand and insufficient supervisors’ support were the main factors contributing to the decline of work ability. Intervention programs to promote and maintain the work ability of Cambodian migrant workers should include the ability to cope with the job demand. Improving effective communication with supervisors would also be very helpful. Moreover, providing health promotion programs to improve health status and considering worker’s employment status to be permanent may help to increase work ability among Cambodian migrant workers.

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REFERENCES Alavinia Sm, van Duivenbooden C, burdorf A. Influenec of work- related factors and individual characteristics on work ability among Dutch construction workers. Scand J Work Environ Health 2007; 33: 315 - 7 Feldt T, Hyvonen K, Makikangas A, Kinnunen U, Kokko K. Development trajectories of Finnish managers’ work ability over a 10 – year follow-up period. Scand J Work Environ Health 2009, 35(1):37-47 Ilmarinen JE. Aging workers. Occup Environ Med 2001:58: 546 – 52. Kaleta D, Makowiec – Dabrowska T, Jepier A. Lifestyle index and work ability. Int J Occup Med Environ Health 2006; 19: 170-7 Min-Chi Chiu, Mao-Jiun J Wang, Chih-Wei Lu, Shung-Mei pan, Masaharu Kumashiro, Juhani llmarinen. Evaluating work ability and quality of life for clinical nurse in Tiwan. Nurs Outlook 2007;55:318326 Rotenberg L, Portela LF, Bank B, Griep RH, Fischer FM, Landsbergis P. A gender approach to work ability and its relationship to professional and domestic work hours among nursing personnel. Appl Ergon 2008;39:646-52 Seitsamo J, Ilmarinen J, Life-style. Aging and work ability among active Finnish workers in 1981- 1992. Scand J Work Environ Health 1997; 23: 20-6 Sugimura H, Theriault G. Impact of supervisor support on work ability in an IT company. Occup Med(Loud) 2010;60:451-7 Tuomi K, Vanhala S, Nykyri E, Janhonen M: Organzational practies, work demand and the well-being of employees: a follow-up study in the metal industry and retail trade. Occup Med (Lond). 2004;54(2):115-21 Vahid gharibi, Hamidreza Mokarami, Abrahim Taban, Mohsen Yazdani Aval, Kazem Samimi, Mahmood Salesi. Effects of Work-Related Stress on Work Ability Index among Iranian workers. Safe and Health at work 2015;31:1-6 Van den Berg TI, Elders LA. De Zwart BC. Burdorf A. The effect of work-related and individual factors on the Work Ability Index : a systematic review Occup Environ Med 2009; 66: 211-20 Van den Berg TI, Alavinia SM, Bredt FJ, Lindeboom D, Elders LA, Burdorf A. The influence of psychosocial factors at work and life style on health and work ability among professional workers Int Arch Occup Environ Health 2008;81:1029-36

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Impact of Social Support Networks on Loneliness among Elderly in Myanmar Khin Myo Wai1 1 College of Population Studies, Chulalongkorn University, Bangkok, 10330, Thailand, [email protected]

ABSTRACT With increasing life expectancy throughout the world, loneliness in old age is becoming an area of great concern. This study aims to explore whether social support networks can reduce loneliness among the elderly. Data are from the 2012 survey of Older Persons in Myanmar, which conducted face-to-face interviews with 4080 persons aged 60 and above. In the study, feelings of loneliness, the outcome variable, are measured in terms of a single-item self-reported scale with three ordered responses, single-item deprivation scale with three ordered responses and a two-item composite loneliness scale with five ordered responses. Owing to the ordered response nature of the dependent variable, ordered response analyses are undertaken to predict social support network factors affecting loneliness. From the findings, being married, having children and relatives in the network, more frequent contact with children, relatives and non-relatives and maintaining a good relationship with family are likely to ward off feelings of loneliness among the elderly. In addition, demographic and socio-economic variables such as age, race, place of residence, health status, contribution to family economic support, a change in the family economic situation, family income, access to media and access to communication are associated with loneliness. Keywords: Loneliness, Social support networks, Elderly, Later life

INTRODUCTION An increase in the number of older persons as a result of demographic changes is associated with the likelihood of more people staying alone and experiencing increased loneliness in later life (United Nations Department of Economic and Social Affairs 2007). Loneliness is an important attribute in evaluating one’s well-being, social integration and isolation (Gierveld & Tilburg 2006). Some studies define it as a subjective unpleasant feeling caused by a gap between desired and recognized social interrelationships (J. D. J. Gierveld 1978; Perlman & Peplau 1981). Social support networks are defined as a set of personal contacts through which one can retain social identity, receive affective support, instrumental support, cognitive support and social outreach (new social contacts) (Walker et al. 1977). Existing studies illustrate that social support networks can buffer feelings of loneliness (Iecovich, et al. 2004; Mullins & Dugan 1990). Although there exist several studies examining the impact of social networks on loneliness, more work, in particular in developing countries where evidence is comparatively limited, needs to be conducted to ascertain the effect of some characteristics of social support networks on loneliness. In Myanmar, according to the 1973 census, the proportion of the population aged 60 years and older was slightly over 6 per cent, but it has gone up to 7.9 per cent in 2010 (United Nations, 2011b). In the Myanmar cultural and social context, it is generally believed that senior citizens are traditionally regarded highly and

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hold a special place in the family and in society (Department of Population & UNFPA, 2012). In spite of these prevalent strong norms and values related to care for the elderly, both demographic and socio-economic changes are likely to place a great stress on these values (Department of Population & UNFPA, 2012). Moreover, changes in living arrangements that result from lower rates of older persons who remain married or remarry due to spousal deaths, etc., (Knodel, 2014) and the migration of adult children for employment opportunities are likely to exacerbate potential changes in traditional social relationships. It suggests that the older persons have the potential to become socially isolated in the future. Therefore, this study attempts to shed light on the importance of social support networks for lessening the feelings of later-life loneliness using data from the 2012 Survey of Older Persons in Myanmar and also constructing measurements of dependent variables and independent variables.

METHOD Data The study makes use of a sample of 4080 people of the age 60 and older drawn from the 2012 Survey of Older Persons in Myanmar, which is nationally representative (except for the exclusion of Kachin State) and was conducted by the Myanmar Survey Research in conjunction with HelpAge International. The total response rate was 92.6% and the refusal rate was only 0.6%.

Measurements of Loneliness In the paper, three measures of loneliness are used: self-reported scale of loneliness (single-item variable) with the scores of 1 (not at all), 2 (some of the time) and 3(often felt lonely); single-item deprivation scale (measurement of intensity of loneliness) with from 1 (more than two), 2 (one or two) and 3 (no one) and a combined intensity two-item loneliness scale with the score ranging from 1 to 5, indicating that the higher the score, the greater the degree of loneliness is.

Statistical Model Owing to the ordered response nature of the explained variables, the study employs three ordered logistic models for three measurements of loneliness.

RESULTS In order to explore the social network variables predicting feelings of loneliness, three ordered logistic regression models were administered. In the first model, the outcome variable was measured by self-reporting; in the second, the deprivation scale; and in the third, the composite index. For all three models, the higher the scale is, the higher the degree of loneliness will be. Additionally, factors influencing loneliness are also investigated by analyzing different samples. For the entire sample, each of the three models identifies all of the social networks’ variables as factors influencing loneliness. The models consistently provide evidence that social support networks tend to reduce loneliness. Yet the first model provides the unexpected association between having non-kin in the network and loneliness. In this regard, the elderly who have non-kin are 1.5 times more likely to be lonely than those without non-kin. The plausible reason is that when the elderly realize they have no contact with their children who consistently remain away from home they may suffer from a sense of loss temporarily, but their

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feelings of loneliness will fade over time, which allows them to find other ways of emotionally depending on themselves. In addition, none of the three models offers the expected association between quality of relationship with non-kin and loneliness. Those with lesser degrees of satisfaction concerning their relationship with non-kin are less likely to be lonely. This is perhaps because those who have a lower degree of satisfaction about their social relationship with non-relatives can have better social relationships with children and family than those who have higher degrees of satisfaction can. In the study, currently married elderly and currently unmarried elderly are analyzed separately. For the currently married, children play less important roles in lowering feelings of loneliness than do children for the currently unmarried. Moreover, the paper analyzed the elderly with children and the elderly without children separately to examine the different determinants of loneliness. Partnership, for those who have children, is less significant in explaining loneliness, but, for those who have no children, partnership plays a much more significant role in buffering loneliness. In addition to the social networks’ variables, family’s economic condition, family income, respondent’s contribution to family income, age, race, place of residence, health status, participation in community activities, access to mass media and access to phone (access to communication) can influence loneliness. Table 1: Results of Ordered Logistic Regression of Social Networks Variables Influencing Feelings of Loneliness Variables Structure Marital status Currently married Separated Divorced Widowed Single(never married) Having child No Yes Having Kin in network No Yes Having Non-kin in network No Yes Interaction Child network in HH Daily or almost daily At least weekly Monthly or every few months

Model I1 Odds Ratio SE

Model II2 Odds Ratio SE

Model III3 Odds Ratio SE

2.541* 2.010** 3.080*** 1.817*

1.106 0.523 0.312 0.488

2.665* 3.535*** 2.699*** 2.759***

1.156 0.874 0.252 0.702

3.279** 3.214*** 3.670*** 2.473***

1.27 0.723 0.313 0.585

0.435***

0.096

0.522**

0.11

0.377***

0.074

0.601***

0.076

0.745*

0.088

0.597***

0.064

1.529**

0.226

0.136***

0.02

0.356***

0.05

1.640*** 2.049** 1.760*

0.218 0.454 0.507

1.461** 1.537 1.583

0.188 0.346 0.425

1.700*** 2.081*** 1.959**

0.2 0.423 0.48

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Variables

Model I1 Odds Ratio SE 2.476** 0.722 1.513 0.713

At least annually No contact Kin network in HH Daily or almost daily 1.379** At least weekly 1.794*** Monthly or every few months 1.476 At least annually 1.027 No kin in hh as well as nearby Non-kin network Daily or almost daily At least weekly 1.013 Monthly or almost monthly 1.272 Once or only a few times 1.974*** Never 1.021 Quality Quality of relationship with family Very Satisfied Somewhat satisfied 1.411** Neither satisfied nor unsatisfied 1.922*** Somewhat unsatisfied 3.326** Very unsatisfied 4.540* Quality of relationship with non-kin Very Satisfied Somewhat satisfied 0.799* Neither satisfied nor unsatisfied 1.212 Somewhat unsatisfied 0.901 Very unsatisfied 2.147 Control Variables INC4 Log Likelihood -2429.474 Model Chi-Square 722.04*** Total Number of Cases 3630 cut 1 2.032 cut 2 4.472 cut3 cut4 -

Model II2 Odds Ratio SE 3.154*** 0.93 2.36 1.083

Model III3 Odds Ratio SE 3.813*** 1.037 2.492* 1.029

0.149 0.284 0.325 0.241 -

1.124 1.761*** 1.062 1.082 -

0.113 0.26 0.214 0.234 -

1.338** 2.148*** 1.424 1.082 -

0.122 0.286 0.266 0.213 -

0.116 0.224 0.2 0.148

0.934 1.389* 1.122 1.066

0.096 0.227 0.112 0.141

0.954 1.426* 1.673** 1.011

0.089 0.211 0.152 0.122

0.147 0.331 1.167 2.708

1.458*** 3.133*** 3.223** 2.101

0.141 0.529 1.2 1.344

1.536*** 3.095*** 4.486*** 4.872**

0.135 0.485 1.52 2.801

0.082 0.203 0.617 2.812

0.929 0.634** 1.599 1.565 INC4 -2798.89 676.34*** 3662 -4.257 -0.427 -

0.087 0.103 1.032 1.964

0.821* 0.824 1.077 1.561 INC4 -3943.47 1028.39*** 3630 -3.268 -0.237 1.885 4.252

0.07 0.123 0.645 2.125

0.638 0.643 -

0.6 0.594 -

0.543 0.541 0.542 0.557

Dependent variable of loneliness was measured by self-reporting coded as 1 “not at all”, 2 “some of the time” and 3”often”

1

Dependent variable of loneliness was measured by deprivation scale coded as 1”no one”, 2” one or two” and 3” more than two”

2

Dependent variable of loneliness was measured by composite index with the scores ranging from 1 to 5. Higher score indicates

3

higher loneliness. Including Control variables.

4

***p<0.001. **p<0.01. *p<0.05

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DISCUSSION AND CONCLUSION As anticipated, the characteristics of social networks of elderly people play a significant role in generating or deterring loneliness. Consistent with existing studies, marital status is the strongest demographic predictor of self-reported loneliness in older persons (Page & Cole, 1991). Especially for the elderly who have no children, partnership is more significant in reducing loneliness. In this regard, the currently married elderly who have no children are less likely to feel lonely than the currently unmarried who have no children. Findings further indicate that elderly widows without children are more prone to loneliness than those who are married, divorced or separated without children. This is perhaps exacerbated by the fact that the proportion of widowed elderly who live alone is high. Results from three quantitative analyses administered in the study have consistently indicated that the elderly who have children are less likely to report loneliness than those who have no children, revealing that children are seen as a very important factor to lessen loneliness. Frequency of contact with children is significantly associated with loneliness. Older persons who have less frequency of contact with children are more likely to feel lonely. Additionally, according to the findings, it is noteworthy that for the elderly who are not currently married, frequency of contact with children is more important in buffering loneliness than for those who are currently married. This is consistent with the hierarchical compensatory model, which implies that there is an order of support providers who may be replaced by others as required, indicating that children may compensate for the lack of partner. Findings from the study support clear evidence showing that later-life loneliness is associated with contact with relatives. The elderly who have relatives in their social network are less likely to feel lonely compared to their counterparts who do not have relatives in their social network. In addition, results support that relatives, for the currently unmarried, are more significant in reducing experiences of loneliness than for the currently married. This is consistent with the hierarchical compensatory model. Yet, in contrast with other studies, one of the three models undertaken in the quantitative analysis of the study provides that senior people with non-relatives in their network have a greater likelihood of being lonely as compared to their counterparts without non-relatives. One possible explanation is that contact with non-relatives may not always be positive. Another explanation is that most of the older persons with non-kin may not receive the social support they want form the network members (e.g., partners, children or family members). From this, it can be inferred that non-relatives cannot be substituted for their family members, especially partners or children. No association was found between non-relatives and loneliness among the elderly without children. This may be because most of the elderly without children may be single and as such have become accustomed to a degree of independence that allows them not to feel lonely even without others around them. Consistent with existing studies, the study proves that maintaining high quality relationships with family members is seen as a very significant factor in buffering feelings of later-life loneliness (Gierveld, 1998). On the other hand, unexpectedly, the results support that the elderly who are satisfied with their relationships with non-relatives have a higher probability of being lonely compared to those who are not. This is perhaps because the elderly who have a satisfying relationship with non-relatives cannot maintain good relations with their family members and cannot achieve their desired relationships with family members. By and large, not only primary sources of social networks but also substitute sources of social networks can

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reduce loneliness. Furthermore, objective characteristics of social networks as well as subjective characteristics play significant roles in lessening the degree of loneliness. Since the study constructs measurements of loneliness based on only two questions, which cannot capture all of the dimensions of loneliness, further research should be conducted by undertaking a more in-depth approach on the basis of qualitative data so as to provide the additional information about loneliness and the additional explanation of why the elderly feel lonely.

REFERENCES Department of Population, & UNFPA. (2012). Aging Transition in Myanmar. Yangon: UNFPA. Gierveld, J. D. J. (1978). The construction of loneliness: Components and measurement. Essence, 2, 221238. Gierveld, J. D. J., & Tilburg, T. V. (2006). A 6‐Item scale for overall, emotional, and social loneliness confirmatory tests on survey data. Research on Aging, 28, 582-598. Iecovich, E., Barasch M., Mirsky, J., Kaufman, R., Avgar, A., & Kol-fogelson, A. (2004). Social Support Networks and Loneliness among Elderly Jews in Russia and Ukraine. Journal of Marriage and Family, 66, 306-317. Knodel, J. (2014). The Situation of Older Persons in Myanmar. Yangon: HelpAge. Mullins, L. C., & Dugan, E. (1990). The influence of depression, and family and friendship relations, on residents’ loneliness in congregate housing. Gerontologist, 30(3), 377-384. Perlman, D., & Peplau, L. A. (1981). Toward a social psychology of loneliness. In S. W. Duck & R. Gilmour (Eds.), Personal relationship3: Personal relationships in Disorder (pp. 31 – 56). London: Academic Press. United Nations. (2011b). World Population Prospects: The 2010 Revision. New York: United Nations. United Nations Department of Economics and Social Affairs (UNDESA) 2007. World Population Ageing. UNDESA, New York. Walker, K. N., MacBride, A., & Vachon, M. L. S. (1977). Social support networks and the crisis of bereavement. Social Science and Medicine, 11, 35-41.

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The Relationships between Social Determinants and Quality of Life among Older Adults in Nursing Homes, East Java Province, Indonesia Fatma S. Ruffaida1, Benjamas Sirikamonsathian2, Kanokwan Wetasin2 1 Kasetsart University, Bangkok, Thailand, [email protected] 2 Boromarajonani College of Nursing Nopparat Vajira, Bangkok, Thailand, [email protected], [email protected]

ABSTRACT Quality of life has become an important component of health surveillance of older adults. Social determinants are the conditions that can affect quality of life. The objective of this study was to examine the relationships between social determinants (e.g., age, gender, marital status, body mass index, disease, length of stay, social support, and social participation) and quality of life among older adults in nursing homes, East Java Province, Indonesia. A cross-sectional study was conducted with 258 older adults in three nursing homes. The data were collected by face-to-face interview with structured questionnaires and anthropometric measurements of weight and height. The data were analyzed using descriptive statistics and Spearman’s Rho. The results revealed that length of stay, disease, social support number, and social participation were related to quality of life (rs = -.218, p < 0.01; rs = -.266, p < 0.05; rs = .174, p < 0.01; rs = .177, p < 0.01, respectively). Based on these findings, health care providers should be concerned about activities that could involve the older adults and the family in nursing home. Further assessment is needed to determine the types of preferable social activities for older adults in order to effectively design appropriate social programs. Keywords: Social Determinants, Quality of Life, Older Adults, Nursing Home, Indonesia

INTRODUCTION The number of older adults in Indonesia increased by 11.39% from 2011 to 2013 (Ministry of Health Republic of Indonesia, 2012, 2014). In particular, the number of older adults in East Java Province was about 11% of the total population in East Java Province. In addition, among 33 provinces in Indonesia, East Java Provinces had the highest number (571,914) of neglected older adults in 2011 (Ministry of Social Republic of Indonesia, 2011). The ageing population could be seen as a success story for public health policies and socioeconomic development since life expectancy was one of the health indicators of the health services in the country (Ministry of Health Republic of Indonesia, 2014). However, the ageing population now challenges the society to adapt in a way that will maximize the health and functional capacity of older people as well as their social participation and security (East Java Provincial Bureau of Public Relations, 2013). Thus, quality of life has become one of the components of health surveillance of older adults (Centers for Disease Control and Prevention, 2011). Furthermore, in East Java Province, Ministry of Social Republic of Indonesia (2003) provided non-profit nursing homes for neglected older adults and older adults who have a risk of being neglected.

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Social determinants of health, including age, gender, marital status, body mass index, chronic disease, length of stay in the nursing home, social support, and social participation, were the conditions that related to quality of life among older adults (Centers for Disease Control and Prevention, 2011, 2014; World Medical Association, 2015). However, previous studies on social determinants and quality of life showed inconsistent findings. There are studies that conversely showed that social determinants were not related with quality of life among older adults (Huang et al., 2003; Li et al., 2013; Orfila et al., 2006; Öztürk, Şimşek, Yümin, Sertel, & Yümin, 2011; Tseng & Wang, 2001). Thus, the objective of the study was to examine the relationships between social determinants and quality of life among older adults in nursing homes. The findings from this study would be useful for health care providers including nurses and social workers to use as supporting information to increase quality of life among older adults in nursing homes.

METHOD Design and Sample A cross-sectional design was used in this study. Two hundred fifty eight older adults were recruited from three nursing homes in East Java Province, Indonesia. The nursing homes are government nursing homes provided for neglected older adults. Purposive sampling method was used to select the participants with inclusion criteria as follows: a) age was equal to or above 60 years old, b) the ability to speak in Bahasa Indonesia, c) good cognitive function (normal or slightly damaged) evaluated by Pfeiffer (1975) “The Short Portable Mental Status Questionnaire”, d) a willingness to join the research project, and e) the older adults who stay in common and private rooms. An exclusion criterion was older adults who were diagnosed with severe dementia, depression, or tuberculosis. Depression was evaluated using a 5-item version of Geriatric Depression Scale (Hoyl et al., 1999).

Instruments The data was collected using four questionnaires; including a) socio-demographic questionnaire that consisted of eight items including age, gender, marital status, height, weight, Body Mass Index (BMI), length of stay, and diseases, b) social support questionnaire (Sarason, Sarason, Shearin, & Pierce, 1987) that consisted of 12 items, c) social activity questionnaire (Krueger et al., 2009) that consisted of five items, and d) Ferrans and Powers Quality of Life Index Nursing Home Version – III (Ferrans, 1998) that consisted of 33 items. The instruments were translated into Indonesian using back translation techniques. The instruments were tested for content validity and reliability. Content validity was tested by three experts including an expert in family, community of health nursing, and geriatric nursing. The experts were asked to rate the clarity and relevance of the instrument using Content Validity Index Items (CVI-I). According to the CVI-I, the items of the questionnaire were valid. Subsequently, the reliability was tested using Cronbach’s alpha coefficient. The questionnaires were tested with 30 older adults in another nursing home that was not included in the study. The results were ranged from 0.78 - 0.87.

Data Collection The study was approved by the Committee and Ethics Review Board (ERB), Committee for Research Involving Human Research Subjects, Boromarajonani College of Nursing Nopparat Vajira, Bangkok, Thailand (ERB No. 14/2015). Face-to-face interviews with questionnaires and anthropometric measurements were used to collect the data. The data was collected by the researcher. Overall, data collection took around 25 minutes for each participant. 88

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Data Analysis Descriptive statistics were used to identify the characteristics of each variable including number, percentages, median, and range. In this study, median and range were used because the distribution of the data was not normal. Further, Spearman Rho was used to examine the relationships between social determinants and quality of life.

RESULTS The results showed that the majority (66.3%) of the participants were female. The median age of participants was 74 years, with a range from 60 to 95 years old. The majority (96.1%) of the participants were single or widowed. More than half (81.8%) of the participants had stayed in the nursing homes for more than six months. More than half (65.5%) of the participants had a normal Body Mass Index (BMI), with BMI range between 15.15 - 29.14 kg/m2. The majority (78.7%) of the participants had a chronic disease. The details of characteristics of individual are shown in Table 1. Table 1: Frequencies and Percentages of Gender, Age, Marital Status, Length of Stay, BMI and Chronic Diseases (n = 258) Variables Gender Female Male Age (years) 60 - 69 70 - 79 80 - 89 90 and over Marital status Single/widow Married Length of stay < 6 months ≥ 6 months BMI (kg/m2) < 18.5 (Underweight) 18.5 – 24.9 (Normal weight) 25.0 – 29.9 (Overweight) Diseases Have chronic diseases Not have chronic diseases

Frequency

Percent

171 87

66.3 33.7

55 119 69 15

21.3 46.1 26.8 5.8

248 10

96.1 3.9

47 211

18.2 81.8

57 169 32

22.1 65.5 12.4

203 55

78.7 21.3

Gender, age, marital status, BMI and social support satisfaction were not related to quality of life. However, length of stay, having a chronic disease, social support number, and social participation were related to quality of life (rs = -.218, p < 0.01; rs = -.266, p < 0.05; rs = .174, p < 0.01; rs = .177, p < 0.01, respectively). The results are summarized in Table 2.

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Table 2: The Relationship between Social Determinants and Quality of Life among Older Adults in Nursing Homes (n = 258) Variables Gender Age Marital Status Length of stay BMI Disease Social Support Number Social Support Satisfaction Social Participation

Quality of Life rs 0.085 0.028 -0.077 -0.218 0.049 -0.266 0.174 0.093 0.177

p-value 0.174 0.659 0.216 <.001 0.236 <.001 <.001 0.136 <.001

DISCUSSION This study showed that older adults who stayed longer in nursing homes had a relatively poorer overall quality of life. The possible explanation was that older adults may feel that they were separated from the society. This study was consistent with the previous studies (Drageset et al., 2009; Khader, 2011; Tseng & Wang, 2001). Tseng and Wang (2001) that showed that older adults may feel that they were abandoned and isolated from society if they stay longer in a nursing home. Having chronic diseases may lead to a lower quality of life. The possible explanation was that older adults who had diseases tended to have limitations in their performance of activities of daily living. As a result, physical health and social activity declined through the effects of chronic diseases and affected older adults quality of life (Centers for Disease Control and Prevention, 2003). This study was consistent with the previous studies (Bilgili & Arpacı, 2014; Orfila et al., 2006; Tseng & Wang, 2001). Bilgili and Arpacı (2014) that showed that older adults without diseases had higher quality of life than older adults people with diseases. This study showed that older adults in nursing homes with the higher social support number had a better overall quality of life. The possible explanation was that older adults in nursing homes in East Java Province, Indonesia had someone who supported them, such as friends, health care providers, and family. Thus, older adults with this support may feel satisfied with overall quality of life in nursing homes. The result of this study was consistent with the previous studies (Chen, Hicks, & While, 2013; Suryati, 2015). This study revealed that older adults in nursing homes with the higher social participation had a better overall quality of life. The possible explanation was that older adults in nursing homes in East Java Province had more scheduled social activities, such as religious meeting, exercise, and crafting. Each of the social activities in the nursing home could enhance the subscale of quality of life. Thus, participation in social activities could enhance quality of life of the older adults. The result of this study was consistent with the previous studies (Mikula et al., 2015; Sampaio, Ito, & Sampaio, 2013; Yuliati, Baroya, & Ririanty, 2014). This study showed that gender was not related to overall quality of life. The possible explanation was that the developmental stages of the older adults, whether male or female, were similar (physically, mentally,

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spiritually, and socially), which could affect the quality of life of older adults (Santrock, 1997). This study was consistent with the previous study (Tseng & Wang, 2001). Further, age was not related to overall quality of life. The possible explanation was that older adults in nursing homes had similar declining health with regard to biological aging. In addition, all of the older adults in the nursing homes received similar services, such as health care services. This study was consistent with the previous studies (Campos, Ferreira e Ferreira, Vargas, & Albala, 2014; Tseng & Wang, 2001). Moreover, marital status was not related to overall quality of life. The possible explanation was that older adults had different residency with regard to gender in some of nursing homes. Thus, older adults who are married also lived separately with their spouse in nursing homes like any other single/widow ones. This study was consistent with the previous studies (Huang et al., 2003; Tseng & Wang, 2001). BMI was not related to overall quality of life. However, this study was inconsistent with the previous studies that revealed that BMI was related to the quality of life of older adults (Barentsen et al., 2012; Öztürk et al., 2011). The possible reason was that obese older adults included in previous studies, were not be found in this study. Thus, BMI may be related to the lower quality of life since obesity was related with increased risk for diabetes, cardiovascular disease, and other chronic conditions (Miller, 2012), but because of the nature of the sample in this study, it was not detected. This study also showed that social support satisfaction was not related to overall quality of life. The possible explanation was that whether older adults were satisfied or unsatisfied with the number of social support, the older adults still had received services from nursing homes. In contrast, a study by Deng, Hu, Wu, Dong, and Wu (2010) found that social support satisfaction related to quality of life among older adults. The possible explanation was that the previous study was conducted in the community dwelling with a very old populations who were very weak and needed more support from family.

CONCLUSIONS This study showed that length of stay, diseases, social support number, and social participation were significantly related to the quality of life among older adults in nursing homes. Based on these findings, health care providers including family and community nurses should be concerned about activities that could involve older adults and the family in nursing homes. Further assessment is needed to determine the types of preferable activities for older adults in order to design appropriate social programs effectively.

Limitation

This study did not have participants who were obese. Thus, the result of this study could be different with other research, which included obese participants.

Acknowledgement

The authors acknowledge Asst. Prof. Dr. Kwanjai Amnatsatsue from Faculty of Public Health, Mahidol University, Bangkok, Thailand, and all faculties of Boromarajonani College of Nursing Nopparat Vajira, affiliated with Kasetsart University, Bangkok, Thailand. The authors appreciate the staff of Nursing Homes in East Java Province, and all participants. This study has sponsored by Directorate of Higher Education, Ministry of Research, Technology, and Higher Education Republic of Indonesia. We also appreciate Kadiri University, Kediri City for supporting this study.

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REFERENCES Barentsen, J., Visser, E., Hofstetter, H., Maris, A., Dekker, J., & de Bock, G. (2012). Severity, not type, is the main predictor of decreased quality of life in elderly women with urinary incontinence: a population-based study as part of a randomized controlled trial in primary care. Health and Quality of Life Outcomes, 10(1), 153. Bilgili, N., & Arpacı, F. (2014). Quality of life of older adults in Turkey. Archives of Gerontology and Geriatrics, 59(2), 415-421. Campos, A. C., Ferreira e Ferreira, E., Vargas, A. M., & Albala, C. (2014). Aging, Gender and Quality of Life (AGEQOL) study: factors associated with good quality of life in older Brazilian community-dwelling adults. Health and Quality of Life Outcomes, 12(1), 166-176. Centers for Disease Control and Prevention. (2003). Chronic Disease Notes & Reports. Centers for Disease Control and Prevention, 16(1), 1-36. Centers for Disease Control and Prevention. (2011). Health-Related Quality of Life (HRQOL). Retrieved December 14th, 2015, from http://www.cdc.gov/hrqol/concept.htm Centers for Disease Control and Prevention. (2014). NCHHSTP Social Determinants of Health. Retrieved February 23rd, 2016, from http://www.cdc.gov/nchhstp/socialdeterminants/faq.html Chen, Y., Hicks, A., & While, A. E. (2013). Quality of life of older people in China: a systematic review. Reviews in Clinical Gerontology, 23(1), 88-100. Deng, J., Hu, J., Wu, W., Dong, B., & Wu, H. (2010). Subjective well-being, social support, and age-related functioning among the very old in China. International Journal Of Geriatric Psychiatry, 25(7), 697-703. Drageset, J., Natvig, G. K., Eide, G. E., Bondevik, M., Nortvedt, M. W., & Nygaard, H. A. (2009). Health-related quality of life among old residents of nursing homes in Norway. International Journal of Nursing Practice, 15(5), 455-466. East Java Provincial Bureau of Public Relations. (2013, November 25). Number of Elderly in East Java Province is Four Million of Total Population. Retrieved March 20, 2015, 2015, from http://birohumas. jatimprov.go.id/index.php?mod=watch&id=2323 Ferrans, C. E. (1998, 2015). Quality of Life Index. Retrieved March 20, 2015, 2015, from www.uic.edu/ orgs/qli/index.htm Hoyl, M. T., Alessi, C. A., Harker, J. O., Josephson, K. R., Pietruszka, F. M., Koelfgen, M., Rubenstein, L. Z. (1999). Development and testing of a five-item version of the Geriatric Depression Scale. Journal of the American Geriatrics Society, 47(7), 873-878. Huang, Z., Neufeld, R. R., Likourezos, A., Breuer, B., Khaski, A., Milano, E., & Libow, L. S. (2003). Sociodemographic and health characteristics of older Chinese on admission to a nursing home: a cross-racial/ethnic study. Journal of the American Geriatrics Society, 51(3), 404-409. Khader, F. (2011). Quality of Life in the Nursing Homes in Jordan: Perspectives of Residents. Care Management Journals, 169-182. Krueger, K. R., Wilson, R. S., Kamenetsky, J. M., Barnes, L. L., Bienias, J. L., & Bennett, D. A. (2009). SOCIAL ENGAGEMENT AND COGNITIVE FUNCTION IN OLD AGE. Experimental aging research, 35(1), 45-60.

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Li, X.-J., Suishu, C., Hattori, S., Liang, H.-D., Gao, H., Feng, C.-Q., & Lou, F.-L. (2013). The comparison of dementia patient’s quality of life and influencing factors in two cities. Journal of Clinical Nursing, 22(15-16), 2132-2140. Mikula, P., Nagyova, I., Krokavcova, M., Vitkova, M., Rosenberger, J., Szilasiova, J., . van Dijk, J. P. (2015). Social participation and health-related quality of life in people with multiple sclerosis. Disability and Health Journal, 8(1), 29-34. Miller, C. A. (2012). Nursing for Wellness in Older Adults. Philadelphia: Wolters Kluwer Health; Lippincott Williams & Wilkins. Ministry of Health Republic of Indonesia. (2012). Indonesia Health Profile 2011. Jakarta: Ministry of Health Republic of Indonesia. Ministry of Health Republic of Indonesia. (2014). Indonesia Health Profile 2013. Jakarta: Ministry of Health Republic of Indonesia. Ministry of Social Republic of Indonesia. (2003). Elderly Social Services Policies and Program in Indonesia. Retrieved April 20, 2015, 2015, from http://www.bkkbn.go.id/arsip/Documents/Perpustakaan/ ALIH%20MEDIA%202012/002/9.Kebijakan%20dan%20Program%20Pelayanan%20Sosial%20 Lansia.pdf Ministry of Social Republic of Indonesia. (2011). Database Ministry of Social Republic of Indonesia. Retrieved April 20, 2015, 2015, from http://database.kemsos.go.id/ Orfila, F., Ferrer, M., Lamarca, R., Tebe, C., Domingo-Salvany, A., & Alonso, J. (2006). Gender differences in health-related quality of life among the elderly: The role of objective functional capacity and chronic conditions. Social Science & Medicine, 63(9), 2367-2380. Öztürk, A., Şimşek, T. T., Yümin, E. T., Sertel, M., & Yümin, M. (2011). The relationship between physical, functional capacity and quality of life (QoL) among elderly people with a chronic disease. Archives of Gerontology and Geriatrics, 53(3), 278-283. Pfeiffer, E. (1975). A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. Journal of the American Geriatrics Society, 23(10), 433-441. Sampaio, P. Y. S., Ito, E., & Sampaio, R. A. C. (2013). The association of activity and participation with quality of life between Japanese older adults living in rural and urban areas. Journal of Clinical Gerontology and Geriatrics, 4(2), 51-56. Santrock, J. W. (1997). Life-Span Development (Sixth Edition ed.). Dubuque: Brown and Benchmark Publisher. Sarason, I. G., Sarason, B. R., Shearin, E. N., & Pierce, G. R. (1987). A Brief Measure of Social Support: Practical and Theoretical Implications. Journal of Personal and Social Relationships, 4(1), 497-510. Suryati, T. (2015). The Corelation between social support and quality of life of elderly at nursing home Tresna Werdha Budi Mulia 4 Margaguna Jakarta Selatan. (Master Thesis), Universitas Indonesia, Depok. Tseng, S., & Wang, R. (2001). Quality of life and related factors among elderly nursing home residents in southern Taiwan. Public Health Nursing, 18(5), 304-311. World Medical Association, I. (2015). WMA Declaration of Oslo on Social Determinants of Health. Retrieved February 23rd, 2016, 2016, from http://www.wma.net/en/30publications/10policies/s2/ Yuliati, A., Baroya, N., & Ririanty, M. (2014). The Different of Quality of Life Among the Elderly who Living at Community and Social Services. 2(1), 87-94.

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Effect of Self-Management Support Program on Knowledge and Self-Care Behaviors of Community-Dwelling Older Adults with Congestive Heart Failure Ketchayanee Waenkaew1, Kwanjai Amnatsatsue1, Patcharaporn Kerdmongkol1 1 Department of Public Health Nursing, Faculty of Public Health, Mahidol University, Thailand E-mail: [email protected]

ABSTRACT Background: Urbanization, advancing age, living with poor health and low socio-economic status have influenced older adults to have poor quality of life and inequality in accessing services. Particularly among older adults with congestive heart failure, a higher rate of readmission and complications has been increasingly reported, especially during the first month after discharge. With self-care decline and poor rehabilitation rate, a self-management support program was developed and tested for its effects on knowledge about disease, self management, and its complication as well as self-care behavior before and after the intervention. Materials and Methods: A two-group pre-posttest quasi-experimental study was conducted at patient’s home in Bangkok from October 2015–December 2015. About 42 participants, who were 60-80 years old, got diagnosis of congestive heart failure stage C, were assigned for the experimental and comparison groups. A comparison group received routine care, while the experimental group received a 4-week self management support program, consisting of health education and skill training on nutrition with restricted fluid and sodium, medical adherence, light exercise, and emergency care; 1 home visit; and 3 telephone follow up. Self report questionnaire, developed by the researcher was used to collect data before and after the intervention. Results: According to paired t-test and independent t-test, after implementing the program, the experimental group had a significantly higher mean score of knowledge as well as self-care behavior than before and those in the comparison group (p-value <.05). Conclusion: The results of this study confirmed that the self-management support program can improve knowledge and self-care behaviors of older adults with congestive heart failure. Future study should be conducted to develop effective guidelines for community-dwelling older adults with heart failure to improve their health outcome. Keywords: Supportive education program, Elderly people, Self-care behavior, Congestive heart failure

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Poster Presentations

Early Marriage and Adolescent Pregnancies in Nepal: Promoting Gender Equity Hari Jung Rayamazi1, Marc Van der Putten1, Charlie Thame1 1 School of Global Studies, Thammasat University, Pathumthani, Thailand

ABSTRACT Adolescent pregnancy is common in South Asia with early marriage as a dominant precursor. Nepal’s socio-cultural context and outcomes mirror the South Asian phenomenon. Addressing gender inequity in Nepal requires an understanding of social determinants and policy to benefit from gender transformative approaches. Questions addressed are: How can we understand gender affecting early pregnancy? What prospects might surface to promote a gender transformative approach? A qualitative documentary research was employed. Documents included journal papers on Bangladesh, India, Sri Lanka and Nepal; relevant government policy; global actors’ policy briefs; and gender transformative approaches published between 2000 and 2015. Reflection on findings was facilitated by Nepali key informants. Societal factors affecting gender inequity involved: patriarchal societies, caste and dowry systems, barriers to education, and socio-cultural values. Global actors’ policy briefs broadly addressed social determinants. Nepal has key policies in place but lacks crosscutting consistency and enforcement. Countries have signed and ratified global charters. However outcomes remain poor. Besides enhancing policy enforcement, gender transformative approaches are required to produce leverage. In addition to addressing girls’ empowerment, men’s power, and gendered vulnerabilities, synchronizing gender strategies is the way forward for Nepal. Gender inequity fuels early marriage and adolescent pregnancy in South Asia. Nurturing a gender transformative society requires strategies involving media, religion, education, family and policy. Keywords: Early marriage, Adolescent pregnancy, Gender equity, Nepal

INTRODUCTION Globally, “pregnancy and childbirth is the number one killer of 15-19 year olds” (Shrestha, 2012). About 16 million adolescent girls aged 15 to 19 and some one million girls under age 15 give birth every year, representing 11% of all births worldwide. About 95% of these births occur in low and middle income countries (WHO, 2011). In South Asia, nearly 60% of all girls are married by the age of 18 years and one fourth is married by the age of 15 years (Mehra & Agrawal, 2004). Within South Asia, the recorded teenage pregnancy rate is highest in Bangladesh (35%), followed by Nepal (21%), and India (21%), (Acharya et al., 2010).

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In Nepal, the legal age of marriage for females is 18 years. However, 17 percent of women age 15-19 have already given birth or are pregnant with their first child. The median age at marriage among Nepali women is 17.5 years (NDHS, 2011). The overall Maternal Mortality Rate in Nepal is 281 per 100,000 live births, whereas 30% these maternal deaths are of adolescent mothers (NHSPIP, 2010). Early marriage is common practice among girls (32% below age 18) in Nepal. While knowledge on contraceptive prevalence and family planning is very high (99.9%) among adolescents, only 14% of married adolescent girls are using modern contraceptive methods (WHO, 2014). This translates in early pregnancy to 30% of married adolescent girls age 15-19, and leads to relatively high adolescent fertility rates (72 births per 1,000 women aged 15-19 in 2013) (WB, 2013). Regional differences exist: adolescent fertility rates in rural Nepal are almost double compared to urban areas (NDHS, 2011). Among married adolescent girls age 15-19 contraceptive use is only 14.4%, whereas the unmet need for family planning among these young women is 42% (WHO, 2014); MoHP, 2012. Prevention of unintended pregnancies continues to be the main focus in population policy, though the broader social policy reforms required to address root causes of gender and health inequity called for at Cairo are often neglected (Casterline & Sinding, 2000) . South Asia presents a large proportion of young people in the world where adolescent pregnancy has emerged as a major public health issue. Within the South Asia region, Nepal, Bangladesh, India and Sri Lanka share similar socio-economic and cultural influences. Although the social determinants of adolescent pregnancy are known, programs often fail to go beyond prevention of unintended pregnancies. Pathways need to be explored to promote gender transformative programming in addressing gender and health inequity in Nepal.

Research Questions • •

In a South Asian context, how can we understand gender as it affect early pregnancy? What prospects might surface to promote male involvement in a gender transformative approach?

METHODOLOGY A qualitative approach to a documentary research was employed yielding 92 papers. Data sources included journal publications, evaluation reports, policy and service frameworks, government, IO and I/NGO documents and unpublished works. Bangladesh, India, Nepal, and Sri Lanka were purposively selected based on similarities in their socio-cultural contexts. Selected global policy actors included UNICEF, WHO, UNFPA, and Ministry of Health and Population of Nepal. Selection criteria for documents included: source authority and relevance, (noting that the authors’ criterion of relevance expanded as understanding evolved throughout the study); peer reviewed papers on gender and early marriage and/or adolescent pregnancy in Bangladesh, India, Sri Lanka and Nepal; global actors’ policy briefs; relevant published government policy; and gender transformative approaches published between 2000 and 2015. The exclusion criterion was papers with only abstracts available.

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Search engines used were Medline, PubMed, Google Scholar, and internet based public access domains, while retrieval was assisted by a Boolean search strategy. Documentary review was facilitated by a thematic content analysis. Finally, reflection on findings was facilitated by interviews with Nepali key informants’ (i.e. social workers and health professionals.)

Results Gender inequity fuels early marriage, which is commonly a direct cause of adolescent pregnancy in South Asia and in Nepal. Key societal factors affecting gender inequity involve: patriarchal societies where women depend on men in public life, family and relationships for decision-making; caste and dowry systems that impact economic status and challenge gender equity; barriers to access education undermining empowerment of girls; and socio-cultural values on virginity and fertility weakening adolescent girls’ voice. There is a vicious circle created by the caste system and the Dalits’ (i.e., low social caste) response to discrimination and abuse. This fuels early marriages within their groups, notwithstanding the abolishment of untouchability in Nepal under the Country Code of Nepal 1963 (Goonesekere, 2009). It is of interest that findings revealed that both low and high castes were considered vulnerable to early marriage and adolescent pregnancy. For low castes, economic hardship pushes people into early marriage, whereas high castes are driven by desire for religious merit. Global actors’ policy briefs broadly address key social determinants such as: (1) policy and program development that involves promotion of the right and access to education for girls, strategies to diminish social support for early marriage, creation of safe school environments, integration of sex education in curricula, adolescent sexual and reproductive health services and poverty reduction; (2) legal measures that involve review of national legislation, law enforcement, and reporting and supportive legal services; (3) development of multi-sectoral approaches including inter-public sector collaborations, fostering collaboration between public sector programs and civil society, developing partnerships, and recognizing and working with family dynamics; (4) fostering of enabling environments through financial strategies, adopting the safe spaces model, awareness raising among key local stakeholders, promoting school health, developing adolescent friendly health services, and nurturing social change; and (5) research based evidence through maintaining surveillance systems, and undertaking action research and evaluative studies. Nepal has key policies in place but is lacking consistency across policies that challenge enforcement of those policies. For example, there are inconsistencies in dowry law: Nepal’s Social Practice Reform Act (1976) restricts acceptance of gifts from either bride’s or groom’s side in marriage and has penalties for doing so. However, Nepali legislation does not completely prohibit the practice of dowry and religious laws drive structural discrimination (Goonesekere, 2009). The Act allows people to give dowry out of their own will up to Rs. 10,000 (Karki, 2014) Further, weak policy enforcement on statutory age, birth and marriage registration, protection of vulnerable castes, and dowry law, together with the lack of monitoring of violations of the law create a gap between policy and practice. Throughout South Asia, including Nepal, the deep-rooted practice of dowry is no match for weak policy formulation and or policy enforcement.

Discussion It is acknowledged that a narrative documentary review is sensitive to potential selection bias in addition to possible analysis and inference biases in selected studies. However, where possible triangulation was ap-

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plied to identify confirmations and or discrepancies. Provided that this study explored publications relevant to early marriage and adolescent pregnancy in Bangladesh, India, Sri-Lanka, and Nepal, findings have to be understood as mirroring the societal context of South Asia and therefore cannot be generalized to the whole of Asia or beyond. South Asia presents a significant proportion of young people globally and adolescent pregnancy has emerged as an important public health problem among them. It is important to note that pre-marital sex is not common practice in South Asia; instead, the dominant precursor for adolescent pregnancy is early marriage. Therefore findings on adolescent pregnancy have to be understood within the context of early marriage. Our review was unable to bring clarity on barriers to legally abolish dowry in Nepal. The country pledged ending child marriage by 2020 (Girls Not Brides, 2015), however given the deep-rooted practice and weak policy enforcement it is unlikely that this goal can be achieved within five years. The Nepal Government provides free education up to lower secondary level. This is clearly an incentive to stimulate inclusion of girls from poor, marginalized, and disadvantaged families. However, Nepal’s education policy is unable to overcome gender inequities and the practice of early marriage for girls. Nepal’s education policy does not include collateral costs like stationary supplies, uniforms, lunch. etc.. which remain as important barriers for girls from poor families. Further, girls who complete lower secondary school education are still under 18 years of age. In absence of free higher secondary school education there is no incentive for postponing marriage beyond lower secondary education level. Global actor policy recommendations address key social determinants and countries have signed and ratified global charters. Outcomes, however, remain poor. In addition to enhancing policy enforcement, gender transformative approaches are required to produce leverage. Gender transformative strategies address underlying causes of gender inequity to create conditions for sustained achievement of girls’ empowerment. It fosters community-led changes in unequal gender relations to promote shared power, control of resources and decision-making. Practically, it means working with government officials, policy makers, and human rights activists, among others, to influence people in the community and young people themselves, including boys, with an aim to obtaining their support, contribution, advocacy, and persuasion for empowering girls and protecting reproductive and sexual health of young people. In the context of Nepal, besides promoting empowerment for girls or addressing men’s power as well as gendered vulnerabilities, synchronizing gender strategies is the way forward. Such synchronized strategies are the deliberate coming together of gender-transformative efforts to reach both men and boys and women and girls. They engage people with a stake in gender-related vulnerabilities and inequalities that hinder girls’ health and well-being. These approaches can occur simultaneously or sequentially, within a particular program or in coordination with other sectors. Gender-synchronized approaches seek to balance power between men and women in order to ensure gender equality and transform (change) social norms that lead to gender-related vulnerabilities. These gender synchronized approaches aim to increase understanding of how everyone is influenced and shaped by socially determined gender roles. These programs view all actors in society in relation to each other, and seek to identify or create shared values among women and men within the range of roles they play (i.e., mothers-in-law, fathers, wives, brothers, daughters(Greene & Levack, 2010).

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CONCLUSION Nurturing a gender transformative society requires addressing both empowerment of girls and women as well as of boys and men’s power through media, religion, education, family and policy. Gender transformative approaches should be synchronized to maximize impact. All concerned actors in society need to be viewed in relation to each other to transform or change social norms and traditions that create gender inequity. Besides girls/women and boys/men these include policy-makers, social services professionals, media, religious and community leaders, and family members.

REFERENCES Acharya, D. R., Bhattarai, R., Poobalan, A., Teijlingen, E. R. v., & Chapman, G. (2010). Factors associated with teenage pregnancy in South Asia. Casterline, J. B., & Sinding, S. W. (2000). Unmet need for family planning in developing countries and implications for population policy. Population and development review, 26(4), 691-723. Girls Not Brides. (2015). Lessons Learned from Selected National Initiatives to End Child Marriage. Retrieved from http://www.ungei.org/resources/files/Girls_Not_Brides.pdf Goonesekere, S. (2009). Harmful Traditional Practices in three Countries of South Asia: culture, human rights and violence against women: United nations. Economic and social commission for Asia and the Pacific (UN. ESCAP). Social development division. Greene, M. E., & Levack, A. (2010). Synchronizing gender strategies: A cooperative model for improving reproductive health and transforming gender relations. Karki, S. (2014). A study on Dowry related Violence in Nepal Mehra, S., & Agrawal, D. (2004). Adolescent health determinants for pregnancy and child health outcomes among the urban poor. Indian pediatrics, 41(2), 137-145. NDHS. (2011). Nepal Demographic Health Survey, Nepal: New ERA/MoHP. NHSPIP. (2010). Nepal Health Sector Programmr Implementation Plan II (NHSP -IP 2) 2010 – 2015. Government of Nepal. Shrestha, A. (2012). Teenage pregnancy in Nepal: consequences, causes and policy recommendations. WB. (2013). Adolescent Fertility Rate. Retrieved http://data.worldbank.org/). WHO. (2011). Early marriages, adolescent and young pregnancies. Report by the Secretariat. Executive Board. 130th Session (Geneva, 1st December 2011), Document EB130/12. Geneva: World Health Organization. WHO. (2014). Health for the World’s Adolescents Report. Highlights from the South East Asia Region. Retrieved from http://apps.who.int/adolescent/second-decade/files/1612

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Changing Trends on Caloric Intake and Diet in Asean: What Endangered Their Status? Samittra Pornwattanavate1, Marc Van der Putten1, Vandita Rajesh1 1 School of Global Studies, Thammasat University, Pathumthani, Thailand

ABSTRACT ASEAN ranks lowest for obese adults compared to other regions. However, a gradual rise is observed. In 2014, the ASEAN region ranked second for increasing prevalence of overweight. Although several studies focused on obesity prevalence and diet pattern, few researches examined changing trends in food consumption in ASEAN. This study determined overweight and obesity prevalence trends in ASEAN and identified changes in calories intake and diet. Secondary descriptive analysis was performed using data from WHO 2010-2014 and FAO 1990-2011. ASEAN countries were selected based on available data. Obesity was defined as a BMI of ≥ 30. Overweight increased in all countries along with an increase in obesity. Vietnam had the highest increase in overweight and the lowest increase in obesity with the highest change in caloric intake. Conversely, Brunei Darussalam showed lowest increase in overweight and ranked second for increasing obesity, while ranking lowest for increased caloric intake. Most ASEAN countries showed increased sugar and wheat consumption while rate of rice consumption decreased. Overweight and obesity prevalence increased in all selected countries, affected by increased consumption of sugars and sweeteners, rice, and wheat. Rice consumption in Thailand, Malaysia, Indonesia and Vietnam decreased, along with a gradual increase in wheat consumption; while Thailand ranked highest for sugar and sweeteners consumption.

INTRODUCTION Background Globalization helps to create an interconnected and interdependent world that enables broader opportunities for cooperation and ease in transfer of goods, services, and technologies across international boundaries. The international trade and commerce boosted by globalization are also having a significant effect on changing traditional diet patterns by simplifying access to previously unavailable food products all around the world (Mendez & Popkin, 2004). Diets of higher fats, carbohydrates, and salt have been found to be associated with development of overweight and obesity (Soon & Tee, 2014). This new trend of overweight and obesity is the result of changes in diet pattern that is often an aftereffect of globalization. For instance, Thailand is an agricultural country, with easy access to abundant healthy fresh foods. Traditional Thai food is nutritious with fresh fruit, vegetable, herbs, legumes, and also various types of fish that can prevent the incidence of chronic diseases (Soon & Tee, 2014). Adversely, Thai traditional food has been infiltrated by the Western consumer culture that has led to a change in diet pattern and health condition. The impact on obesity is a significant issue in both the developed and the developing countries (Ramachandran & Snehalatha, 2010) 4th International Conference on New Voices, 4 March 2016 |

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Currently, the prevalence of overweight/obesity is on the rise on a global scale. According to a global estimate by the World Health Organization (WHO), in 2014, there were about 1.9 billion overweight and 600 million obese persons aged 18 years and above. It is estimated that by 2030 more than half of world’s population will be overweight or obese; 1.12 billion obese and 2.16 billion overweight people, (Kelly, Yang, Chen, Reynolds, & He, 2008). Globally, in 2014, the age-standardized prevalence of overweight in both sexes doubled to 3.7 % of the global population during a four year period, 2010 to 2014 (WHO,2014). A comparison of the WHO region (2014) indicated that the prevalence of overweight, defined as BMI ≥ 25 kg/m², in Americans was the highest followed by Europe, Eastern Mediterranean, Western Pacific, Africa and South East Asia. Even though prevalence of overweight in South East Asia region was the lowest when compared to other continents. there is a gradual rise in the rates of overweight in South East Asia. South East Asia region ranked second in increasing trend on prevalence of overweight between 2010 to 2014. This may be marked as a warning sign regarding the possible obesity crises to hit ASEAN population in the near future. Despite the extensive research that has focused on prevalence of overweight and obesity and diet pattern, there is hardly any research that examines the changing trend in food consumption. Moreover, most studies examine the prevalence of obesity and related risk factors at a specific point of time or adopt a cross-sectional studies; only a few studies present changing trends in food consumption particularly in ASEAN region and link their association with prevalence of overweight and obesity (Sidik & Rampal, 2009; Peltzer et al., 2014; Cheong, Kandiah , Chinna ,Chan & Saad, 2010). Almost none have examined the changing trends in diet pattern during the past two decades with the same period of rapid globalization (C.R., 2013). Consequently, the purpose of the study was to determine overweight and obesity prevalence trends in ASEAN between 2010 and 2014 and identify changing trends in food consumption in ASEAN countries between 1990 and 2011.

METHODOLOGY Study Design The study used a quantitative approach to analyze data from WHO and FAO on prevalence of overweight/ obesity and food consumption in ASEAN in a rapid the age of globalization.

Inclusion criteria 1. Secondary data on prevalence trends of overweight and obesity that have a clearly defined measure of overweight as an adult who has a BMI between 25.0-29.9 kg/m² and define obesity as an adult who has a BMI of 30 kg/m2 or higher (WHO, 2015). 2. Secondary data that examine obesity in adults; World Health Organization (2014) use age 18 years and over, for estimation of adult’s age. 3. The ASEAN countries included in the quantitative documentary review were Brunei Darussalam, Singapore, Malaysia, Thailand, Indonesia, Laos PDR, Philippines and Vietnam.

Exclusion criteria The quantitative documentary review excluded two countries in ASEAN members namely, Cambodia and Myanmar, because both of them were low-income countries that still face challenges from under nutrition more than over nutrition. The review analysis also excluded any studies outside ASEAN membership.

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Quantitative data analysis Secondary data from existing publications of the WHO has been used in descriptive analysis of prevalence of overweight and obesity in 2010 and 2014 (WHO, 2015) and compared the prevalence of overweight and obesity between 2010 and 2014 among eight countries in ASEAN region. The percentage of prevalence was calculated for each country and the results were plotted on a bar graph. Changing diet patterns was analyzed using secondary data from FAO food balance sheet to examine the changing trends in food consumption among seven countries in ASEAN region namely, Brunei Darussalam, Malaysia, Thailand, Indonesia, Philippines, Laos PDR, and Vietnam in 1990, 2000, 2010 and 2011. This time frame was selected because globalization accelerated rapidly during this 20-year period (C.R., 2013). The food balance sheet presented the commodity availability of human consumption in each country. The per caput supply of each type of food consumption obtained by the primary and processed food supply (in calories) was divided by the countries’ population in a specific period of time. Food consumption variables that were analyzed in the study from FAO (FAO, 2015) were: • Total food consumption per capita per day (Kilocalories) • Sugar and sweeteners consumption per capita per day (Kilocalories) • Rice and wheat consumption per capita per day (Kilocalories) The data on these variables were examined from the years 1990, 2000, 2010 and 2011 to assess changes among the seven countries in ASEAN region. Without the distribution by age group, total food consumption was based on the average estimated amount of calories needed to set a benchmark for comparison of total caloric balance for the population. The estimated total caloric intake to maintain caloric balance is 2,200 kcal/person/day among a moderately active lifestyle population. (Zelman, 2008). The American Heart Association recommends the maximum consumption of sugar and sweetener among the general population in one day as 125 calories (31.25 grams or 7.5 teaspoons) per capita per day (Johnson et al., 2009). The Recommended Daily Intake (RDI) of carbohydrate is 55 percent of total food consumption per day, equal to 1,210 kcal per day (Pickut, 2015).

FINDINGS Overweight prevalence trends in ASEAN The age-standardized prevalence of overweight among adults (both sexes included) increased from 2010 to 2014 in all countries in ASEAN region (see Figure 1). The prevalence of overweight among Brunei population was the highest followed by Singapore, Malaysia, Indonesia, Philippines, Vietnam, and Lao PDR respectively. Vietnam had the highest increasing trend of prevalence of overweight between 2010 and 2014 (2.2 %) while Brunei was the lowest.

Source (WHO, 2014)

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Figure 1: Prevalence of overweight in adults aged 18 years and above by ASEAN countries (Both sex, age-standardized estimated, BMI between 25.0-29.9 kg/m²)

Obesity prevalence trends in ASEAN The age-standardized prevalence of obesity in adults (both sexes included) has increased from 2010 to 2014 in all countries in ASEAN region (see Figure 2). Brunei Darussalam has the highest number of obese adults in ASEAN region, followed by Malaysia, Thailand, Singapore, Indonesia, Philippines, Vietnam and Lao PDR. Malaysia has the highest increasing trend in prevalence of obesity compared to others countries in ASEAN region during the four year period, 2010 to 2014 (2.8 %).

Source (WHO, 2014) Figure 2: Prevalence of obesity in adults aged 18 years and above by ASEAN countries (Both sex, age-standardized estimated, BMI ≥30 kg/m²)

Changing trends on total food consumption Table 1 illustrates that the total food consumption increased by 140-800 kcal/day in all countries in ASEAN region in two decades (from 1990 to 201a). Vietnam significantly increased 811 kcal/day during the twenty-first year period. Back in the 1990s, the total food consumption in Thailand, Lao People’s Democratic

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Republic and Vietnam was less than 2,200 kcal/day. In 2011, the total food consumption in Brunei Darussalam, Malaysia, Thailand, and Indonesia, Vietnam was more than 2,700 kcal. Table 1: Total food consumption by ASEAN countries from 1990 to 2011 (Kilocalories/capita/day) Countries Brunei Darussalam Malaysia Thailand Indonesia Philippine Lao PDR Vietnam

Total food consumption (Kilocalories/ capita/day) 1990 2000 2010 2011 2,806 2,799 2,887 2,949 2,648 2,844 2,871 2,855 2,180 2,604 2,756 2,760 2,338 2,436 2,651 2,712 2,257 2,392 2,582 2,572 2,015 2,116 2,323 2,356 1,905 2,239 2,678 2,716 Source (FAO, 2015)

Changing trends on sugar and sweetener consumption In 2011, Daily intake of sugar and sweeteners consumption in the Brunei, Malaysian, Thai, Filipino and Indonesian populations was higher than recommendation per day. Brunei, Thai and Malaysian population ate sugar and sweeteners at more than twice the recommended maximum of sugar and sweetener per one day. Thailand has the highest increasing percent of sugar and sweeteners consumption to total food consumption during the 21 years period, through 1990 to 2011 (+ 5.82 %) (see Table 2). Table 2: Percent of sugar and sweeteners consumption to total food consumption by ASEAN countries from 1990 to 2011

Countries Brunei Darussalam Malaysia Thailand Indonesia Philippine Lao PDR Vietnam

Percent of sugar and sweeteners consumption to total food consumption ** Increasing or 1990 2000 2010 2011 decreasing trends (1990-2011) 10.83% 9.68% 13.40% 13.46% 2.63% (TF* = 2,806) (TF = 2,799) (TF = 2,887) (TF = 2,949) 13.22% 13.96% 14.00% 14.08% 0.86% (TF = 2,648) (TF = 2,844) (TF = 2,871) (TF = 2,855 ) 8.49% 10.91% 13.93% 14.31% 5.82% (TF = 2,180) (TF= 2,604) (TF= 2,756) (TF= 2,760) 5.86% 6.45% 5.24% 5.27  -0.59% (TF = 2,338) (TF = 2,436) (TF= 2,651) (TF= 2,712) 11.83% 11.58% 8.68% 9.06% -2.77% (TF= 2,257) (TF= 2,392) (TF= 2,582) (TF= 2,572) 1.04% 1.94% 2.28% 2.46% 1.42% (TF= 2,015) (TF= 2,116) (TF= 2,323) (TF= 2,356) 2.52% 5.53% 3.59% 3.31% 0.79% (TF= 1,905) (TF= 2,239) (TF= 2,678) (TF= 2,716) Source (FAO, 2015)

*TF mean Total food consumption

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** Percent of sugar and sweeteners consumption to total food consumption

= Sugar and sweeteners consumption (kcal/capita/day) x 100 Total food consumption (kcal/capita/day)

Changing trends on rice and wheat consumption Carbohydrate is an essential source of energy for humans. Rice and wheat are one source of energy derived from carbohydrate. Rice consumption was calculated as combined calories from milled rice while wheat consumption was calculated as combined calories from wheat and products of wheat that ASEAN population consumed per day. Table 3 shows that most of ASEAN countries eat rice as a main staple, but now the tendency of rice consumption as the only staple food is decreasing and is being gradually replaced by increasing wheat consumption in Brunei, Malaysia, Thailand, Indonesia and Vietnam. (See Figure 3) In 2011, the population of Indonesia, Philippines, Lao PDR and Viet Nam consumed carbohydrates at more than the recommended maximum per day (1,210 kcal/day). Table 3: Rice and wheat consumption by ASEAN countries from 1990 to 2011 (Kilocalories/ capita/ day)

Countries Brunei Darussalam Malaysia Thailand Indonesia Philippine Lao PRD Vietnam

1990 Rice Wheat

2000 Rice Wheat

2010 Rice Wheat

2011 Rice Wheat

664

291

728

464

744

416

748

435

810 1,131 1,292 922 1,416 1,353

215 31 65 149 4 23

821 1,166 1,282 1,020 1,412 1,437

300 53 116 195 10 53

754 1,132 1,300 1,140 1,430 1,398

396 78 160 176 14 80

751 1,113 1,312 1,168 1,436 1,397

397 83 168 157 15 83

Figure 3: Rice and Wheat consumption by ASEAN countries (Kilocalories/ capita/day) While wheat has fewer calories per kg and more fiber, a paper on Trend in wheat based products in South East Asia by Dr. Norizad Abd Rashid menSource (FAO, 2015) tions that wheat based products (i.e., wheat flour,) is used in bread, baguettes, noodle, instant noodle, cakes, pastries and biscuits. 100 grams of bread contain 267 calories (USDA, 2014). The switch over to wheat could be beneficial (fewer calories per kg, more fiber, etc.) and could lead to a reduction in overweight and obesity. However, the ASEAN population continues to eat rice as a main staple and uses wheat products as

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fast food or dessert. They eat rice as a main meal, breakfast, lunch and dinner and then also eat dessert after meals, therefore gaining in daily calories.

DISCUSSION AND CONCLUSIONS The research paper applied a documentary review of the literature by using a quantitative approach in analyzing secondary data from WHO and FAO. In the process of applied documentary review, the study had a number of limitations. Firstly, the data on the prevalence of overweight/obesity applied self-reporting to measure weight and height, which may have led to incorrect reports on prevalence of overweight/obesity due to under-reporting of weight and over-reporting of height (Banwell et al., 2009). Secondly, the years of data collection are also different because of limitation of data available. However, the result really indicates prevalence trends increasing on overweight/obesity, caloric intake, and diet over the same period as globalization accelerated. None of the research papers in the past has studied this topic in the ASEAN region. The overweight and obesity prevalence trends increased in all countries that were studied. There are possible confounding factors that may have affected obesity such as LBW, exercise, and trade. Currently, lifestyles in the age of globalization have changed in terms of reducing energy expenditure such as decreased physical activity in leisure time, workplace, and resulting from more convenient transportation. In addition, processed food has altered the diet pattern by increasing the intake of sugar, sweetener, wheat, fat and animal products (Popkin, 2006; Foo, Vijaya, Sloan, & Ling, 2013; Costa-Font et al., 2013). Further study is needed to address these contributing factors and the effect of economic globalization on diet intake. Key determinants of overweight and obesity come from the fundamental equation of energy balance: energy storage = energy intake – energy expenditure (WHO, 2000, p.102). Positive energy storage happens when energy intake through food consumption is more than energy expenditure through physical activity. Inversely, negative energy storage is energy expenditure is more than energy intake (WHO, 2000). According to the result of this study, Vietnam had the highest increase in overweight and the lowest increase in obesity. Conversely, Brunei Darussalam had the lowest increase in overweight, and it ranked second for increasing obesity. Interestingly, in the past two decades, the highest change in caloric intake was in Vietnam (811 kcal/day), while the lowest change was in Brunei Darussalam (143 kcal/day). Most of ASEAN countries ate sugar and sweetener and carbohydrate more than maximum recommendation per day in 2011. This represents a danger sign that ASEAN population should be concerned in the near future about increases in obesity and overweight.

REFERENCES Banwell, C., Lim, L., Seubsman, S. A., Bain, C., Dixon, J., & Sleigh, A. (2009). Body mass index and health-related behaviours in a national cohort of 87 134 Thai open university students. Journal of epidemiology and community health,63 (5), 366-372. C.R. (2013). When did globalization start? http://www.economist.com/blogs/freeexchange/2013/09/economic-history-1 [access date: 1 January 2015] Cheong, S. M., Kandiah, M., Chinna, K., Chan, Y. M., & Saad, H. A. (2010). Prevalence of Obesity and

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Factors Associated with it in a Worksite Setting in Malaysia. Journal of community health, 35(6), 698-705. Costa-Font, J., Mas, N., & Navarro-Palau, P. (2013). Globesity: is globalization a pathway to obesity?. London: LSE Health Foo, L. L., Vijaya, K., Sloan, R. A., & Ling, A. (2013). Obesity prevention and management: Singapore’s experience. obesity reviews, 14(S2), 106-113 Food and Agriculture Organization. (2015). Food balance sheets. http://faostat3.fao.org/download/FB/*/E [access date: 14 January 2015] Kelly, T., Yang, W., Chen, C. S., Reynolds, K., & He, J. (2008). Global burden of obesity in 2005 and projections to 2030. International journal of obesity, 32(9), 1431-1437. Mendez, M., & Popkin, B. (2004). Globalization, urbanization and nutritional change in the developing world. Globalization of food systems in developing countries: Impact on food security and nutrition, Journal of Agricultural and Development Economics, 1(2), 220-241. Norizad Abd Rashid, N. A. (n.d.).Trends in wheat based products in South East Asia. Retrieved 29, 2015 from http://www.ausgrainsconf.com/sites/default/files/file/2012/Presentations/Dr%20Nasir%20 Aazudin.pdf Johnson, R. K., Appel, L. J., Brands, M., Howard, B. V., Lefevre, M., Lustig, R. H., ... & Wylie-Rosett, J. (2009). Dietary sugars intake and cardiovascular health a scientific statement from the american heart association. Circulation, 120(11), 1011-1020. Peltzer, K., Pengpid, S., Samuels, T., Özcan, N. K., Mantilla, C., Rahamefy, O. H., ... & Gasparishvili, A. (2014). Prevalence of overweight/obesity and its associated factors among university students from 22 countries. International journal of environmental research and public health, 11(7), 7425-7441. Pickut, W. (2015). The Recommended Daily Intake of Calories, Carbs, Fat, Sodium & Protein. http://www. livestrong.com/article/288657-the-recommended-daily-intake-of-calories-carbs-fat-sodium-protein/ [access date: 10 June 15] Popkin, B. M. (2006). Global nutrition dynamics: the world is shifting rapidly toward a diet linked with non-communicable diseases. The American journal of clinical nutrition, 84(2), 289-298. Ramachandran, A., & Snehalatha, C. (2010). Rising burden of obesity in Asia. Journal of obesity, 2010. doi:10.1155/2010/868573 Sidik, S. M., & Rampal, L. (2009). The prevalence and factors associated with obesity among adult women in Selangor, Malaysia. Asia Pacific Family Medicine, 8(1), 2. Soon, J. M., & Tee, E. S. (2014). Changing Trends in Dietary Pattern and Implications to Food and Nutrition Security in Association of Southeast Asian Nations (ASEAN). International Journal of Nutrition and Food Sciences, 3(4), 259. doi: 10.11648/j.ijnfs.20140304.15 United States Department of Agriculture (2014).Cooked rice and wheat. Retrieved 11, 2015 from http:// ndb.nal.usda.gov/ndb/foods World Health Organization. (2000). Obesity: Preventing and managing the global pandemic. Singapore: WHO Press. World Health Organization (2014). Global Health Observatory data on overweight and obesity in adults. http://www.who.int/gho/ncd/risk_factors/overweight/en/ [access date: 25 February 2015] World Health Organization. (2014). Overweight data by WHO region and South East Asia region. http:// www.who.int/gho/ncd/risk_factors/overweight/en/ [access date: 25 February 2015] World Health Organization. (2014). Obesity data by WHO region and South East Asia region. http://www.

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who.int/gho/ncd/risk_factors/obesity/en/ [access date: 25 February 2015] World Health Organization. (2015).Obesity and overweight. http://www.who.int/mediacentre/factsheets/ fs311/en/ [access date: 14 January 2015] Zelman, K. M. (2008). Estimated Calorie Requirements. http://www.cnpp.usda.gov/sites/default/files/ usda_food_patterns/EstimatedCalorieNeedsPerDayTable.pdf [access date: 15 September 2015]

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Pharmaceutical Companies’ Promotions of Antibiotics for Upper Respiratory Infections and Equity in Access to Treatment in Nepal Pramesh Koju1, Stéphane P. Rousseau1, Marc Van der Putten1 1 School of Global Studies, Thammasat University, Pathumthani, Thailand

ABSTRACT Various promotional activities are provided by pharmaceutical companies that influence the selling of antibiotics by community pharmacies. At the same time, the majority of health spending is on medicine, and affordability of antibiotics has always been a crucial issue in most developing countries. Equity refers to the effective access to antibiotics at an affordable price especially by poor populations. This study identified different forms of promotional activities adopted by pharmaceutical companies in community pharmacies and affordability of those antibiotics to populations with the lowest wages in the area in Kavrepalanchok district of Nepal. A descriptive cross-sectional study was conducted with all community pharmacies in the two main towns of Kavrepalanchok district of Nepal. Face to face interviews were conducted among the participants with structured questionnaires. Affordability was determined by comparing the total cost of selected antibiotics for standard treatment against the lowest wage for unskilled workers working in Nepal enterprises. The study concluded that financial bonuses, free samples, and brochures were the most popular promotional activities. Irrespective of the prices of antibiotics, it was observed that almost all of the best-selling antibiotics for acute upper respiratory infections were unaffordable for unskilled workers (poor population) costing them more than a days’ wage according to the World Health Organization (WHO).

INTRODUCTION Although antibiotics are classified as prescription-only drugs, they are widely used as over-the-counter drugs for upper respiratory tract infections in Nepal. Likewise, in the context of Nepal, people try to self-medicate with antibiotics or refer to community pharmacies when they fall sick rather than visit general health practitioners. The unnecessary use of antibiotics actually contributes not only to the development of antimicrobial resistance but also to the economic burden to the health care system (Wutzke et.al, 2007; Shehadeh et al., 2012). There are 51 allopathic pharmaceutical manufacturing companies and 280 foreign companies in Nepal that distribute the same kinds of antibiotics under different brand names. Similarly, though they have the same composition, the prices of different brands vary. As a result, companies are moving towards leading the pharmaceutical market and gaining more profit, which leads them to promote their products to medical doctors as well as community pharmacies. Additionally, sometimes the price of a medicine seems to increase due to the promotional activities of pharmaceutical companies (Subedi, 2009). One study in Nepal noted that expensive antibiotics were more often prescribed and dispensed than cheaper ones (Panth et al., 2014). It is also true that pharmaceutical companies influence community pharmacies by providing financial incentives for those who can sell expensive products in a greater quantity (Holloway et al., 2008). In order to maintain a balance in a tough competitive environment, big companies try to gain a larger share of the market through unethical practices and extensive promotions by advertisements, gifts, free medicine samples, incentives, and financial bonuses to all the concerned sectors including community pharmacies (Harper et al., 2009). 110

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One-third of the global population still lacks reliable access to needed medicines (WHO, 2009). According to the WHO (2008), even worse scenarios exist in Africa and Asia where 50% of the population lack access to medicines. Moreover, in developing and less developed countries, people spend up to 70% of their overall health spending on medicine, compared to 10-18% in the developed world (Cameron et al., 2009). Most of the people of developing countries like Nepal have to spend out-of-pocket for these medicines resulting in unaffordability. At the same time, one-third of developing countries either have no regulatory authority or limited capacity to regulate the market of medicine (WHO, 2009). Additionally, a study of promotional spending on prescription drugs found that the amount of money involved in drug promotion by manufacturers is at least 30 times more than the money spent on drug information by the government (Alam et al., 2009). In an interview conducted in the study by Subedi (2009), the president of the Nepal Medical Association (NMA) said that if the ethical guidelines of medicines were implemented, the price of medicine would certainly decrease. Lack of strong policies on the selling of antibiotics and promotions by pharmaceutical companies has a negative effect on the affordability of antibiotics. Additionally, the consumer law and protection agencies in Nepal are not as strong as in developed countries due to lack of effective monitoring and control over unethical activities of pharmaceutical companies (Sharma, 2013). The main purposes of the study was to identify different forms of promotional activities adopted by pharmaceutical companies in community pharmacies, and to assess the affordability of those antibiotics to populations with the lowest wages in Kavrepalanchok district of Nepal.

METHODOLOGY A descriptive cross-sectional study was conducted with all community pharmacies, i.e., 34 in number (listed by the Department of Drug Administration, Nepal) in two main towns of Kavrepalanchok district of Nepal. The district and towns were purposively selected using the following criteria: the investigator is acquainted with the district and has well-established networks with local stakeholders including community pharmacies. Towns were selected because they are relatively more developed than other areas of the district and have infrastructures that include educational institutes, and health care facilities like hospitals, health centers, and community pharmacies. Convenience sampling was applied to select questionnaire respondents representing each of the community pharmacies based on who was on duty during the survey. Face-to-face interviews were conducted among the participants with a structured questionnaire for which written consent was taken prior to the interview. The research proposal was submitted for approval to the Ethical Review Committee of Thammasat University. Confidentiality was maintained by replacing personal identifiers by a respondent codes and using a password protected electronic database and respondents’ codebook stored on a computer hard disk. The draft questionnaire was evaluated by experts and pilot-tested using test-retest reliability techniques before the actual survey. Data was entered in the database using Statistical Package for the Social Science (SPSS) version 21.0 for the analysis. Affordability was determined by comparing the total cost of selected antibiotics for a standard treatment (full course of treatment) against the lowest wage for unskilled workers working in all other enterprises excluding those working in tea farms and the jute industry in Nepal at the time of the survey based on figures from the Nepal Gazette, 2009. True affordability is difficult to assess, however treatment costing one days’ wages or less for a standard treatment (full course of treatment) of an acute condition was considered affordable (WHO, 2008).

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RESULTS From the survey of all antibiotics, different forms of promotional activities were identified (Figure 1). Among the promotional activities, offering free samples was observed 40 times (37%), financial bonuses 36 times (33%), and brochures 25 times (23%) whereas promotions with offering gifts and books were only observed 7 times (6%) and 1 time (1%) respectively. Figure 1: Proportion of Promotional Activities Observed for all Antibiotics While looking at promotional activities for the generic antibiotics (Table 1), it was clear that the antibiotics which were top selling were those with a high number of promotional activities. Table 1: Frequencies of Forms of Promotional Activities per Generics

S. No

Generic Name

1 2 3 4 5 6 7 8

Amoxicillin Azithromycin Amoxicillin+Clavulanate Cefixime Ciprofloxacin Cephalexin Cefadroxil Cefpodoxime Total

Brochures 7 12 2 4 0 0 0 0 25

Promotional Activities Financial Books Gifts Bonus 0 4 16 0 2 7 0 1 6 1 0 4 0 0 1 0 0 1 0 0 1 0 0 0 1 7 36

Free Sample 15 8 8 6 2 0 0 1 40

Total 42 29 17 15 3 1 1 1 109

Here, the highest number of promotional activities were observed for Amoxicillin followed by Azithromycin and Amoxicillin+Clavulanate with a substantial number of financial bonuses, free samples, and brochures. Though they had the three common highest promotional activities, they occurred at different frequencies. The prices of different brands of antibiotics from the survey ranged from 10 to 55 Nepalese Rupees (local currency). While considering some of the indications (Table 2.) such as streptococcal pharyngitis, two antibiotics were not affordable for standard treatment, which required more than a day’s wages; these unaffordable antibiotics were Amoxicillin (1.9 day’s wage) and Amoxicillin+Clavulanate (4.7 day’s wage). In acute bacterial sinusitis, all of the selected antibiotics cost more than a day’s wage and are unaffordable: Amoxicillin required 2.7 day’s wages followed by 3.9 day’s wages for Azithromycin and 9.8 day’s wages for Amoxicillin+Clavulanate which required almost one-third of a monthly salary. In the case of pertussis, Azithromycin was used most of the time among the three selected antibiotics requiring 1.4 day’s wage, which is also unaffordable.

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Table 2: No. of Day’s Wages of the Lowest Wage of Unskilled Worker Needed to Purchase Standard Treatments

Antibiotics

Strength (Tablet / Capsule)

No. of units a day

Duration days

Mean Price (Rs)

No. of units a day × Duration of days × Mean price (Rs)

Day’s wages to pay for treatment

Amoxycillin

500mg

3

10

10

3×10×10= 300

1.9

Amoxycillin+Clavulanate

500 to 875mg

2

10

35.88

2×10×35.88=717.6

4.7

Azithromycin

500mg

1

3

42.31

1×3×42.31= 126.93

0.8

Amoxycillin

500mg

3

14

10

3×14×10= 420

2.7

Acute Bacterial Amoxycillin+Sinusitis Clavulanate

625 mg

3

14

35.88

3×14×35.88=1506.96

9.8

Azithromycin

500mg

1

14-Oct

42.31

1×14×42.31=592.34

3.9

Azithromycin

500mg

1

5

42.31

1×5×42.31= 211.55

1.4

Indications

Streptococcal Pharyngitis

Pertussis

DISCUSSION Considering the landscape of pharmaceutical companies in Nepal, there is competition between the domestic companies and international companies to sell their brands in a small market (Sharma, 2013). In the study, the author argues that despite the benefits of the promotional activities from pharmaceutical companies, community pharmacies also exhibit trust in certain brands of medicines produced by specific companies based on their own experiences (Brhlikova et al., 2011). From the survey, some significant promotional activities were recorded, such as offering free samples, financial bonuses, brochures, etc. However, the distribution of promotional activities was not the same for all brands of antibiotics. Among all the promotional activities, financial bonuses were most popular, which has also been observed in other studies (Radyowijati et al., 2003; Holloway et al., 2008; Subedi, 2009; Sharma, 2013). On the other hand, it was not uncommon to observe multiple promotional activities for some of the brands. Possible reasons for the difference in promotions might be that companies intentionally adopt a different strategy than the competition is already practicing. Another reason could be that pharmaceutical companies offer promotional activities according to the ability of the particular pharmacies in selling their brands. The implementation of the guidelines regarding promotional activities was not effective due to lack of resources and conflict of interest between stakeholders and support; this resulted in continuous unethical promotion from pharmaceutical companies (Sharma, 2013). The money spent on marketing and promotional activities by companies will eventually be added to the price of the medicine that is passed on to the consumers (Sharma, 2013). The consumers with low-incomes are constrained to buy fewer antibiotics than the required dosage, which can eventually result in an irrational use of drugs. In such instances, the irrational use of antibiotics leads to antibiotic resistance and eventually results in much more expensive 2nd and 3rd line treatments or hospitalization, which will hike up the expenses and affect the poor populations due to lack of affordability. The cost of treatment increases if the unit price of the antibiotic is high. In the study, it was found that most of the antibiotics are considered unaffordable. It should also be considered that the treatment costs refer to medicine only and excludes the cost of doctor’s visits (including opportunity costs) and diagnostic tests.

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Moreover, it is important to consider the availability and fluctuation in a supply of the medicines while analyzing their affordability. Furthermore, since many people in Nepal earn less than the lowest wage of unskilled workers working in enterprises, the treatment could be too costly for those poor populations as well. Given that 25.2% of the population are living below the national poverty line, defined as a person per-capita total annual consumption below 19,261 Nepalese Rupees (approx. USD 180) (CBS, N., 2011) and 24.5% of the population are living below the international poverty line, defined as income of $1.25 a day (World Bank Group, 2012), the treatments are actually far more costly for an even greater number of people than this study reflects. In addition, the population living with chronic diseases, needing lifelong treatment, as well as those who require multiple therapies of antibiotics face additional burdens. Also, the treatment cost becomes unaffordable to families who have more than one member that needs these sorts of treatments. Studies show that several families have to go through traditional financial coping mechanisms such as taking a loan from local money lenders or selling household goods (Cameron et al., 2011).

CONCLUSION AND RECOMMENDATIONS Although the ultimate consequences of the promotional activities used by pharmaceutical companies for selling antibiotics in community pharmacies are well recognized, they continue to be a crucial issue in most developing countries. The study revealed that financial bonuses, free samples, and brochures were the most popular means of promotion. Irrespective of the prices of antibiotics, it was observed that almost all of the best-selling antibiotics were unaffordable for unskilled workers (poor population) costing them more than a days’ wages, showing the inequity in health care in Nepal. The findings of this study could provide a foundation for further research on the affordability of medicines in Nepal. Further in-depth studies on the promotional activities used by pharmaceutical companies in the community pharmacies is needed to explore the issue of ethical practices. Such a study should involve customers, community pharmacies, marketing representatives and executives of pharmaceutical industries, and authorized personnel from the government sector. Further research is needed to measure the affordability of antibiotics for chronic conditions of upper respiratory infections. Since there are no studies conducted on the affordability of any kind of medicines in Nepal, it should be considered an urgent need to conduct such research that might expose the true extent of inequity regarding the availability and affordability of drugs. The ethical guidelines for promotions of drugs set by the National Drug Regulatory Authority of Nepal should be implemented effectively, and a clear policy regarding a rational use of antibiotics with the availability of low price generic antibiotics and regulation of the price of antibiotics should be developed.

REFERENCES Alam, K., Shah, A. K., Ojha, P., Palaian, S., & Shankar, P. R. (2009). Evaluation of drug promotional materials in a hospital setting in Nepal. Southern med review, 2(1), 2. Brhlikova, P., Harper, I., Jeffery, R., Rawal, N., Subedi, M., & Santhosh, M. R. (2011). Trust and the regulation of pharmaceuticals: South Asia in a globalised world. Global Health, 7(10). Cameron, A., Ewen, M., Ross-Degnan, D., Ball, D., & Laing, R. (2009). Medicine prices, availability, and affordability in 36 developing and middle-income countries: a secondary analysis. The Lancet, 373(9659), 240-249. Cameron, A., Ewen, M., Auton, M., &Abegunde, D. (2011). The world medicines situation 2011. Medicine prices, availability and affordability.

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CBS, N. (2011). Poverty in Nepal. National Report. Gazette, N. (2009). Notice of Government of Nepal (GoN). Ministry of Labour and Transport. Part, 58. Harper, I., Rawal, N., & Subedi, M. (2009). Disputing Distribution: Ethics and pharmaceutical regulation in Nepal. In Tracing Pharmaceuticals Dissemination Workshop. Kathmandu: Martin Chautari and University of Edinburgh. Holloway, K. A., Karkee, S., Tamang, A., Gurung, Y. B., Pradhan, R., & Reeves, B. C. (2008). The effect of user fees on prescribing quality in rural Nepal: two controlled pre‐post studies to compare a fee per drug unit vs. a fee per drug item. Tropical Medicine & International Health, 13(4), 541-547. Panth, N., Paudel, K. R., Chaudhary, B., & Thapa, K. K. (2014). A STUDY ON THE PRICE VARIABILITY AMONG THE ORAL ANTIBIOTICS AVAILABLE IN A WESTERN REGION HOSPITAL-A CONTEXT OF NEPAL. Radyowijati, A., & Haak, H. (2003). Improving antibiotic use in low-income countries: an overview of evidence on determinants. Social science & medicine, 57(4), 733-744. Sharma, A. (2013). ETHICAL PROMOTIONAL PRACTICES BY PHARMACEUTICAL COMPANIES IN NEPAL: ARE THEY IN BREACH OF THEIR PROMISES? (Doctoral dissertation, Webster University Thailand). Shehadeh, M., Suaifan, G., Darwish, R. M., Wazaify, M., Zaru, L., & Alja’fari, S. (2012). Knowledge, attitudes and behavior regarding antibiotics use and misuse among adults in the community of Jordan. A pilot study. Saudi Pharmaceutical Journal, 20(2), 125-133. Subedi, M. (2009). Trade in Health Service: Unfair Competition of Pharmaceutical Products in Nepal. Dhaulagiri Journal of Sociology and Anthropology, 3, 123-142. World Health Organization. (2008). Measuring medicine prices, availability, affordability and price components. WHO (2009). Measuring Transparency in the Public Pharmaceutical Sector: Assessment Instrument. Geneva: WHO World Bank Group (Ed.). (2012). World development indicators 2012. World Bank Publications. Wutzke, S. E., Artist, M. A., Kehoe, L. A., Fletcher, M., Mackson, J. M., & Weekes, L. M. (2007). Evaluation of a national programme to reduce inappropriate use of antibiotics for upper respiratory tract infections: effects on consumer awareness, beliefs, attitudes and behaviour in Australia. Health Promotion International, 22(1), 53-64.

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Comparative Study on Prevalence and Modifiable Risk Factors for Diabetes Mellitus in Eritrea Elias Teages Adgoy1, William Brady1, Uma Langkulsen1 1

School of Global Studies, Thammasat University, Pathumthani, Thailand

ABSTRACT Background: The prevalence of Diabetes Mellitus (DM) is increasing globally, and Eritrea is no exception. In addition to the already existing communicable diseases, DM is becoming one of the most prevalent non-communicable diseases in Eritrea, demanding resources for prevention and treatment. Objective: This study aimed to contribute to priority setting in prevention of DM by describing its prevalence and modifiable risk factors in Eritrea in comparison to other East African countries. Methods: A literature review was done on 22 publications, reports and books that mainly focused on Eritrea and East African countries from 2003 – 2015 and the prevalence of DM and modifiable risk factors. Results: In Eritrea the number of DM cases increased from 5370 in 2010 to 7388 in 2014. Based on surveys conducted in Eritrea in 2004 and 2010, the prevalence of DM was 2.3 and 4.7 percent, respectively. In Eritrea the prevalence of DM was relatively high (4.7%) as compared to Zambia (2.7 %), but closer to that of Malawi (5.6%), and Kenya (5.3%), whereas considerably lower than that of Tanzania (9.1%).. There was no difference in the prevalence of low fruit and/or vegetables consumption between Eritrea (97.5%), Malawi (97.5%) and Tanzania (97.2%). Physical inactivity ranged from 7.5 percent in Tanzania to 17.7 percent in Eritrea. The prevalence of alcohol consumption for Eritrea, Tanzania and Malawi was 38.2 percent, 29.3 percent and 16.9 percent, respectively. Tobacco smoking habit was very low in Eritrea (2.2%) as compared to Tanzania (11.8%) and Malawi (14.1%). Conclusion: The review concludes that DM is increasing in Eritrea as in other East African countries. High alcohol consumption and low dietary fruit and/or vegetable intake are believed to be strong contributing factors. Therefore, the review recommends that a comprehensive study on modifiable risk factors should be done; wide-ranging health promotion and prevention activities should be enforced; strategy, policy, protocols and guideline for the minimization of modifiable risk factors should be developed. Key Words: East Africa, Eritrea, Diabetes Mellitus, Modifiable risk factors

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BACKGROUND Diabetes Mellitus (DM) is a metabolic disorder that has multiple contributing causes. Insufficient amounts of insulin or the body’s failure in using the insulin hormone can cause DM. DM is normally categorized in three ways: Type 1, Type 2 and Gestational Diabetes Mellitus (IDF, 2013). According to the ICD-10 (International Classification of Diseases, Revision 10) Version 2015 classification, DM is classified as between E10 - E14, and has complications with fourth-character subdivisions. Type 1 DM is classified as E10 with a childhood onset, whereas type 2 DM is classified as E11 being common in individuals with normal or increased body weight, and has a characteristic of onset at early or late adulthood, with nonketotic and stable health (WHO, 2015). Gestational DM (GDM) occurs usually at the 24th gestational week of pregnancy. While GDM disappears normally later in life, there is a high chance of getting Type 2 Diabetes Mellitus (IDF, 2013). DM has also remained as one of the major endocrine and globally epidemic diseases representing Non-communicable Diseases (NCDs) in the world as it creates a public health burden in the developed high income countries and is a rapidly growing problem in the developing low and middle income countries (WHO, 2010). Global prediction of adults 20-79 years of age suffering from DM were estimated to rise in number from 381.8 million in 2013 to 591.9 million in 2035 showing a 55 percent rise (IDF, 2013). The increasing prevalence of DM is an alarming threat to the economies and health care systems worldwide, especially in developing nations. DM can cause serious economic burdens to the families of those affected by the disease. Furthermore, the epidemic is growing in conjunction with increasing urbanization, nutritional transitions and sedentary lifestyles (Hall et al., 2011; IDF, 2013). Diabetes Mellitus is increasing significantly and, as a result, is becoming one of the major diseases that result in morbidity and mortality in Sub-Saharan Africa (IDF, 2013). In 2013 approximately half of the adult deaths under the age of 60 years due to diabetes were in developing Sub-Saharan African countries (IDF, 2013). Eritrea, similar to many developing countries around the world, is facing high morbidity and mortality rates as a result of the double challenge of combating the burden of communicable and non-communicable diseases due to current epidemiological and nutritional transitions (Seyum et al., 2010). The World Health Organization estimate shows there were around 47,000 diabetic cases in Eritrea in 2000 and this number is projected to be 142,000 by 2030. DM was the seventh highest cause of mortality in Eritrea for the age group above five years old in 2011 (MOH. Eritrea, 2013). Therefore, to prevent and minimize the prevalence of DM, identifying the modifiable risk factors and knowing their prevalence is mandatory. Because of the risk factors that include mainly life style changes, such as decreased physical exercise, tobacco smoking, alcohol consumption, and dietary changes, the number of cases is projected to have almost doubled (Windus et al., 2007). Knowing the prevalence of DM and understanding the causes and attributed modifiable risk factors of the disease is important for the prevention and risk minimization of DM. Therefore, the researcher believes that by reviewing the prevalence of DM and modifiable risk factors of the disease in Eritrea and comparing it with other similar east African nations, a deeper and clearer understanding of the problem can be un-

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derstood. The researcher conducted an in-depth literature review and assessed available information and research to develop a study that could help Eritrea create a healthcare system that is better equipped to deal with the challenges posed by DM.

OBJECTIVE This study aimed to contribute to priority setting in prevention of DM by describing its prevalence and modifiable risk factors in Eritrea in comparison to other East African countries.

METHODOLOGY A literature review of quantitative data from secondary sources on the prevalence of DM and modifiable risk factors was done. Quantitative data were extracted and analyzed from legitimate and credible sources that were collected for research purposes, on routine data collection and population based surveys. A Boolean search strategy was used to retrieve documents and publications relevant to the topic from various search engines including PubMed, the Lancet, and Google Scholar, International and regional organizations websites. Total data records collected using key word searches were 298; after a primary review and the removal of duplications, out of 224 publications 74 were left and finally, the review used 22 publications, reports and books that focused mainly on Eritrea and East African countries.

Inclusion Criteria Published (scientific publications, journals) and unpublished materials and reports from 2003 – 2015 on the prevalence of DM and modifiable risk factors for Eritrea and East African countries that were written in English were included.

Exclusion Criteria Journals that have abstracts only and other information dated before 2003 and after 2015 were excluded.

Data Analysis A comparative analysis was used to analyze data in the literature review to describe the prevalence and modifiable risk factors attributable to DM in Eritrea and other East African countries. Quantitative data was gathered and sorted according to the variables that the research questions need to answer. Data interpretations and comparisons were done based on the reviewed prevalence of the variable of interest.

RESULTS The rapid increase of DM prevalence is evident in Eritrea and in other African, East African and other developing countries. Based on nationally representative surveys conducted in Eritrea in 2004 and 2010, DM prevalence was 2.3 and 4.7 percent, respectively; but no survey has been conducted on DM since 2011(MOH. Eritrea & WHO, 2004; MOH. Eritrea & WHO, 2012). According to the Ministry of Health report, the number of DM cases increased from 5370 in 2010 to 7388 in 2014 (MOH. NHMIS, 2015). In Eritrea, the prevalence of DM was relatively high compared to Zambia (2.7 %), but closer to the prevalence for Malawi (5.6%), and Kenya (5.3%) (Ayah et al., 2013; Msyamboza, et al., 2014; Nsakashalo-Senkwe et al., 2011), and considerably lower than that of Tanzania (9.1%) (MOH. Tanzania & WHO, 2012). In Malawi, the prevalence of diabetes increased from less than 1% in 1960s to 5.6% in 2009 (Msyamboza, Mvula, & Kathyola, 2014; MOH. Malawi & WHO, 2010) 118

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Figure 1: Trend in the Number of Diabetic Cases in Eritrea, 2010-2014

Source: MOH. NHMIS, 2015. Table 1: Prevalence of Diabetes Mellitus Country Eritrea Eritrea Kenya Kenya Malawi Tanzania Tanzania Zambia

Year 2004 2010 2009 2010 2009 2000 2011-2012 2011

Study design Cross-sectional survey Cross-sectional survey Cross-sectional survey Cross-sectional survey Cross-sectional survey Cross-sectional survey Cross-sectional survey Cross-sectional survey

Sample Size 1825 5730 1459 2045 3056 770 5680 1928

Age group 25 - 64 25 - 74 >17 >18 25 - 64 >15 25 - 64 > 25

Prevalence (%) 2.3 4.7 4.2 5.3 5.6 5.8 * 9.1 2.7

Remark: Raised FBS indicates fasting plasma glucose level ≥ to126 mg/dl (7.0 mmol/l) & those on medication for raised blood glucose *Urban According to the population based cross-sectional survey on prevalence of modifiable risk factors for the three countries, there was no difference in the prevalence of low fruit and/or vegetables consumption between Eritrea (97.5%), Malawi (97.5%) and Tanzania (97.2%). Physical inactivity ranged from 7.5 percent in Tanzania to 17.7 percent in Eritrea. The prevalence of alcohol consumption for Eritrea, Tanzania and Malawi was 38.2 percent, 29.3 percent and 16.9 percent, respectively. Tobacco smoking was very low in Eritrea (2.2%) as compared to Tanzania (11.8%) and Malawi (14.1%). Table 2: Prevalence of modifiable behavioral risk factors based population based survey Risk factor

Country

Year

Study design

1. Fruit and Vegetables consumption <5 servings / day

Eritrea Malawi Tanzania

2010 2009 2012

Cross – sectional Survey Cross – sectional Survey Cross – sectional Survey

Sample size 6235 5177 5680

Age group 25 - 74 25 - 64 25 -64

Prevalence (%) 97.5 97.5 97.2

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Risk factor

Country

Year

Study design

Physical inactivity

Eritrea Malawi Tanzania Eritrea Malawi Tanzania Eritrea Malawi Tanzania

2010 2009 2012 2010 2009 2012 2010 2009 2012

Cross – sectional Survey Cross – sectional Survey Cross – sectional Survey Cross – sectional Survey Cross – sectional Survey Cross – sectional Survey Cross – sectional Survey Cross – sectional Survey Cross – sectional Survey

Alcohol consumption

Tobacco smoking

Sample size 6235 5177 5680 6235 5177 5680 6235 5177 5680

Age group 25 - 74 25 - 64 25 - 64 25 - 74 25 - 64 25 - 64 25 - 74 25 - 64 25 -64

Prevalence (%) 17.7 9.5 7.5 38.2 16.9 29.3 2.2 14.1 11.8

DISCUSSION The results of many of these studies, with the exception of Zambia (2.7%), indicated that the projections made by the International Diabetes Federation that DM prevalence would be at 5.7 percent for the African region and 8.3 percent globally were correct (IDF, 2013). Even though Eritrea’s DM levels are lower than the global projections, studies of Eritrea and Sub Saharan African countries show an overall increase and shift in DM prevalence to low income and developing countries (Hall et al., 2011; IDF, 2013; Sierra, 2009). Therefore the above studies indicate that the rapid increase in prevalence of diabetes is evident in Eritrea and other East African countries. Fruit and Vegetables consumption that accounts for less than 5 servings / day is believed to increase the prevalence of DM. According to the cross-sectional survey results, the review indicated that there was no difference in the prevalence of low fruit and/or vegetables consumption between Eritrea (97.5%), Malawi (97.5%) and Tanzania (97.2%). These results indicate that the prevalence for such habits was very low and could lead to a higher prevalence of DM for those countries (MOH. Eritrea & WHO, 2012; MOH. Tanzania & WHO, 2012; Msyamboza et al. 2011). A systematic review study on consumption of vegetables and fruits indicated that eating green leafy vegetables can reduce the risk of getting DM by 14 percent (Carter et al., 2010). Based on this finding it comes to an agreement with other review studies that indicated that increased daily intake of green leafy vegetables and fruits reduces the risk of Diabetes Mellitus significantly (Bazzano & WHO, 2005 p; Montonen et al., 2005). Relying on the above documented study findings, the increase in prevalence of DM in this region may, conversely, have an association with less fruit and vegetable consumption. Although the fruit and vegetable consumption is believed to have an impact on DM prevalence, in Eritrea the dietary habit for staple food is different. The most common type of traditional food / bread in Eritrea is injera made up of flours of teff (Keih Teff, Sergean and Xaeda Teff) sorghum, millet and barley. Although further studies are required for its advantage, people are accustomed to eat injera that is prepared from teff, which is rich in iron, potassium, calcium, important amino acids and high fiber and complex carbohydrates (McGuigan, 2010). As is shown in Table 2, physical inactivity was recorded ranging from 7.5 percent in Tanzania to 17.7 Percent in Eritrea (MOH. Eritrea & WHO, 2012; MOH. Tanzania & WHO, 2012). All the reviewed studies showed a similarity in prevalence of physical inactivity which was documented as being low overall in the region. A review statement from the American Diabetic Association (ADA) stated that many randomized studies suggested that exercise alone can minimize the development of DM similar to the way diet can, and

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the way diet and exercise combined can actively decrease chances of DM (Sigal et al., 2006). From this review we can understand that the progress of DM can also be equally reduced by both diet management and physical exercise. So the potential decrease in prevalence of physical inactivity in Eritrea is crucial but its effect in minimizing the prevalence of DM needs to be combined with other determinant factors for better and significant reduction. The prevalence of alcohol consumption for Eritrea, Tanzania and Malawi was 38.2 percent, 29.3 percent and 16.9 percent, respectively. Alcohol consumption was recorded high in Eritrea in 2010 as 38.2 percent. In Eritrea, the legal age for being served alcohol in commercial areas is 18 years of age, but it is very difficult to control the noncommercial ceremonial and household production and consumption of alcohol. Even if there are some written formal restrictions in some areas and advertisements of health risks due to drinking alcoholic beverages, there is no nationally written policy that focuses on limiting alcohol use nor are there health warnings on alcoholic bottles or containers (WHO, 2014). In considering alcohol consumption as a contributing factor of diabetes mellitus in Eritrea, it is not only about the amount and the number of consumers. The type and content of the locally produced traditional alcoholic drinks is not standardized and its alcohol content and composition is not clearly known; its side effects as a risk factor to DM also need further studies. Tobacco smoking habits were very low in Eritrea (2.2%) as compared to Tanzania (11.8%) and Malawi (14.1%). In Eritrea it was recorded as the lowest in 2010 with a prevalence of 2.2 percent and the highest in Malawi having 14.1 percent in 2009. Even though the smoking prevalence is decreasing; it is likely that the already existing high prevalence of smoking (8.7%) in 2004 had its effect on the slow progress of the increase of DM prevalence in Eritrea because DM is a chronic disease. Generally speaking the prevalence of DM is believed to increase as a result of individual or combined effect of the modifiable risk factors.

CONCLUSION The review concludes that DM is increasing in Eritrea as in other East African countries. High alcohol consumption and low dietary fruit and/or vegetable intake are believed to be strong contributing factors; in Eritrea these factors are reaching alarming levels that require comprehensive, measurable, and immediate changes. If no action is taken to address these modifiable behavioral determinants, reduction in the prevalence of DM attributed to these factors may be stalled. Therefore, the review recommends a timely and comprehensive study on dietary consumption habits and alcohol use in Eritrea should be done. Wide-ranging health promotion and prevention activities focusing on the determinants of the disease should be enforced, and strategies, policies, protocols and guidelines for the minimization of risk factors should be developed and disseminated.

REFERENCES Ayah, R., Joshi, M. D., Wanjiru, R., Njau, E. K., Otieno, C. F., Njeru, E. K., & Mutai, K. K. (2013). A population-based survey of prevalence of diabetes and correlates in an urban slum community in Nairobi, Kenya. BMC Public Health, 13(1), 371. Bazzano, L. A., & WHO. (2005). Dietary intake of fruit and vegetables and risk of diabetes Mellitus and cardiovascular diseases: WHO Geneva.

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Carter, P., Gray, L. J., Troughton, J., Khunti, K., & Davies, M. J. (2010). Fruit and vegetable intake and incidence of type 2 diabetes Mellitus: systematic review and meta-analysis. BMJ, 341, c4229. doi: 10.1136/bmj.c4229 Hall, V., Thomsen, R. W., Henriksen, O., & Lohse, N. (2011). Diabetes in Sub Saharan Africa 1999-2011: epidemiology and public health implications. A systematic review. BMC Public Health, 11, 564. doi: 10.1186/1471-2458-11-564 IDF. (2013). IDF DIABETES Atlas Sixth edition. Retrieved 15 May, 2015 IDF. (2014 ). International Diabetes Federation Africa: Eritrea. Retrieved 20 May, 2015 MOH. Eritrea. (2013). Eritrea National Health Managment Information System; Eritrea Annual Health Service Activity Report of Year 2012. Retrieved 15 April, 2015. MOH. Eritrea & WHO. (2012). National STEPS Survey for Chronic Non-Communicable Diseases and their Risk Factors. MOH. Eritrea & WHO. (2004). NATIONAL NON COMMUNICABLE DISEASE ( NCD) RISK FACTOR BASELINE SURVEY ( USING WHO STEPSwise APPROACH ). MOH. Malawi & WHO. (2010). Malawi National STEPS Survey for Chronic Non-Communicable Diseases and their Risk Factors. MOH. NHMIS. (2015). Eritrea Annual Health Service Activity Reports. MOH. Tanzania & WHO. (2012). Tanzania National STEPS Survey for Chronic Non-Communicable Diseases and their Risk Factors. . WHO STEPS chronic disease risk factor surveillance. Montonen, J., Knekt, P., Harkanen, T., Jarvinen, R., Heliovaara, M., Aromaa, A., & Reunanen, A. (2005). Dietary patterns and the incidence of type 2 diabetes. Am J Epidemiol, 161(3), 219-227. doi: 10.1093/ aje/kwi039 Msyamboza, K. P., Mvula, C. J., & Kathyola, D. (2014). Prevalence and correlates of diabetes Mellitus in Malawi: population-based national NCD STEPS survey. BMC Endocr Disord, 14, 41. doi: 10.1186/1472-6823-14-41 Msyamboza, K. P., Ngwira, B., Dzowela, T., Mvula, C., Kathyola, D., Harries, A. D., & Bowie, C. (2011). The burden of selected chronic non-communicable diseases and their risk factors in Malawi: nationwide STEPS survey. PLoS One, 6(5), e20316. doi: 10.1371/journal.pone.0020316 Nsakashalo-Senkwe, M., Siziya, S., Goma, F. M., Songolo, P., Mukonka, V., & Babaniyi, O. (2011). Combined prevalence of impaired glucose level or diabetes and its correlates in Lusaka urban district, Zambia: a population based survey. Int Arch Med, 4(1), 2. doi: 10.1186/1755-7682-4-2 Seyum, B., Mebrahtu, G., Usman, A., Mufunda, J., Tewolde, B., Haile, S., . . . Negassi, E. (2010). Profile of patients with diabetes in Eritrea: results of first phase registry analyses. Acta diabetologica, 47(1), 23-27. Sierra, G. (2009). The global pandemic of diabetes. African Journal of Diabetes Medicine, 17(11), 4-8. Sigal, R. J., Kenny, G. P., Wasserman, D. H., Castaneda-Sceppa, C., & White, R. D. (2006). Physical activity/ exercise and type 2 diabetes: a consensus statement from the American Diabetes Association. Diabetes Care, 29(6), 1433-1438. doi: 10.2337/dc06-9910 WHO. (2010). Global status report on noncomunicable diseases WHO. (2015). International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10)-2015-WHO Version for ;2015. Retrieved 16 May, 2015. Windus, D. W., Ladenson, J. H., Merrins, C. K., Seyoum, M., Windus, D., Morin, S., . . . Goldfeder, J. (2007). Impact of a multidisciplinary intervention for diabetes in Eritrea. Clin Chem, 53(11), 1954-1959. doi: 10.1373/clinchem.2007.095 122

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Barriers to Accessing Adolescent Sexual and Reproductive Health Services Among Undocumented Migrants in South Africa: a Documentary Review Keith Mukondwa1 1 School of Global Studies, Thammasat University, Pathumthani, Thailand

ABSTRACT Adolescent sexual and reproductive health access continues to dominate the development agenda since the historic 1994 Cairo Conference. It has become a huge public health concern for the increasingly diverse undocumented adolescents who have become an important component as irregular migration patterns and profiles shift in South Africa. The inherent nature of irregular migration increases exposure and vulnerabilities making access to sexual and reproductive health services (SRH) imperative. Findings from this study revealed that access to SRH services among undocumented adolescent migrants is poor, and can be attributed to diverse structural, socio-cultural and financial barriers. For South Africa, conflicting health and migration policies lead to inconsistencies in service provision making it difficult for both adolescents and health service providers to strike a balance between migration and health considerations. Migration remains politically sensitive with punitive measures for those who are undocumented and subsequently marginalized and excluded from accessing all social services, health included. Health policies on the other hand are non discriminatory, employing an all inclusive approach to all adolescents irrespective of migration status. While this study demonstrated that adolescent SRH services among undocumented adolescent may be poor, such findings are, however, inconclusive to suggest that SRH outcomes are also poor.

INTRODUCTION As international migratory trends and movements shift, reaching an all time high of 214 million, 10-15% are estimated to be undocumented. Children and youth under the age of 20 years are slowly becoming an important part of these flows (IOM 2010, Adepoju 2008). The proportion of undocumented adolescent migrants in South Africa who undertake the perilous journey or overstay on their visa regulations has also increased considerably. These migrants are coming from different countries, for different purposes and different lengths of stay. While the bulk of them are coming from Southern Africa, it is the sudden growth of undocumented adolescent migrants from other African countries (e.g., Congo, Nigeria, Somalia, Ethiopia), as well as Asian countries (i.e., Thailand and Bangladesh), that raises a lot of concerns and implication (IOM 2006) Of increasing concern is the finding that, by opting for the undocumented route, this diverse population has made no adequate preparation or consideration towards potential challenges likely to be faced in host countries. The inherent nature of irregular migration poses exposure to increased vulnerabilities, making access to sexual and reproductive health services (SRH) imperative especially for a region known to have problems with ASRH access.

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Given the increased diversity and complexity of vulnerable migrants in SA, need and access to ASRH services becomes a very important issue. Access is further compromised by the fact that this group is often young, geographically clustered in certain areas, and needs to stay in South Africa for a considerably longer period of time. The source of care for this group is within government public health agencies since access to private sources is poor owing to actual or perceived costs (I.O.M 2013, UNPFA 2013). Owing to this factor, access to government run health agencies becomes a central issue to explore in this study

METHODOLOGY A narrative descriptive documentary review of literature employing qualitative approaches was used to analyze journals, articles, unpublished and published reports as well as relevant documents available from public access search engines on South Africa from 1994-2015 using a Boolean search strategy. The keywords used for searching the literature include: (undocumented “OR” irregular) “AND” (adolescents “OR” migrants) “AND” (reproductive “OR” sexual health) “AND” (health barriers “OR” health services access “OR” services “OR” HIV/AIDS) “AND” (“OR” health equity “OR” migration policies) “AND” (South Africa “OR” Sub-Saharan Africa “OR” SADC). The ranking system used in this study was based on an improvised Likert Scale where the frequency was used as a basis for measurement in an ascending order illustrated below. So factors with fewer citations were then placed on this scale to assign a ranking system in the ascending order as described below.

Occasionally 1

2

3

*Ranking: According to frequency with which a factor was mentioned in literature

Often 4

RESULTS Literature meeting the search criteria consisted of 35 publications from which 15 were “grey literature” publications consisting primarily of reports and online publications, 11 were publications from various UN Agencies, five were peer-reviewed publications, three were media publications, and two publications by the South African Government. The unbalanced representation of literature illustrates a dearth of information on the scope and dimension of adolescent migration that provides a basis for future studies. The review also established that access to SRH services among undocumented adolescent migrants is poor due to diverse structural, socio-cultural and financial barriers shown below.

Structural barriers Structural barriers (e.g., conflicting health and migration policies, legal status, inadequate state protection, quality of services) emerged very strongly and were cited in 30 of the 35 reviewed articles; 85% of the literature highlighted their profound effects on ASRH access. Such a measure is, however, inadequate, prompting the need to establish which of the structural factors had more effect. In that case, all structural factors were then placed on the Likert scale presented above, and frequency was used as a basis for measurement. Conflicting policies were more frequently cited by 25 of 30 articles on structural barriers, giving them a total of 83%, thus ranked as a 4. The discriminatory nature of migration policies makes them not congruent with growing migrant health needs leaving gaps which further expose vulnerability, while health policies built on equality principles reaffirm the government’s commitment towards realization of SRH to all adolescents

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(Chiguvare 2008, Farran 2014, MSF 2008, Department of Health 2012). This conflict makes it difficult for both adolescents and health service providers to strike a balance between migration and health considerations leading to neglect of ASRH needs. Barriers related to legal status were cited in 50% (15) of the 30 articles and ranked as a 2. Poor legal status induces fear of arrest and deportation, which drives migrants into a clandestine existence. This factor is further amplified by the absence of a child perspective within migration laws and policies, which largely results in migration control taking precedence over child protection making children even more prone to gross human rights violations (MSF 2009, Veary, Wheeler et al. 2011). Children’s rights are enshrined in the South African Constitution (Human Rights Watch 2009, I.O.M 2006) and reaffirmed by South Africa’s commitment and obligations to several international and regional declarations, conventions and legislations relating to children. Upholding these rights within the migration context becomes a mammoth task due to the absence of adequate protective factors. Additionally, there is lack of awareness on specific rights for undocumented adolescent migrants from health service providers and the migrants themselves making it challenging to implement target specific interventions. Barriers in relation to inadequate state protection were cited in 10 of the 30 articles (33%) and ranked as a 1. Underpinned by fragmented policy response, the plight of undocumented children remains ignored. The fact that it is not explicitly clear in South African laws, especially in the Child Care Act, on how this population is covered and protected leaves more loopholes for vulnerability and exploitation (Shaeffer 2009, Chiguvare 2013, Swamba 2014). The results thus indicate that barriers related to conflicting health and migration policies were cited more often than others making them more important while barriers related to state protection were occasionally mentioned hence less important.

Socio-cultural barriers Applying the same method shown above, socio-cultural barriers (difference in languages, culture and religion, limited education, weak social support) were mentioned in 26 of the 35 literature sources, which came to 74%. Each of the key factors was also measured with language related barriers ranked as a 4 as they were mentioned in 19 out of the 26 articles (73%). Language differences emerged as a dominant theme inducing fear of improper diagnosis as well as development of distorted and biased understanding of the functioning of the health system as noted by various scholars (Fritsch 2014, Johnson et al. 2009, MSF 2009, UNPFA 2009, Kropiwnicki 2010, I.O.M 2011, Munyewende, Rispel et al. 2011) Barriers to community and social exclusion were mentioned in 16 of the 26 sources (61%) and were ranked as a 3. This arises from a context that to date South Africa has experienced three extremely violent waves of xenophobic attacks on foreigners. Fear of being attacked results in limited social movement, especially in public spaces, and impacts greatly on SRH services given that public spaces are often seen as starting points for distribution and access. Living in exclusion and hibernation impacts heavily on community integration and weakens social support structures with potential implications for social participation in economic, social and political spheres, a pre-requisite for successful realization of SRH access. Culture-related barriers mentioned by 10 authors of 26 authors, (38%) ranked as a 2 and were also found to be a major stumbling block to expedient access to ASRH services with grave consequences being felt by undocumented adolescent migrants outside Southern Africa. These cultural conflicts gave public health officials unjustified power to withdraw consent to service provision. Barriers on education were only mentioned in seven sources, (36%) and ranked as a 1. With limited educational levels, this could impact on knowledge of service availability and services offered rendering the use of school based interventions invaluable for this migrant population. Decision-making

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and risk taking is worsened in contexts whereby lack of education is already a barrier. The conclusion made is that language related barriers were cited more often while barriers related to education were occasionally mentioned.

Financial barriers Financial barriers (health-related costs, poor working conditions and poverty) were mentioned in 15 of the 35 sources (42%). A breakdown of each key factor was done and affordability of health related costs emerged strongly having been cited by 9 of the 15 authors thus 60%. Whether these costs are real or perceived, South African public health system is denoted by the user fee principle. This principle is exercised in most public health institutions and commonly applied through a means test leading to a number of inconsistencies and misinterpretation. How the means test is conducted remains a mystery to most health workers and service uses in the absence of a standardized guide. It is, however, known that the South African public system applies this principle in relation to category and means of the patient where in the end there is a subdivision of patients into either full paying or subsidized. Of particular importance is the fact that most migrants lack accurate information on how this principle is applied creating distorted images on health care costs. Exploitative working conditions were ranked as a 2, mentioned by eight authors (53%). Lack of documentation may present room for increased exploitation from unscrupulous employers who create unfavourable working conditions, which may have important implications towards prioritization of ASRH health needs. Barriers associated with poverty were mentioned in five articles, with 33% and duly ranked as a 1. For undocumented adolescents, increasing poverty levels highlight uncertain livelihoods where priority is often placed towards pursuing economic livelihoods over health issues. The socio-economic context in turn shapes sexual behaviours and decisions whereby potential SRH needs are not considered, which can be equally disastrous especially in relation to HIV/AIDS and STIs.

CONCLUSION Barriers in the realization of ASRH among undocumented migrants exist whether perceived or real. The evidence provided in this study thus indicates that access to SRH services among undocumented adolescent may be poor. However, such findings are insufficiently conclusive to warrant the suggestion that SRH outcomes are also poor. Taking into account this observation, it is therefore imperative that an epidemiological study on the SRH status of undocumented adolescent migrants be conducted.

REFERENCES Adepoju, A. (2008). Migration and social policy in sub-Saharan Africa. IOM–International Organization for Migration. Geneva, Switzerland. Chiguvare, B. (2013). Children crossing borders: an evaluation of state response to migrant unaccompanied minors at Musina-Beitbridge border post, South Africa.MA Thesis. University of Johannesburg. Crush, J. and G. Tawodzera (2011). Medical xenophobia: Zimbabwean access to health services in South Africa, Idasa. Department of Health; Republic of South Africa (2007). South Africa Demographic and Health Survey. Pretoria. South Africa

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Farran, A. G. (2014). Young Migrants particularly those in vulnerable situation. In Migration and Youth: Challenges and Opportunities” Cortina .J, Taran .P and Raphael.A.Global Migration Group. Retrieved from http://www.globalmigrationgroup.org/sites/default/files/5._Chapter_2.pdf Human Rights Watch. (2009). Discrimination,Deportation and Denial.Human Rights abuses facing migrants living with H.I.V/Aids.Retrieved from https://www.hrw.org/.../discrimination-denial...deportation/human-rights Department of Health.Republic of South Africa (2011). Sexual and Reproductive Health and Rights: Fulfilling our Commitments 2011–2021 and beyond -Final Draft. Government Press, Pretoria International Organization for Migration.IOM (2013). The well-being of economic migrants in South Africa: Health, Gender and Development.International Organization for Migration,Geneva I.O.M. (2006). Breaking the Cycle of Vulnerability: Responding to the health needs of trafficked women in East and Southern Africa. IOM, International Organization for Migration, Regional Office for Southern Africa. Pretoria: Medicins Sans Frontiers.MSF (2009). No Refugee: Access denied.Medical and humanitarian needs of Zimbabweans in South Africa.Medicins Sans Frontiers,Cape Town. Munyewende, P., et al. (2011). Exploring perceptions of HIV risk and health service access among Zimbabwean migrant women in Johannesburg: a gap in health policy in South Africa&quest.Journal of public health policy: S152-S161. South Africa Lawyers for Human Rights Commission; SALHRC (2010). The right to health care for undocumented migrants in South Africa.Retrieved from www.sahrc.org.za Shaeffer, R. (2009). No Healing Here [electronic Resource]: Violence, Discrimination and Barriersto Health for Migrants in South Africa, Human Rights Watch. Swamba, A. B. (2014). Towards understanding the experiences of accessing antiretroviral treatment services among Congolese adolescence at clinics in Yeoville, Johannesburg.MA Thesis,University of Johannesburg United Nations Population Fund.UNPFA. (2009). Adolescent Sexual and Reproductive Health Toolkit for Humanitarian Settings.http://www.unfpa.org/publications United Nations Population Fund.UNPFA.(2013). UNFPA South Africa 2013 Annual Report.UNFPA Country Office,Pretoria Veary, J., et al. (2011). Migration and Health in SADC: A Review of the Literature, IOM. Regional office for Southern Africa.

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Medical Cost of Surgical Diseases on the Early Implementation of National Health Insurance in a Top Referral Hospital: Case Study from Indonesia Annette d’Arqom1, Abdul Khairul Rizki Purba1, Kuntaman Kuntaman2 1 Department of Pharmacology and Therapy, Airlangga University, Surabaya, Indonesia 2 Department of Microbiology, Airlangga University – Dr. Soetomo Hospital Surabaya, Indonesia

ABSTRACT Background: Universal health coverage remains as a hot issue in developing countries. In 2014, Indonesia launched the national health insurance with projection toward universal health coverage. In order to create a balance between patient needs and insurance coverage, it is important to know the real medical cost of each disease. In surgical diseases, many factors needed to be considered in the calculation of medical cost, including type and invasiveness of procedures, patient status, and medical complications. Objective: To illustrate the medical cost needed to treat surgical diseases on the early implementation of national health insurance in a top referral hospital in Indonesia, thus can be taken as consideration for insurance coverage decision making. Method: A retrospective study is conducted to patients who admitted between February–March 2014 into a top referral hospital in Indonesia followed by systemic random sampling. Subjects are grouped by the primary diagnoses including acute appendicitis, lower leg fracture, benign prostate hyperplasia, and hernia inguinalis that considered as the top surgical diseases in Indonesia. Furthermore, patients are categorized based on type and invasiveness of surgical procedures, type and onset of medical complications. Total medical cost and cost of each component such as drugs, usable non-drugs, accommodation, laboratory, and medical fee are analyzed using descriptive comparative method. Average length of stay, total medical cost, average daily cost, and component fee in patients with or without complication are presented and compared. Hypothesis: After national health insurance implementation, hospital are divided based on the location, facilitates, doctor’s specialization, number of beds, etc. Therefore, mostly patients in a top referral hospital are patients that cannot be treated in a lower class hospital. Consequently, patients who are admitted to a top referral hospital have complications or need special treatments. It can be hypothesized that an average length of stay will be longer and a total medical cost that needed to paid is higher than patient without complications. In addition, longer stay and more invasive procedure in developing country might cause more complications. In the other hand, this condition needs special treatment from sub-specialized medical professional, more advanced drugs, and more laboratories tools to treat or diagnose the diseases. As a results, medical service fee, drugs, and laboratories are the major components that patients or insurance need to pay.

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Relationship between Hygiene Behaviors with Protozoa and Intestinal Parasitic Infections of the Student in Wat Santithamratbamrung School, Nakhornnayok Pattakorn Buppan1*, Pimchanok Tamchuay1, Rungnapa Khunset1, Punchaporn Sudchalit1 1 Program in Health Promotion, Faculty of Health Science, Srinakharinwirot University, Thailand * [email protected]

ABSTRACT Background: Intestinal parasitic infections are among the major public health problems in Thailand. Poverty, illiteracy, poor hygiene, lack of access to potable water and hot and humid tropical climate are among the factors associated with intestinal parasitic infections. Epidemiological information on the prevalence of various intestinal parasitic infections in different localities is a prerequisite to develop appropriate control measures. Objective: The present study was to estimate prevalence and identify factors associated with intestinal parasitic infections of children in grade 4-6 at Wat Santithamratbamrung School, Nakhonnayok, and to determine correlation between infection and various factors that could potentially influence the rate of infection. Methods: A cross sectional survey was conducted from March to December 2015 in grade 4-6 at Wat Santithamratbamrung School, Nakhonnayok, based on a simple random sample of 74 samples (35 boys and 52 girls). Data were gathered through direct interview by using a pretested questionnaire, and screening by simple smear technique and concentration technique for the presence of eggs and cysts. Data entry and analysis were done using SPSS version 16 software. Results: Out of 74 study subjects (35 boys and 52 girls). Helminths found in students included Ascaris lumbricoides 4.1%. For protozoa, 27% of students were infected, including Entamoeba histolytica 9.5%, Entamoeba coli 4.1% and Giardia lamblia 13.5%. In addition we found mixed infection of helminths and protozoa at 2.7%. The relationships between the risk of infection with helminths including hand washing practice, eating behavior half-cooked meat type boiled mussels, boiled fish and pickled fish. The effects related to protozoa and helminths infection a significantly (p-value < 0.05). Discussion: Intestinal parasites were prevalent in varying magnitude among the schoolchildren. The prevalence of infections were higher for protozoa compared to helminths. Measures including education on personal hygiene, environmental sanitation, water supply and treatment should be taken into account to reduce the prevalence of intestinal parasites. Acknowledgments: We are grateful to Faculty of Health Science, Srinakharinwirot University, Thailand for this support.

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Food Preferences, Taste Preferences and Physical Activities in Relation to Body Mass Index of Students in Srinakharinwirot University, Ongkharak Campus Chanakarn Charoenphan1, Patticha Boonyanet1, Paphassara Borngern1, Kun Silprasit2, Sirikul Thummajitsakul1* 1 Faculty of Health Science, Srinakharinwirot University, Nakhon-Nayok, 26120,Thailand 2 Faculty of Environmental Culture and Ecotourism, Srinakharinwirot University, Bangkok, Thailand, 10110, [email protected] * [email protected]

ABSTRACT Background: Food preferences, taste preferences and physical activities were reported involving non-communicable diseases (NCDs) in people of many developed and developing countries (Bartoshuk et al., 2006; Shereen et.al. 2014). However, data involving dietary preference and physical activities of young adults are still restricted. Thus, our goal of this study was to determine the preference of food groups and taste, and physical activities among students in relation to body mass index. Methods: A preliminary study on the preference of food groups and taste, and physical activities of 143 subjects, who were male or female young adults with the age >18 years and studying in Srinakharinwirot university, Ongkharak campus, were surveyed by a questionnaire that was evaluated by three experts. Each item of the questionnaire was rated by using a 5-point likert scale. The BMI values of the subjects were calculated and recognized according to the Asian cut-off point criterion into underweight (< 18.5 kg/m2), normal weight (18.5-22.9 kg/m2) and overweight (> 23 kg/m2). Results: The all participants showed 18.2, 55.2, and 26.6% of underweight, normal weight, and overweight, respectively. The normal weight group revealed the greatest preference for protein groups (3.22+0.83) and spicy food consumption (1.70+1.13), and showed the lowest favorite for umami and sweet test (2.27+1.24 and 1.76+1.04, respectively). Moreover, normal weight students exhibited the most physical activity for each activity of daily living (3.09+1.18), housework (1.53+0.95), aerobic exercise (1.90+1.07), strength training and endurance exercises (1.25+1.34), flexibility exercises (1.00+1.17), and sport competition (0.89+1.23). However, non-significant difference of the dietary preference and the physical activities was detected among the BMI groups. Discussion: The preliminary research demonstrated that the normal BMI group was found the most prevalence. The levels of the preferences of food and taste and physical activities in the BMI groups of the students were observed, and association of the preference of food groups and taste and the physical activities among BMI groups was shown, insignificantly. Nevertheless, more subjects were required to further study. Keyword: Food preferences, Taste preferences, Physical activities, Young adults

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A Review on Barriers to PMTCT Services of HIV Infected Mother and Child in India and Indonesia Nang Sam Si Phong1, Vandita Rajesh2, Nitaya Vajanapoom2 1 2

UNAIDS, Myanmar School of Global Studies, Thammasat University, Pathumthani, Thailand

ABSTRACT Prevention of mother to child transmission (PMTCT) is an important HIV control measure. In India and Indonesia, HIV prevalence in 2013 was lower than in their neighboring countries (in India (0.3) and Indonesia (0.5)). However, the burden of HIV among pregnant women and children showed an increase – with an incidence rate of 0.003 and 0.008 among children in 2013 in India and Indonesia respectively. To describe and compare the barriers faced by HIV infected women to accessing PMTCT services in India and Indonesia and the responses to address them, a qualitative approach was used to analyze selected documents. Forty-five studies were identified, and twenty-one were focused on for the review. Barriers identified were 1) Lack of social support and encouragement, and fear of disclosure of HIV status by women due to socially constructed roles of women, and stigma and discrimination, 2) Cultural and traditional practices 3) Poor quality health services and 5) Proximity to health care centers that make it possible to continue utilization of PMTCT services. This study mainly focuses on the barriers related to socio-cultural factors. The consequences of stigma and discrimination against HIV infected women were critical barriers to treatment in both countries. The health facilities in PMTCT services centers are more widely available in India than in Indonesia. The cultural, traditional and religious contexts in Indonesia are different from India, but the stigma and discrimination are similar in both countries. However, the response to the latter was different.

INTRODUCTION Globally, the adult prevalence rate for HIV was 0.8% (UNAIDS, 2013), and in 2014 an estimated 36.9 million people were living with HIV. Of the 34.3 million adults living with HIV, 17.4 million were women. In 2014, the number of newly infected HIV cases was estimated to be 2 million, of which 1.8 million were estimated to be adults (UNAIDS, 2013). AIDS is one of top ten causes of death among children under 5 years of age worldwide (WHO, 2013a). For the majority of these children, mother-to-child transmission is the primary mode for HIV infection. Improving prevention of mother to child transmission (PMTCT) of HIV infection is one of the most effective ways to reduce incidence of HIV and child mortality caused by AIDS (PMTCT strategic vision 2010-2015, 2010). HIV prevalence in India (0.3) and Indonesia (0.5) in 2013 was lower than in their neighboring countries. However, the burden of HIV among pregnant women and children showed an increase in these countries with incidence rates of 0.003 and 0.008 among children in 2013 in India and Indonesia respectively (UNAIDS, 2015a) (Table 1). Indonesia is the only country in South East Asia where the prevalence of HIV infection has increased over time (Figure 1). Indonesia and India are low and middle-income countries according to the world development categorization. Both countries reported low prevalence rates compared to other countries in South and South East Asia. Most of the literature about the barriers for HIV infected

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women and children to attend PMTCT programs were carried out in African countries. However, the factors that are found in Africa may be different from the factors that are found in the Indonesian and Indian settings. The complexity of services within the healthcare system, geographical distribution, and sociocultural factors can affect women in accessing PMTCT services (Shrinivas Darak, 2012). There were studies for individual countries but there has been no review or study that compares these two countries; the two most populated countries in their regions with different contexts. Therefore, this study reviewed the barriers for HIV infected women and their children to access PMTCT programs and the responses to those barriers in India and Indonesia. Table 1: Incidence of HIV infection in India and Indonesia

INDIA: Incidence of HIV infection in children (0-14 years) (%) INDONESIA: Incidence of HIV infection in children (0-14 years) (%)

2012 0.004 0.007

2013 0.003 0.008

Sources: http://www.unaids.org/en/dataanalysis/datatools/aidsinfo http://www.photius.com/wfb2000/countries/india/india_people.html Figure 1: Prevalence of HIV infection in South East Asia

Source: Health Sector Response to HIV in The South-East Asia Region

Review Questions • • •

What are the barriers that prevent HIV infected mothers and children from accessing PMTCT services in India and Indonesia? What are the differences in the barriers that exist in India and Indonesia? What are the responses to the barriers in these two countries?

Objectives • • •

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To describe the barriers that prevent HIV infected mothers’ and children’s access to PMTCT in India and Indonesia To compare the barriers that prevent HIV infected mothers and children from accessing PMTCT in India and Indonesia To describe the responses to the barriers that prevent HIV infected mothers and children from accessing PMTCT in India and Indonesia

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METHODOLOGY A qualitative approach was used to analyze selected documents. The inclusion criteria for selection were studies, documents, journals, reports and unpublished articles that referred to barriers to access of PMTCT services in India and Indonesia from the year 2000 to July 2015 and that were written in English only. The Boolean search strategy was used to identify documents from PubMed, Science Direct, Google Scholar, and grey literature; this strategy was used with search engines to identify documents by keywords according to the following logic: “PMTCT” OR “MTCT” OR “PPTCT” AND “Indonesia” OR “India”; “PPTCT” OR “MTCT” OR “PMTCT” AND “barriers” OR “obstacles” AND “Indonesia” OR “India”. For the purpose of simplicity, the terms MTCT and PPTCT were combined and used as PMTCT in the findings, discussion and conclusion sections. A content analysis of qualitative data was applied to selected documents. The collected data were preliminarily analyzed to cover barriers to accessing PMTCT programs in Indonesia and India.

FINDINGS AND DISCUSSION Forty-five scientific documents were selected based on the review questions and objectives of the review study. Shortlisted manuscripts were examined to check if they met the inclusion criteria; those with only abstracts but no full text, were removed from the database. The results of this review focuses on a total of 21 studies from India and Indonesia. Among the 21 studies, ten studies were about socio-demographic factors, stigma and discrimination, HIV awareness, knowledge of HIV testing, and outcomes of HIV infections in pregnant women; six studies focused on services provided by public and private programs to HIV positive patients including pregnant women; two studies were about the perception of HIV among non HIV infected patients and health care providers; two were about HIV knowledge and awareness among workers, and one study was about the socio-cultural and political factors faced when developing HIV programs. The barriers were categorized into three: 1) sociocultural factors such as lack of support and encouragement, 2) stigma and discrimination from spouses, family, society and cultural factors, and 3) poor quality health services, and proximity of health care centers in Indonesia and India. Table 2: Socio-cultural factors in India and Indonesia India Stigma and discrimination from spouse family society



• •

Fear of disclosing their HIV status to partners, afraid of being rejected, discriminated against, abandoned, or subjected to violent acts from partners, fear of being considered unfaithful, blame, isolation from family (Ekstrand et al., 2012) Societies where women were often physically, emotionally and financially dependent on parents, husband, and family Stigma and discrimination due to HIV were also related to misconceptions about HIV transmission and moral judgment (Rahangdale et al., 2010)

Indonesia • • • •

Difficulties in disclosing their HIV status to their husbands, Fear of physical abuse, violence, rejection and divorce Women were dependent, passive and had poor access to education Women experienced internal as well as external stigma because of their HIV status (Weaver et al., 2014)

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India Cultural factors

• • •

Traditional marriage • Limited social, economic and political power • Cultural and institutional issues resulted in unique factors (Rahangdale et al., 2010)

Indonesia Traditional polygamy and early marriage Traditionally patriarchal societies, common practice of marriage of young girls, women restricted in accessing knowledge, information and health education (Jacubowski, 2008)

A critical obstacle that prevents HIV infected women from disclosing their HIV status is fear of being rejected, discriminated against, abandoned or subjected to violent acts targeted towards them by their partners or family members. The lack of disclosure of their HIV status to their husband or partners leads to their need to also conceal and sometimes avoid seeking care for their own health issues. As a result, many women do not and feel they cannot access PMTCT services in health care centers. This critical obstacle is found to be similar in both India and Indonesia. Three studies in India showed that HIV infected women reported fear of disclosure of their HIV status to their families and their partners (Amy Medley, 2004; Ekstrand et al., 2012; Rahangdale et al., 2010). HIV infected women are frequently viewed as women without moral values and are discriminated against by their families and societies. Rahangdale et al., (2010) stated that in Indian society, it is commonly believed that a woman’s family is an integral part of a woman’s support system, and that a woman’s physical, emotional, and financial well-being depend on her parents, her husband, and her husband’s family. Women are not only being discriminated against by their families, but they also self-stigmatize. One study, using an ethnographical method, showed results that were similar to findings from Indonesia and India. For example, one young woman from the study who perceived herself as being HIV infected blamed herself, believing that the disease only occurred in the immoral or drug-abusing (Carr & Gramling, 2004). The results of the review were also found to be similar to results from a European study that examined the issue of disclosure by HIV infected women about their HIV status (Carr & Gramling, 2004). The lack of social support and support from family members were also associated with low attendance of health care service centers and low adherence to treatment schedules by HIV infected women. ART is a life-long therapy that is much more manageable with support from the families for the duration of the treatment. One study from sub-Saharan Africa also found that a lack of emotional, financial and physical support from family acted as obstacles to utilization of PMTCT (Gourlay, Birdthistle, Mburu, Iorpenda, & Wringe, 2013). These obstacles lead to a failure in PMTCT services even though HIV infected women are aware of the program and the subsequent benefits of accessing the services (Mita Anindita, 2013). Regarding the disclosure of HIV status, stigma and discrimination, lack of support from family and society, and the socially constructed roles attributed to women were found to be significant barriers for HIV infected women to attend PMTCT care centers in both countries. The traditional, religious and cultural contexts in India were different from those in Indonesia. In Indonesian society, traditional and religious values strongly influenced marriage. The traditional practices in Indonesia are polygamy and early marriage, both of which played an important role in augmenting women’s vulnerability to HIV. The practices were prevalent in different parts of the country and varied with socio-economic status (Jacubowski, 2008). Indian society puts significant value on fertility and, as a result, the social pressures for having children are very high for women (Cohen, 2009). Cultural and traditional roles force women to live with limited social, economic, and political power (Gupta et al., 2008). After marriage, women were more vulnerable to HIV due to an increase in continuous exposure to unsafe sex and their inability to negotiate their sexual preferences with their partners. One study from Kenya also

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supported the results from this review (Murithi et al., 2015). Additionally, the religious, cultural and traditional marriage practices actively hindered women from accessing their education and health care. These factors were found to be similar in India and Indonesia. But the responses to this discrimination in India were different from Indonesia. India introduced social protection as a response while Indonesia used peer leaders to increase coverage of community-based PMTCT. In India, social protection actions were initiated in four states, and additional actions aimed at stigma reduction were done in two states for reduction of stigma and discrimination for PLWHA. Social protection was designed to reduce vulnerability and manage economic risks of individuals, households and communities dealing with HIV (Robert Holzmann, 2003). For instance, collaboration was initiated between stakeholders, Police Academy, Care and Services centers and communities to add value to collective responses for HIV (Department of AIDS Control, 2013). Thus the states that had these interventions and PMTCT program implementation witnessed an increase in participation of HIV infected women in the PMTCT program. The Government of India and Indonesia used interpersonal communication, health talk, mass media, internet and mobile phones to disseminate HIV information (Department of AIDS Control, 2013; National AIDS Commission, 2012). However, though awareness-raising programs were established in both countries, there were still people who did not know about HIV and the PMTCT program. This shows that the actions taken by the government were insufficiently providing information about HIV related knowledge, treatment and care. Not only is awareness about HIV important but human resources, infrastructures and facilities for HIV testing and ART treatments are also important for improving accessibility of the available services. Four out of 21 reviewed studies cited a lack of awareness of existing PMTCT options (ALexandra Rogers, 2006; Gita Sinha, 2008; Mariana Posse, 2008; Rahangdale et al., 2010). The difference in Indonesia has been the focus of its national program on the most at risk population, which are injectable drug users, sex workers, and men who have sex with men (National AIDS Commission, Coordinating Minister for People’s Welfare-Republic of Indoneisa, 2010). Socioeconomic status is an important factor to consider when examining continuing utilization of PMTCT for women in both India and Indonesia. In both countries, national programs launched free ART programs in high prevalence states, which resulted in reduced mortality of PLWHA (Department of AIDS Control, 2013; National AIDS Commission, Coordinating Minister for People’s Welfare-Republic of Indoneisa, 2010). The accessibility to health care centers also depends on treatment and services provided to HIV infected mothers and children, and the availability of DNA PCR at service centers. The services were available in urban areas more than rural areas. Location of service delivery points (Thida et al., 2014), insufficient drug supply, frequent appointments to health care centers, limited privacy and lack of understanding of the need to attend health care centers also act as barriers for HIV infected women. The national program from Indonesia planned to expand its integration of the PMTCT services into basic mother and child services with trained staff (National AIDS Commission, 2012). Three out of 21 studies cited transportation difficulties and long distances from home to health care centers as being barriers to PMTCT access (Mariana Posse, 2008; Rahangdale et al., 2010; Rudi Wisaksana, 2009). A study from Africa also showed the same result as this review. The difficulties associated with travelling to the health care centers exist in both countries, but regarding the geography of the countries, the landform of India provides more over ground connectivity whereas Indonesia has more islands (Weaver et al., 2014).

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CONCLUSION One of the main barriers to accessing PMTCT services that has been identified in this study is the traditional culture that influences the society and community in India and Indonesia. Due to socially constructed and imposed roles of women, women had limited opportunities to access education and information, both of which are important for a woman’s health and life. Non-disclosure of their HIV status and lack of support from family were also reasons for low participation of HIV infected women in the PMTCT programs. The reported barriers in India and Indonesia are similar to those reported from African countries despite having different cultural traditions (Gourlay et al., 2013). From this study, socioeconomic status of the families, lack of awareness, knowledge about HIV/AIDS transmission, care and treatment, and prevention were found to be associated with the accessibility of the program. After comparing the two countries, it can be concluded that the cultural, traditional and religious contexts in Indonesia are different from India, but the stigma and discrimination faced by HIV infected women are similar in both countries. The government response to the stigma and discrimination was different in India and Indonesia. Due to the difference in the implementation of government responses, the participation of HIV infected women in PMTCT programs is increasing in India. The national program in India responded by using evidence-based and region-specific strategies to scale up the treatment and prevention intervention. Country specific, evidence-based and creative strategies and interventions aimed at reducing the barriers faced by HIV infected women are vital to improving access to PMTCT services.

REFERENCE ALexandra Rogers, Anand Meundi, Ambikadevi Amma, Aruna Rao, Prasanna Shetty, Jubin Antony, Divya Sebastian, Padma Shetty, and Avinash K. Shetty. (2006). HIV-Related Knowledge, Attitudes, Perceived Benefits, and Risks of HIV testing Among Pregnant Women in Rural Southern India. Amy Medley, Claudia Garcia-Moreno, Scott McGill, & Suzanne Maman. (2004). Rates, barriers and outcomes of HIV serostatus disclosure among women in developing countries: implications for prevention of mother-to-child transmission programmes. Carr, R. L., & Gramling, L. F. (2004). Stigma: a health barrier for women with HIV/AIDS. J Assoc Nurses AIDS Care, 15(5), 30-39. doi: 10.1177/1055329003261981 Cohen, Patrice. (2009). AIDS and Maternity in India: Social Sciences Perspectives. Department of AIDS Control. (2013). Statement Containing Brief Activities of the Department of AIDS Control India in 2013. Ekstrand, M. L., Bharat, S., Ramakrishna, J., & Heylen, E. (2012). Blame, symbolic stigma and HIV misconceptions are associated with support for coercive measures in urban India. AIDS Behav, 16(3), 700-710. doi: 10.1007/s10461-011-9888-z Gita Sinha, Ashok Dyalchand, Manisha Khale, Gopal Kulkarni, Shubha Vasudevan and Robert C. Bollinger. (2008). Low_Utilization_of_HIV_Testing_During_Pregnancy_What Are the Barriers to HIV testing for Women in Rural India? Gourlay, A., Birdthistle, I., Mburu, G., Iorpenda, K., & Wringe, A. (2013). Barriers and facilitating factors to the uptake of antiretroviral drugs for prevention of mother-to-child transmission of HIV in sub-Saharan Africa: a systematic review. J Int AIDS Soc, 16, 18588. doi: 10.7448/IAS.16.1.18588

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Gupta, R. N., Wyatt, G. E., Swaminathan, S., Rewari, B. B., Locke, T. F., Ranganath, V., . . . Liu, H. (2008). Correlates of relationship, psychological, and sexual behavioral factors for HIV risk among Indian women. Cultur Divers Ethnic Minor Psychol, 14(3), 256-265. doi: 10.1037/1099-9809.14.3.256 Jacubowski, N. (2008). Marriage is not a safe place: heterosexual marriage and HIV-related vulnerability in Indonesia. Cult Health Sex, 10(1), 87-97. doi: 10.1080/13691050601058573 Mariana Posse, Filip Meheus, Henri van Asten, Andre van der Ven, Rob Baltussen. (2008). Barriers to access to antiretroviral treatment in developing countries: a review. doi: 10.1111/j.1365-3156.2008.02091.x Mita Anindita, Zahroh Shaluhiyah, Antono Suryoputro. (2013). Non Disclosure of Hiv Positive Status of Women to Their Partner : Implication For PMTCT in Central Java Indonesia. doi: 10.7237/ sjmct/217 Murithi, L. K., Masho, S. W., & Vanderbilt, A. A. (2015). Factors enhancing utilization of and adherence to prevention of mother-to-child transmission (PMTCT) service in an urban setting in Kenya. AIDS Behav, 19(4), 645-654. doi: 10.1007/s10461-014-0939-0 National AIDS Commission. (2012). Country Report on the Follow up to the Declaration of Commitment On HIV/AIDS (UNGASS). National AIDS Commission, Coordinating Minister for People’s Welfare-Republic of Indoneisa. (2010). National HIV and AIDS Strategy and Action Plan 2010-2014. PMTCT strategic vision 2010-2015. (2010). Preventing mother-to-child transmission of HIV to reach the UNGASS and Millennium Development Goals. Rahangdale, L., Banandur, P., Sreenivas, A., Turan, J. M., Washington, R., & Cohen, C. R. (2010). Stigma as experienced by women accessing prevention of parent-to-child transmission of HIV services in Karnataka, India. AIDS Care, 22(7), 836-842. doi: 10.1080/09540120903499212 Robert Holzmann, Lynne Sherburne-Benz and Emil Tesliuc. (2003). Social Risk Management, The World Bank’s Approach to Social Protection in A Globalizing World. Rudi Wisaksana, Bachti Alisjahbana, Reinout van Crevel, Nirmala Kesumah, Primal Sudjana, Rachmat Sumantri. (2009). Challenges in delivering HIV-care in Indonesia: Experience from a Referral Hospital. Shrinivas Darak, Mayuri Panditrao, Ritu Parchure, Vinay Kulkarni, Sanjeevani Kulkarni and Fanny Janssen. (2012). Systemic review of public health research on prevention of mother to child transmission of HIV in India with focus on provision and utilization of cascade of PMTCT services. Thida, A., Tun, S. T., Zaw, S. K., Lover, A. A., Cavailler, P., Chunn, J., . . . Clevenbergh, P. (2014). Retention and risk factors for attrition in a large public health ART program in Myanmar: a retrospective cohort analysis. PLoS One, 9(9), e108615. doi: 10.1371/journal.pone.0108615 UNAIDS. (2013). UNAIDS report on the global AIDS epidemic UNAIDS. (2015a). AIDS info online database. Retrieved 15th May, 2015, from http://aidsinfo.unaids.org/ Weaver, E. R., Pane, M., Wandra, T., Windiyaningsih, C., Herlina, & Samaan, G. (2014). Factors that influence adherence to antiretroviral treatment in an urban population, Jakarta, Indonesia. PLoS One, 9(9), e107543. doi: 10.1371/journal.pone.0107543 WHO. (2013a). Causes of Child Mortality. Retrieved 12th September, 2015, from http://www.who.int/ gho/child_health/mortality/causes/en/

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Women’s Autonomy in Family Planning among Myanmar Migrant Women in Pathum Thani, Thailand: A Pilot Study Hlwan Moe Paing1, Charlie Thame1, Uma Langkulsen1 1 School of Global Studies, Thammasat University, Pathumthani, Thailand

ABSTRACT Background: The level of women’s participation in decision-making, financial autonomy and freedom of mobility is one of the most important factors for uses and outcomes of family planning and reproductive health, which directly impact on their health and well-being. Migration, a global phenomenon, affects millions of people to relocate and reconstruct their lives beyond their territory. A variety of push and pull factors, encourage Myanmar people to migrate to Thailand. The majority of these migrants both documented and undocumented, often lack access to basic rights including access to reproductive health services which incorporates family planning. This study aimed to explore whether socioeconomic factors exert a role in Myanmar migrant women’s autonomy in using family planning. Objectives: Develop a cultural appropriate survey instrument that enables describing Myanmar migrant married women’s autonomy, in the Pathum Thani community, in terms of decision-making, financial autonomy, and freedom of mobility. Methods: This study involved a cross-sectional descriptive pilot study among women workers in the Myanmar migrant community of Thanyaburi district, in Pathum Thani province, Thailand, using criterion-based convenience-sampling. Based on 10 prior in-depth interviews, a multidimensional instrument, including participation in decision-making, financial autonomy and freedom of mobility, was developed to determine the level of women’s autonomy and describe the relationship towards the use of family planning. The questionnaire was employed in a survey among fifty-five respondents. Results: The instrument proved to be appropriate for Burmese, Karen and Mon ethnic groups within the Myanmar migrant community at Thanayaburi. Findings illustrated that respondents using family planning had greater levels of autonomy. Women’s autonomy was affected by implications of complex of socio-economic barriers such as: culture, financial status, migrant status, education level, proficiency in Thai language, awareness of family planning methods, and Thai health policy on the migrants. Conclusion: The survey instrument was suitable for the multi-ethic migrant community of Thayaburi. Although findings point to a relationship between women’s autonomy and the use of family planning, the sample size was too small to provide power of analysis. No statistical significant association could be established. Further studies with larger sample sizes are required.

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Exploring Business Models at the Bottom of Bangalore´s Pyramid Sprunken, J.C.E.1, Angeli, F.2 1 Vrouwenweg 23, Nykerkerveen, The Netherlands 2 Department of Health Organization, Policy and Economics, Maastricht University, The Netherlands

ABSTRACT Background: This study provides valuable information to Project EXHALE, an initiative of Maastricht University, which aims to address the issue of Household Air Pollution (HAP) in urban India. HAP is the biggest environmental threat to global health at this moment. It is estimated that 2.8 billion people still depend on traditional stoves and open fires, using biomass fuels such as wood, animal dung, and coal. The inefficient burning of these fuels results in high levels of pollutants. Project EXHALE, is currently developing an Improved Cook stove (ICS). ICS are a type of health-protecting technology, which are designed to burn fuels more efficiently, resulting in less HAP. It is envisioned to create a sustainable social business model which will make the ICS accessible to the poorest of Bangalore. However, most market-based ICS programs are unsuccessful. To be able to successfully distribute ICS within the slums of Bangalore, an appropriate business model must be identified for Project EXHALE. Innovative business models could have great opportunities to contribute to poverty alleviation, while ensuring self-sustainability and long-term commitment to the regions of interest. However, knowledge is still limited about how business models could meet the characteristics of the markets and individuals at the bottom (base) of the income pyramid (BoP) of the world. Objective and Aim: The main objective of this study is to gain an understanding of what makes a business model successful in the slums of the Bangalore. This study aims to provide essential information to the design of Project EXHALE´s business model by investigating the BoP market of Bangalore. Moreover, this study contributes to fill the gap of knowledge about business models at the BoP. Methodology: This study explores the BoP markets of Bangalore, India through an institutional lens. A multiple case study approach, investigating seven businesses, was used. Businesses were selected through a theoretical sampling technique. Business were eligible if they were operating in some of the poorest slum settlements of Bangalore, which were identified by the visibly poor housing structures and living conditions. There was a focus on formal business operating on a medium- or larger scale. However, slums in Bangalore are severely underserved by the formal sector. Only one medium-sized social business, was identified. However, informal economies play an important role at BoP markets. Therefore, six local businesses operating in the informal sector were included in this study. Semi-structured interviews were conducted and transcribed. The data analysis included a within-case as well as a cross-case analysis. Results: Through the data analysis, five themes were identified on how the specific BoP market conditions relate to the operating of the business models. Firstly, the interviewees emphasized the importance of building a relationship with the customer. In the slums, this involves much direct interaction, which is key to develop essen-

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tial interpersonal trust. Moreover, a good relationship provides the businesses valuable information about the customers´ demands and needs and is an important marketing strategy. Secondly, it was identified that even though the customer base can be considered as heterogeneous (in terms of language, place of origin, culture etc.) the people have rather homogeneous needs. Thirdly, the slum dwellers´ lack of (financial) resources results in a similar stock for the local businesses, which only sell cheap, basic items. The social business needs to create demand for their more expensive product by clearly demonstrating the products on sale. Fourthly, resources are not only scarce, the availability of money is also incredibly unreliable. Therefore, most local businesses offer credit-based payments to their customers. The social business offers instalment-based schemes. To all business models, offering such alternative payment methods is risky, as collecting repayments can be challenging or impossible. However, without alternative payment methods customers are often limited in their ability to buy products, which eventually harms both the customer and the business. Lastly, seeing the complexity of the market, especially the social business identified partnerships to be key to the development of the business model. Conclusions: The findings of this study lead to several propositions for what constitutes the success of business models in this environment. The importance of customer relationships to business activities in Western markets is well established. However, the results of this study demonstrate its relevance in the BoP context as well. Including the poor in the business models is an essential sales- and marketing strategy. Therefore this study Proposes that People at the BoP should play a central role in the business model. A large customer base facilitates economies of scale, which helps businesses to sell quality goods at affordable prices, with attractive margins. However, it is argued that as the poor are culturally heterogeneous, BoP endeavors face high distribution and marketing costs. However, the findings of this study demonstrate the potential for business models to benefit from a customer base of a sufficient size by responding to homogeneous needs. Benefiting from the commonalities within the communities requires a well understanding of who the business model is serving. Therefore the second proposition is: it is crucial to understand the characteristics of the target population. There is still much unknown about which value propositions can be successful at the BoP. According to BoP scholars, it is a misconception that there is only a subsistence economy at the poorest tier of society. This study confirms the current BoP market mainly offers basic and cheap goods as the slum dwellers are financially constrained. However, it also shows the potential for creating a market for new products and services. The third proposition is: Demand can be created for new, relatively expensive products and services. The slums dwellers in Bangalore face at least three types of financial constraints: Low levels of income, irregularity of available finances and incapability of making savings. The irregularity of available finances and the lack of savings are insufficiently taken into account in BoP literature. However, both the social business and the local businesses included in this study presented various strategies to overcome the financial constraint of the poor, by offering alternative payment methods to the poor. It is proposed that: Appropriate consumer finance is necessary to overcome the financial constraints of the poor. BoP scholars view partnerships are crucial to serve the BoP successfully, as different actors strengthen each other’s capacities, address limitations one single party could not address and subsequently create mutual benefits. The findings of this study confirm this view. Therefore, the final proposition is: The business model should include the right partnerships at the local and global level

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Stakeholder Perceptions in Challenges of the Ghanaian Mental Healthcare System and mplementation of the New Mental Health Act Anne van Driessche1 1 Maastricht University, Netherlands

ABSTRACT Background: The mental healthcare system of Ghana is highly centralized with a treatment gap of 98%. A new Mental Health Act was passed in 2012 to move towards community-based mental healthcare. Objective: The objective of this study was to identify challenges of the Ghanaian mental healthcare system and to evaluate how the new Act is planning to change the system. Methods: 25 qualitative in-depth semi-structured interviews were done with different stakeholders: healthcare providers, policy makers and caregivers in the Greater Accra Region. The principles of the WHO Mental Health Policy and Service Guidance Package (2003) were used for analysis: accessibility, equity, comprehensiveness, coordination and continuity of care, effectiveness, and respect for human rights. Findings: Several challenges were identified. Services are less accessible for people living in the north of Ghana where there is inequity because people have to pay high out-of-pocket payments for services. Comprehensiveness is hindered due to an insufficient government budget and lack of mental healthcare providers. In addition, the ill-defined position of the Mental Health Authority obstructs coordination and continuity of care. Effectiveness is impeded by overuse of medication and the lack of established posts for psychologists. Patients are often brought to prayer camps, where human rights abuses are regularly reported. Conclusions: Insufficient funds and lack of mental healthcare professionals are major factors affecting quality of mental healthcare in Ghana. The provisions of the new Act are unclear around these issues.

INTRODUCTION Although exact numbers are lacking, sources estimate that mental disorders represent 9% of the total disease burden in Ghana and 16% of the disease burden among adults aged 15-59 (de Menil et al., 2012). Of the estimated 2.4 million people with mental health problems in Ghana only 67,780 (i.e. 2.8%) received treatment in 2011, leaving an enormous treatment gap of 98% (Barke, Nyarko & Klecha, 2010). The number of beds that are offered in the psychiatric hospitals in Ghana appear to be insufficient, considering that only 1.17% of mentally ill people received treatment from public hospitals (Fournier, 2011). The mental healthcare system in Ghana is highly institutionalized with only three major psychiatric hospitals, all located in the south of the country. There is evidence that the focus should be on primary care instead of tertiary care. Integrating mental health services into primary care is the most viable way of closing

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the treatment gap and ensuring that people get the mental healthcare they need (WHO & Wonca, 2008). Delays in treatment can lead to increased morbidity and mortality, including the development of various psychiatric and physical comorbidities and the adoption of life-threatening and life-altering self-treatments (e.g., licit and illicit substance abuse) (McLaughlin, 2004). Before the new Mental Health Act 846 of 2012, the Mental Health Decree NRCD 30 was in place, which focused, among other things, on voluntary and involuntary treatment and law enforcement. This law had been in place since 1972, with revisions in 2011 (Roberts et al., 2013). However, the law, including its revisions, were never fully implemented and it was decided that the Mental Health Decree NRCD 30 was outdated by both national and international standards. Therefore, the revised Mental Health Act 846 was passed in 2012. The Act emphasizes de-institutionalization, de-medicalization and de-hospitalization of mental healthcare, and the reduction of stigmatization of mental health patients. The emphasis was intended to be on community-based healthcare (The Kintampo Project, 2012). Other important changes the new Act proposed were the establishment of a Mental Health Authority (MHA) and a Mental Health Fund. The aim of the Fund is to provide financial resources for the care and management of persons suffering from mental disorders (Doku et al., 2012).

METHODS The main goal of this research is to develop recommendations on steps to be taken by stakeholders to ameliorate the mental healthcare system. Interviews of health care providers, policy makers, and caregivers were conducted, the objectives of which were to identify challenges to the Ghanaian mental healthcare system and to evaluate how the new Act would change the system.

Participants and procedure Twenty-five qualitative in-depth semi-structured interviews were done with 12 healthcare providers in public institutions, five policy makers and eight caregivers of mentally ill patients in the Greater Accra Region (for details, see table 1). The data collection period was from April to June 2014. Challenges to the current mental healthcare system and expected difficulties in the implementation of the new Act were main topics of the interviews. An interview guide was used for the semi-structured interviews. For health care providers, the focus of the interviews was on diagnosis, treatment and challenges encountered . The interviews with policy makers focused on what had been done on a legal basis to combat mental illnesses and what the role of the New Mental Health Act of 2012 was. The emphasis in the interviews with caregivers was on payments for services. A translator guided the interviews of those caregivers who did not speak English. Participants were selected through purposive sampling.

Data analysis A thematic approach per group of interviewees was used to categorize the findings. Subsequently, the categories and quotes were matched with principles of the WHO Mental Health Policy and Service Guidance Package (2003): accessibility, equity, comprehensiveness, coordination and continuity of care, effectiveness, and respect for human rights. These principles were discussed in the module ‘Organization of Services for Mental Health’, one of the modules of the Mental Health Policy and Service Guidance Package (for definition of these principles, see table 2).

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Table 1: Data collection scheme

Ghana Health Service – Headquarters Ministry of Health Accra Psychiatric Hospital

Policy Health Care Caregivers Makers Providers 2 1 2

4

4

Pantang Hospital

5

4

Korle Bu Teaching Hospital – Psychiatric Unit

3

Total

5

12

Characteristics of the location –– Located in Accra –– Located in Accra –– Located in Accra –– Was built and accommodated patients in 1906 (Ewusi-Mensah, 2001) –– Offers in-patient and outpatient services, limited counselling and therapy, and clinical training for doctors, psychologists and psychiatric nurses (Fournier, 2011). –– Capacity is 800 beds, but accommodates more patients (Barke, Nyarko & Klecha, 2011). –– Located near Madina –– Commissioned in 1975 –– Offers other health services such as child services and HIV counselling and screening besides psychiatric services. It also offers many educational services for nurses (Fournier, 2011). –– Capacity is 500 beds, but cannot be used due to lack of maintenance of buildings and insufficient number of health workers (Barke et al., 2011). –– Located in Accra –– The Psychiatry Unit was established in 2011. –– The Unit provides psychiatry care for in-patients and out patients and the Unit is part of the Korle Bu Teaching Hospital that was established in 1923. (Korle Bu Teaching Hospital, 2014).

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Table 2: definition of the principles of the WHO Mental Health Policy and Service Guidance Package Principles (WHO) Accessibility Equity Comprehensiveness Coordination and continuity of care Effectiveness Respect for human rights

Definition Essential mental healthcare should be available locally, and includes outpatient and inpatient care, as well as rehabilitative care People most in need of services should be able to access those services Mental health services should include all facilities and programmes that are required to meet the essential care needs. Refers to the essence of intersectoral cooperation, and other organizational aspects Using effective interventions for the different mental disorders Services should respect the autonomy of persons with mental disorders and persons with mental disorders should be empowered and encouraged to make decisions that affect their lives. It also includes using the least restrictive types of treatment.

FINDINGS Challenge 1 and 2: Accessibility and Equity There was no geographical proximity of mental health care hospitals or psychiatric units, to the people who lived in the north of the country, and there were long waiting times. The former law had stated that mental healthcare was supposed to be free. Therefore, healthcare insurance providers had decided not to include mental healthcare in their package. Due to the lack of internally generated funds, patients had to pay high out-of-pocket fees for their treatment and medication. Healthcare providers tried to provide medication to patients as much as possible by gathering samples from pharmacies, for instance. “Sometimes you may offer that you buy their medication, or talk to the pharmacy if they have samples they are willing to give and if they have substitute generic drugs that would be equally okay for the patient.” (healthcare provider 12) From the interviews with the caregivers of patients, it became clear that, in total, patients paid a minimum of 60 and a maximum of 650 cedi for services, varying from administration matters (Folder) to payment for laboratory tests (see table 3). Table 3: Cost scheme mental health services

Services Folder Laboratory tests Medication New identity card Health checks Transport to health facility Optional costs:

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Costs (1 Ghanaian Cedi = 0.26 USD) 5 – 10 cedi 10 – 60 cedi 10 – 30 cedi (per month) 1 – 5 cedi 5 cedi 30 – 170 cedi

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Services –– Transfer to another ward –– ‘Extra hard work’ –– Consultation (Korle Bu) –– Admission at Pantang (1 month)

Costs (1 Ghanaian Cedi = 0.26 USD) 10 cedi 10 cedi 50 and 40 cedi 300 cedi Total 60 – 650 cedi

Challenge 3: Comprehensiveness – factors hindering an optimal mix of services There were different perceptions within the population about the causes of mental illness and duration of treatment. The trust in psychologists within the population was minimal, due to the lack of professional recognition given to psychologists by the government and the perception that only medication can help in the treatment of mental health problems. Secondly, the mental health institutions not only lacked internally generated funds but also lacked budget allocations from the government; both of which hindered an optimal mix of services. In addition, there was a lack of human resources. Most healthcare professionals did not want to specialize in the mental health sector, due to bad work conditions. Examples of such work conditions were the lack of allowances when there are injuries among the personnel, the lack of available supplies such as gloves, and the danger that aggressive patients bring on a daily basis. These factors contributed to low willingness of healthcare professionals to specialize in mental health. “The risk of working as a nurse in the mental health sector is as high as a military man in the battle field.” (healthcare provider 8)

Challenge 4: Coordination and continuity of care There was uncertainty about the establishment and role of a separate Mental Health Authority (MHA) that would coordinate the mental healthcare system independently, outside the Ghana Health Service (GHS). Opponents of a separate MHA feared its establishment would lead to a lack of communication, uncoordinated activities, and a lack of budget for mental health within the GHS. From the perspective of caregivers, it appeared that families were insufficiently informed about the condition of their family members. They would have liked to know more about the causes, the duration and the treatment possibilities for the condition of their family member. Lastly, the government and hospital did not acknowledge and support Substance Abuse Departments, which are the responsible units for treating patients with substance abuse problems. There was a general perception within the population and government that having an addiction problem was not a disease, but merely the result of personal responsibility., This complicated the position of Substance Abuse Departments within the mental health sector. The Substance Abuse Department at Korle Bu for example, was located far from other buildings and did not have any sign board identifying it or required supplies.

Challenge 5: Effectiveness There was a lack of use of psychosocial rehabilitation interventions for patients. One of the explanations was that there was overuse of medication. This was seen as an easier and cheaper option for treating people. Furthermore, the general population did not normally regard psychological interventions as important. The lack of established posts for psychologists was another reason that the role of psychosocial rehabilitation has lagged behind.

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Challenge 6: Respect for human rights Patients that did not have easy access to formal services regularly ended up in prayer camps. Prayer camps are privately owned Christian religious institutions established for the purposes of prayer, counseling, and spiritual healing. There were several hundred prayer camps in Ghana, and they were not state-regulated. Human rights abuses regularly happened, such as chaining, fasting and beating. Oversight of camps by an ad hoc committee of elders was limited and camps were inconsistent in the application of guidelines. “Prayer camps do more harm than good but it would be dangerous to ban them right now. We don’t have the resources to cover them. Any considered estimate says that there are over 300 or 400 thousands of prayer camps scattered over the country. We need a systematic approach where you educate the prayer camp healers.” (policy maker 3) Another challenge was reintegration of patients into their families. Family members often did not accept the former patient back into their lives because of feelings of shame with regard to the community.

CONCLUSIONS AND RECOMMENDATIONS After analysis of the results, two major structural barriers were identified. The first structural barrier was that the mental health sector had never had an internally generated fund (IGF), which has influenced the quality of the system considerably. Some stakeholders had propositions to increase IGF; for example, differentiating between people who could pay for the services and excluding payment of fees from people who could not afford to. Option two was to open up the market for psychiatric drugs, so that competition would decrease the prices of the medicines. The last option, which had the highest chance of succeeding according to the interviewees, was committing the insurance providers to take up some of the costs. The lack of mental healthcare providers was a second structural barrier. Some policy makers argued that as a consequence of the new Act, there would be a major role for occupational therapists and social workers. If this would be the case, the overuse of medication of patients would simultaneously decrease. Moreover, there were more plans regarding writing official job descriptions and making mental health training programmes available and more easily accessible. Improving the working environment and infrastructure would make working in the mental health sector more attractive. Although the passage of the Mental Health Act 2012 is considered a major milestone in addressing mental health as a public health issue, and also in the protection of human rights of people with mental disorders in Ghana, one can argue that the Act could have been more specific on how to reach its stated goals. There are still uncertainties about the finance system for the enactment of the law. The structural barriers mentioned above are recognized in the Act. However, practical information on how to improve and consequently move from the institutional care to community based care is lacking. A percentage of the overall health budget of Ghana or at least a fixed annual allocation should be formulated and earmarked for expenditure on the sector mental health. The same applies to motivating healthcare professionals to work in the mental healthcare sector. A step-by-step plan to motivate them is required, starting with more research that explores the barriers to working in the mental health sector for healthcare professionals.

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REFERENCES Barke, A., Nyarko, S. & Klecha, D. (2011). The stigma of mental illness in Southern Ghana: attitudes of the urban population and patients’ views, Social Psychiatry and Psychiatric Epidemiology, 46, 11911202 Doku, V. C. K., Wusu-Takyi, A. & Awakame, J. (2012). Implementing the mental health act in Ghana: any challenges ahead? Ghana Medical Journal, 46, 4 Ewusi-Mensah, I. (2001). Post colonial psychiatric care in Ghana, The Psychiatric Bulletin, 25, 228-229 Fournier, O. (2011). The Status of Mental Health Care in Ghana, West Africa and Signs of Progress in the Greater Accra Region, Berkeley Undergraduate Journal, 24, 3 Korle Bu Teaching Hospital (2014), Brief History, Retrieved from http://www.kbth.gov.gh/index.php?id=126 on 22-07-2014 McLaughlin, C. G. (2004). Delays in Treatment for Mental Disorders and Health Insurance Coverage, Health Services Research, 39, 2, 221-224 Menil, de V., Osei, A., Douptcheva, N., Hill, A. G., Yaro, P., De-Graft Alkins, A. (2012). Symptoms of common mental disorders and their correlates among women in Accra, Ghana: A population-based survey. Ghana Medical Journal, 46, 2 Roberts, M., Mogan, C. & Asare, J. B. (2014). An overview of Ghana’s mental health system: results form an assessment using the World Organization’s Assessment Instrument for Mental Health Systems (WHO-AIMS). International Journal of Mental Health Systems, 8, 16 The Kintampo Project (2012). Ghana’s New Mental Health Act: A Brief Guide, Retrieved from http://www. thekintampoproject.org/news/2012/12/22/ghanas-new-mental-health-act-a-brief-guide.html on 15-7-2014 World Health Organization (WHO) (2003). Mental Health Policy and Service Guidance Package – Organization of Services for Mental Health World Health Organization (WHO) & World Organization of Family Doctors (Wonca) (2008). Integrating mental health into primary care: A global perspective, Retrieved from http://apps.who.int/iris/ bitstream/10665/43935/1/9789241563680_eng.pdf on 9-9-2014

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Food Security on St. Eustatius: Perceptions of Agricultural Development Erin H.C. Kuipers1, Teresa E. Leslie2, Agnes M. Meershoek3 1 Faculty of Health Medicine and Life Sciences, Maastricht University, The Netherlands 2 Eastern Caribbean Public Health Foundation, Sint Eustatius, Caribbean, The Netherlands 3 Department of Health Ethics and Philosophy, Maastricht University, The Netherlands

ABSTRACT Background: High food import on St. Eustatius poses dangers not only to economic development but also to the health status of the population. Agricultural development is regarded as a potential solution to both the economic vulnerability and to improve the health situation on the island. Overcoming existing barriers requires the exploration of people’s views on agricultural development, the use of novel technologies, and their visions for the future of the island. The objective of this study has been to identify expectations, concerns and issues of agricultural stakeholders. Methods: 24 qualitative in-depth interviews were conducted with policy makers, farmers, store and restaurant owners, agricultural experts, politicians and community members. Participants were retrieved through both purposive and snowball sampling. Subthemes were used to guide the interviews and gain contextual information. The interviews were transcribed and results were categorized according to the subthemes. Results: Although the island community expresses both knowledge and willingness to obtain a healthier diet, they denoted several structural barriers. Stakeholders put forward several solutions that they believe would lead to increased food self-sufficiency of the community. They express hope that increase of local food production may be a solution to overcome these barriers. They agree that the method of hydroponics is worth exploring, provided that the implementation takes into account challenges inherent to the island. Overall, increased attention should be paid to continuity, cooperation, and education during the design and implementation of future agriculture projects. Discussion: It is critical to recognize the presence of several conflicting issues between stakeholders. These issues provide evidence for the multifaceted nature of the problem at hand. In turn, it is fundamental that a balance is established between local food supply and demand. Financial resources, infrastructure and cooperation are essential components of this balance. Investments in hydroponics should be coupled with investments in market expansion, for example with the creation of an export channel. Additionally, export offers an opportunity for St. Eustatius to work together with neighbouring islands. Ultimately, the agricultural development of St. Eustatius may not only benefit the island itself but also contribute to strengthen the agricultural sector in the rest of the CARICOM.

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The Role of Strengthening Primary Health Care Service Provider’s Accountability in Improving Maternal Health in Nepal Kritika Dixit1*, Charlie Thame1**, Marc Van der Putten1*** 1 School of Global Studies, Thammasat University, Pathumthani, Thailand, * [email protected] ** [email protected], *** [email protected]

ABSTRACT Social accountability (SAcc) in maternal health has gained increased recognition, globally. In Nepal, absenteeism, understaffing, inadequate transparency, accountability monitoring and supervision have raised questions regarding stewardship of health workers. SAcc tools are deployed to improve maternal health services. The study aims to identify SAcc tools applied in South Asia (SA) in maternal health, explore challenges and demonstrate their potential usages in women’s health and empowerment in Nepal. Literature was reviewed from scientific journals and unpublished sources using Boolean search strategy. Case-study research design was used, employing qualitative methodology. Three health posts in Doti district were purposively selected. Purposively sampled health workers were interviewed, and a focus group discussion with mothers was done which was noted, translated and analyzed using thematic content analysis. Findings showed that citizen report cards, community score cards, social audits, and public hearings were commonly used SAcc tools. The tools improved service delivery and health of pregnant women, increased their access to facilities and empowered them through awareness campaigns and mobilization. The challenges were inappropriate timing of the social audit coming at a busy time of the year, low people’s participation and provider’s poor understanding of the tools and socio-cultural contexts. Research on application of tools into diverse contexts would help establish cross-cultural feasibility of these tools, which can help Nepal establish proper accountability mechanisms, improving health of mothers.

INTRODUCTION Social accountability in health systems has become increasingly important in the delivery of fundamental public health functions. This involves empowering people to make governments accountable for the commitments they have made to effectively deliver services, by asserting the rights of citizens to accessible health services and improve their lives by addressing social and systemic barriers that undermine health (UNICEF, 2014). Evidence from developing countries like Tanzania, Rwanda and Nigeria highlights problems where accountability has been jeopardized as government health providers referred their patients to private health clinics, or they do not show up for work in health facilities at the assigned hour, or both (Dieleman, et. al., 2011; Anyanwu, 2015). There are various SAcc tools like expenditure tracking surveys, citizen report cards, community score cards, and social audits, public hearings, citizens’ charter, etc., used in programs and activities supported by international agencies like World Bank (WB) in the health spheres of many countries (World Bank, 2005b). These tools have been significant in monitoring performance of health institutions, women’s empowerment and participation by exposing corruption and absenteeism, and raising awareness

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of providers’ responsibilities by dissemination of information and creating pressure between various actors (Wilson, 2014). They, thus, improve health services through evidence based dialogue to enhance accountability in health services (World Bank, 2005b), thus increasing the effectiveness and efficiency of programs. Nevertheless, problems in maternal health care are daunting in Nepal. Inadequate awareness of women, and poor health systems, dearth of health professionals in facilities due to absenteeism or vacant posts, limited availability of medicines, medical equipment and supplies in rural areas, overcrowded health facilities, not operating timely services, insufficient monitoring and supervision mechanisms, and poor financial management are common problems (Simkhada, et. al., 2006; Gurung, et. al., 2015). One of the contributing factors to these problems is the lack of accountability to local people (Wilson, 2014). Various SAcc tools like public audits, community score cards, public expenditure tracking, citizen charter, and social audits have been implemented in Nepal with the help of international organizations. The government in 2009 endorsed social audit activities in the Aama Program of Nepal (MoHP, 2013/14) by formulating its own guidelines and methodologies. The program is a government implemented maternal health program that seeks to increase access to maternal health care by offering free ANC checkups and cash incentives and health facilities delivery incentives based on the mandates and guidelines of the programs. The social audit guidelines emphasize the necessity of enhancing information delivery among people through mutual dialogue; maintaining adequate transparency while handing over cash incentives to mothers and health facilities; promoting responsibility, accountability, and rights of people over the program by fostering people’s meaningful participation and ownership, and by promoting accountability of health workers. Piloting was conducted to test the effectiveness of the tools, and success led to implementing another scaled-up program in Doti district (Neupane, 2011). Since the WB is a pioneer in developing and implementing SAcc tools in various South Asian (SA) countries including Nepal, a review of the literature can provide a roadmap to understanding what the key successful factors are when implementing the tools at the community level and some of the associated challenges. Thus, it can serve as a lesson to Nepal when seeking to improve the functioning of these tools, and thereby to improve the health of mothers. Therefore, this study facilitates the understanding of to what extent the inception of social audit in the health program implemented by the government of Nepal has been successful at the ground level, and provides a reflection on how successful donor agencies have been in implementation of these tools at the same level.

OBJECTIVES • • •

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Identify common WB SAcc tools applied in health services in SA countries and demonstrate their usage in empowering women and improving maternal health Identify factors influencing the functioning of SAcc tools in health services and challenges to implementing social accountability tools in Nepal Demonstrate the usage of the tools in empowering and improving maternal health in cultural setting of Nepal

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Citizen Report Card

Challenges





Improved communications and information dissemination though media (USAID, 2009) Informed people about health seeking behavior (Shukla, et. al, 2013)

Lack of proper monitoring mechanism to identify if the providers have responded to the complaints from citizens (Devkota, et. al, 2013); inadequate understanding of the tools and social context among implementers (World Vision, 2015; Neupane, 2011); lack of sufficient funds (Wilson, 2014); culture of silence among pregnant women to share pregnancy problem could alter information (Wilson, 2014)









Active participation of women helped in realizing their health needs and services avail (Andersson, 2011) Media mobilization increased awareness about danger signs and risks in pregnancy

India, Bangladesh, Nepal

In Bangladesh, Maternal, Neonatal and Child Health (MNCH) committees empowered community people. In Nepal, Health Facility Management Committee showed improved performance of health workers; encouraged frequent meetings; increased community participation; improved communication between service providers and users; increased availability of health workers and service utilization; more birth delivery at centers (Barnes, 2011). Studies in Nepal, India, and Pakistan showed that formation of women’s groups increased women’s mobilization and participation (Manandhar et al., 2004; Tripathy et al., 2010). Women’s groups improved dissemination of information on maternal and child health problems and their solution that helped to improve maternal and child care within households (Leppard, et. al., 2011). In Nepal (Female Community Health Volunteers) and India (Accredited Social Health Activists) were significant in improving maternal health by monitoring health condition of pregnant women and newborns, recommending women to seek ANC during pregnancy, and preparing them for delivery using skilled birth attendants at a birthing center (Powell-Jackson, et. al., 2009). In Nepal, Key Informant Monitoring and Community Health Score Board tool were successful in identifying favorable social environments for better health care through mobilization of local men and women groups. It increased involvement of service providers and community people and their relationships; improved quality care, and behavior, and privacy in health facilities which increased demand for health services (Price, & Pokharel, 2005; World Bank, 2005c). Media have been instrumental in disseminating messages about maternal and child health in the community (Joshi, 2013).





Increased interaction be• tween people and providers (Green, 2011)

Afghanistan, Pakistan, India, Nepal

Public Hearing The tool where government authorities share information to public and beneficiaries about their work (PRAN, 2011).

Various other initiatives in women empowerment





Social Audit Accountability tool where officials submit their programmatic activities to an audit and community members can collectively monitor and enquire about the implementation and effectiveness of health programs (Khalid, 2010)

Transparency, accountability and responsiveness Participation of community stakeholders like religious leaders, teachers (Satia, et. al., 2014). Regular coordination meeting and reporting (WRAI, 2012)

India, Nepal

Assessment tool, a survey with quantitative assessment of health services (Coventry & Hussein, 2010)

Factors that influenced • implementation of social audit in Nepal •

Afghanistan, India, Nepal

Countries

Community Score Card

An assessment tool where scores are given by health officials to their own performances and service users also score the performance of service providers (PRAN, 2011)

Name of SAcc tool

Definition

METHDOLOGY A case study research design was used, employing a qualitative methodology. Primary qualitative data from a focus group discussion (FGD) and key informant interviews (KII) with health care providers were done. The review of literature on eight South Asian (SA) countries included Nepal, India, Pakistan, Bhutan, Bangladesh, Afghanistan, Maldives and Sri Lanka on lessons learned in the use of World Bank (WB) SAcc tools. The primary study areas were purposively selected: three health posts in social audit implemented Doti district. Purposively sampled health workers as key informants were interviewed and a FGD with mothers, who were selected using snowball sampling, was done. Two qualified public health students were appointed to collect information and facilitate discussion. Mothers were those having children under the age of five years and who visited the health post for pregnancy checkup or delivery. Literature was reviewed from published scientific journals and unpublished sources between 2000 A.D. to 2015A.D. using Boolean search strategy that documented interventional activities of deployed tools by WB in SA countries for improving accountability in maternal health services. Information from KII and FGD was analyzed based on thematic content analysis of issues facilitating discovery of regularities, comprehension of meaning and reflection. Qualitative secondary data analysis was conducted in a simple descriptive manner. Comparative analysis of the replicability of accountability tools in the cultural context of Nepal was conducted using key aspects like core SAcc and implementation components. Data and source triangulations were undertaken to validate findings.

ETHICAL CONSIDERATION Approval was sought from Thammasat University’s Ethical Review Committee prior to conducting data collection. Written informed consent was obtained from KII and FGD participants. Participants’ confidentiality was secured by using alpha-numeric ID codes in place of their names; electronic transcripts and logbook were password protected.

RESULTS The common SAcc tools used in SA identified from literatures were Community Score Cards, Citizen Report Cards, Social Audit and Public hearing. Primary Data Collection

KII:

Factors that influenced implementation of social audit were: Strong support from local people and stakeholders of the program; improved transparency in the services, which increased trust among service users; yearly conduct of the audit and provision of training on audit. The informants reported increased awareness among women, increased demand for services, increased ANC checkup and birth deliveries at health facilities on time. All have led to improved health and reduced deaths of women. The challenges were timing of conducting social audit, which was done during end of fiscal year when other reporting was done, thus limiting time for the audit; lack of involvement of health workers; low budget allocation

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FGD:

Women’s empowerment was identified since women in FGD were aware about the risks and vulnerabilities during pregnancy and incentives given by health facilities when they have four times ANC checkup and birth delivery at the health institution. There was low women’s participation in community awareness program because they were busy with their household chores, or unaware of such programs in community, or not informed ahead of time. Women were satisfied with services from health care providers. Household decisions were made by older person at home especially by mother-in-laws or husbands but were influenced by FCHVs suggestions to delivering baby at health facilities.

DISCUSSION The limitations of the study were: secondary reviews of the articles were mainly based on grey literature from organizational reports. There were no adequately published and reviewed documents that detailed how the accountability tools created an impact on the maternal health. Also, most of the studied reports were based on short term activities; therefore, the impact of the effectiveness of the tools that led to empowerment and decreases in maternal mortality could not be justified. Lastly, the study is constrained by a small sample size that includes only one FGD and three KIIs conducted in one of the districts of Nepal Adequate orientation and training of health workers on methodological guidelines and reporting mechanisms, community participation and media mobilization were common drivers in the proper implementation of the tools. These results coincided with findings in a study done by Kok et al. (2014), which showed that application of social accountability tools involved frequent training, supervision and monitoring, community people involvement in programs and strong coordination between service providers and service seekers; all of which improved performance of providers. Studies from India showed that conducting repeated public hearings increased awareness and participation among community people. Andersson (2011) mentioned that combining qualitative and quantitative findings from the audits provided better results. Thus, these successes could be potential lessons for Nepal in implementation. Shukla & Sinha (2014) indicated public hearings were ineffective when officials of health facilities did not participate. This resembles our findings from KIIs, where the informants mentioned their low involvement in social audit process. This shows that the implementation is more of a top down process in contrast to the bottom-up process of social accountability. A report by Green (2011) provided a case example from Maharastra state of India. To improve understanding by both respondents and interviewers, the questions in the community score card were developed into locally familiar pictures. Example: Roti, a local type of bread round in shape, was used as a symbol to rank the score for satisfaction or dissatisfaction towards providers. ‘Full Roti’ meant ‘very good’, ‘half Roti’ equated to ‘partial satisfaction’ and ‘no Roti’ meant ‘very poor’ (Singh & Moran, 2010). Thus, implementation of the tools by understanding the social context increased its effectiveness in the community and could be a potential lesson for implementation of the tools in Nepal as well as in other countries. However, the organizational reports and articles lacked clear data on the methodological process of the data collection by the tools. For example, to what extent was the marginalized population involved in any discussion forums and included in quantitative figures? This is crucial to picture how much real progress

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was achieved and what underpinned the problems or what triggered the social accountability activities. A study conducted by Singh and Vutukuru (2010) also argued that despite audits focused on empowerment of women by providing employment, reports were unclear as to what extent marginalized groups or women had benefitted or participated, and were heard in the process of the audits. Thus, although social accountability tools have been forged in health programs, the methodological process on data clarity was found to be imprecise, which can raise questions about the validity of the results.

CONCLUSION Thus, the study conducted in Doti and SA showed that application of the tools empowered mothers and improved their health. However, they needed proper understanding of the socio-cultural context since this may influence access to, and utilization of, health services and women’s participation in health programs. Although health interventions attempt to promote the empowerment of women, they are often conducted by non-governmental organizations. Therefore, they are mostly short-term activities and may not fill the void of bringing sustainable impacts to the health of mothers. The fragmented nature of these activities also incurs more costs. Thus, detailed research on application of tools into diverse contexts would help establish the cross-cultural feasibility of these tools. Identifying challenges from past experiences of SA countries and incorporating appropriately designed SAcc tools for maternal health programs can help Nepal establish proper accountability mechanisms, improving the health of mothers.

REFERENCES Andersson, N. (2011). Building the community voice into planning: 25 years of methods development in social audit. BMC Health Services Research,11(Suppl 2), S1. doi:10.1186/1472-6963-11-S2-S1 Anyanwu, E. B. (2015). The Practice of Medical Referral: Ethical Concerns. American Journal of Public Health Research, 3(1), 31-35. Barnes, B. (2011). Case Study: Linking Governance and Empowerment to Improved Maternal and Newborn Health Services in Nepal. Retrieved from: http://www.care.org/sites/default/files/documents/ MH-2011-Nepal-Case-Study-Governance-and-Health.pdf Coventry, C., & Hussein, M. (2010). Responsiveness and Accountability in the Health Sector in Pakistan: A Literature Review. Devkota, B., Ghimire, J., Devkota, A., Gupta, R.P., Mahato, R.K., Thapa, N., Shrestha, B., Tuladhar, P. (2013). Health governance at local level from human resource for health prespectives: the case of Nepal. Journal of Nepal Health Research Council, 11(24), 133-7. Dieleman, M., Shaw, D. M., &Zwanikken, P. (2011).Improving the implementation of health workforce policies through governance: a review of case studies. Hum Resour Health, 9(10), 10-1186. Green, C. (2011). Community monitoring in a volunteer health worker setting: a review of the literature. Kampala, Uganda: inSCALE Gurung, G., Derrett, S., Hill, P. C., & Gauld, R. (2015). Governance challenges in the Nepalese primary health care system: time to focus on greater community engagement? The International journal of health planning and management. Joshi, A. (2013). Do they work? Assessing the impact of transparency and accountability initiatives in service delivery. Development Policy Review,31(s1), s29-s48. Khalid, M. Y., Kamal, S., Noor, M. T., Akbar, S. H., Hasan, B., & Mahmud, K. (2010). Social Audit of Local Governance and Delivery of Public Services: 2010

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Kok, M. C., Dieleman, M., Taegtmeyer, M., Broerse, J. E., Kane, S. S., Ormel, H., & de Koning, K. A. (2014). Which intervention design factors influence performance of community health workers in low-and middle-income countries? A systematic review. Health policy and planning, czu126. Leppard, M., Rashid, S., Rahman, A., Akhter, M., & Nasreen, H. (2011). Voice and Accountability: The Role of Maternal, Neonatal and Child Health Committee. Bangladesh: University of Aberdeen UK & BRAC RED Ministry of Health and Population (MoHP) [2013/14]. Annual report 2013/14. Department of Health Service. Retrieved from: http://dohs.gov.np/wp-content/uploads/2014/04/Annual_Report_2070_71. pdf Neupane, B.D. (2011). A Review of Social Audit Guidelines and Practices in Nepal (DRAFT). Nepal Health Sector Support Program (NHSSP). Retrieved from: http://www.nhssp.org.np/gesi/Social%20 Audit%20Review%20-%20Final%20Draft%20Report%20-%2010%20Oct%202011.pdf Powell-Jackson, T., Morrison, J., Tiwari, S., Neupane, B., Castello, A.M. (2009). The experiences of districts in implementing a national incentive program to promote safe delivery in Nepal. BMC Health Services Research, 9:97. doi:10.1186/1472-6963-9-97 Price, N., & Pokharel, D. (2005). Using key informant monitoring in safe motherhood programming in Nepal. Development in Practice, 15(2), 151-164.

Program for Accountability in Nepal (PRAN, World Bank) [2011]. Accountability, Social accountability and PRAN.



Satia, J., Misra, M., Arora, R., & Neogi, S. (Eds.)[2014]. Innovations in Maternal Health: Case Studies from India. SAGE Publications India.

Shukla, A., & Sinha, S. S. (2014). Reclaiming public health through community-based monitoring.

Shukla, A., Saha, S., Jadhav, N. (2013). Community Based Monitoring and Planning in Maharashtra‐A Case Study. SATHI, India and COPASAH

Singh, R. and V. Vutukuru (2010). Enhancing Accotability in Public Service Delivery through Social Audits: A Case Study of Andhra Pradesh. New Delhi: Centre for Policy Research Simkhada, B., van Teijlingen, E., Porter, M., & Simkhada, P. (2006). Major problems and key issues in Maternal Health in Nepal. Kathmandu University Medical Journal, 4(2), 258-263 Unicef(2014). What Nepal can teach us about social accountability. Accessed on 10th April 2015. Retrieved from http://blogs.unicef.org/2014/03/26/what-nepal-can-teach-us-about-social-accountability/ United States Agency International Development (USAID) [2009]. Time to deliver on maternal health and family planning best practices: White Ribbon Alliances in Asia and the Middle East make it happen. Retrieved from: www.healthpolicyinitiative.com/Publications/Documents/807_1_WRA_Alliances_Make_It_Happen_Final_July_2009_acc2.pdf Wilson., A.(2014). Making local health services accountable: Social auditing in Nepal’s health sector. Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ). World Bank (2005b).Sourcebook on “Social Accountability: Strengthening the Demand Side of Governance and Service Delivery” Chapter 3: Methods and tools. Retrieved from http://www.worldbank.org/socialaccountability_sourcebook/PrintVersions/Methods%20and%20 Tools%2006.22.07.pdf World Bank (2005c). Sourcebook on Social Accountability: Strengthening the Demand Side of Governance and Service Delivery. Chapter 4: Social accountability in the health sector. Retrieved from: http:// www.worldbank.org/socialaccountability_sourcebook/PrintVersions/Health%2006.22.07.pdf

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World vision (2015). Changing Lives through social accountability. Case Studies from World Vision’s UK Government’s Department for International Development (DFID) Programme Partnership Arrangement White Ribbon Alliance India [(WRAI), 2012]. National Accountability for Delivery. Retrieved from: http:// www.who.int/woman_child_accountability/ierg/reports/2012_24N_WRA_National_Accountability_for_Delivery.pdf

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Policy Reform for Sex Work: Criminalization and Decriminalization in the Context of Feminist Ideologies, Social Determinants of Health and Human Rights Khine Su Win1*, Fabio Saini1** 1 School of Global Studies, Thammasat University, Pathumthani, Thailand * [email protected] ** [email protected]

ABSTRACT Background: Criminalization of voluntary sex work is one of the structural determinants of inequities for Female Sex Worker (FSW) and maintaining social exclusion inherent in patriarchy and heteronormativity. In recent years, many national policies reform for sex work appear to reflect either abolitionist feminism or sex positive feminism. Whether these policy approaches address structural determinants of inequities for FSW as women at bottom of heteronormative hierarchy remains to be seen. Objectives: 1) To identify whether current legal framings of sex work challenge or maintain heteronormative and patriarchal constructs of women engaging in sex work, and how this in turn contributes to heightened health inequities especially for FSW. 2) To analyze whether opposing feminist ideologies, namely the abolitionist and the sex positive ideologies, contribute to challenge or reinforce heteronormative and patriarchal constructs of women in sex work, as well as the contribution of these ideologies to rights-based frameworks. 3) To provide suggestions from a rights and equity perspective for policy reform for sex work especially in South East Asia. Methodology: This study is a content analysis of literature by applying the Critical Frame Analysis (CFA). The CFA is a methodological framework for in-depth analysis of diverse political framing in diagnosis (What is the problem?) and prognosis (What is the solution of the problem?). The diagnosis and prognosis are related to different theory concepts of gender inequality, and gender political discourse such as intersections with other inequalities, inclusion of voices, and addressing structures that produce gender inequality. Key findings: Abolitionist feminism conceptualizes gender inequality within hegemonic patriarchal masculinity paradigm with no intersections other socio-economic inequalities. It constructs a ‘victim’ identity for all women engaging in sex work by conflating prostitution and human trafficking for sexual exploitation, and denies possibility of voluntary sex work. It advocates partial criminalization of prostitution i.e. criminalization of clients and third parties, and the social rehabilitation of the ‘victims’. Sex-positive feminism problematizes heteronormativity as a root cause of gender inequality. It recognizes voluntary sex work as work and views criminalization of voluntary sex work as a form of structural violence against women who do not conform to the ‘victim’ identity. Moreover, sex positive feminism examines how gender inequality intersects with other drivers of inequities such as class, ethnicity, or race. The proposed solution is decriminalization of sex work to provide legal protection as workers and decreases their vulnerabilities to ill health and abuse.

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Conclusions: Abolitionist feminism denies personal agency and voice of voluntary FSW who do not identify as ‘victims’. Thus, it reinforces inequitable power hierarchies of heteronormativity, and contributes to social exclusion of voluntary FSW and structural violence against them. It also reinforces patriarchal construction of women’s subordination to men by constructing women as powerless victims. By contrast, sex-positive feminists’ legal framework to sex work challenges power dynamics of heteronormativity by addressing the structural violence through a rights-based frame work, and transforms cultural paradigm by constructing voluntary FSW as a normative group. However, both ideologies have limitations in their conceptualization of sex work and FSW as well as of men’s roles in challenging and transforming the power structures at the root of gender equality.

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An Approach to Assessing Disease Surveillance in Myanmar Wai Phyo Thant1 1

School of Global Studies, Thammasat University, Pathumthani, Thailand, [email protected]

ABSTRACT Background: Quality of information is essential for effective communicable disease surveillance. In era of globalization, communicable disease surveillance became paramount in support of controlling pandemic threats. As advances in technology redefine the ways people, systems and information interact, resource-poor communities are often excluded, which impacts on health equity. Deficiencies in terms of infrastructures, supplies and human resources create barriers in the development of an efficient surveillance system in Myanmar. Very few studies touched upon disparities in Myanmar’s health information system (HIS). Flaws in Myanmar’s HIS remain greatly unknown which hinders system’s development. Objective: This study addressed the question of efficiency of Myanmar’s current HIS by assessing its core capacity and identified key challenges to be addressed in paving the way for systems development. Methodology: A case study design was applied, employing a combined methodology which involved a documentary review and a cross sectional descriptive study. A total of 47 documents were selected for inclusion comprising of 11 key documents and 36 fringe documents serving the development of a conceptual framework for a communicable disease surveillance system and assessment of its efficiency. The cross-sectional survey provided the means to assess Myanmar’s current HIS efficiency by applying a purposive sampling to health professionals working in national and sub-national disease control settings resulting in 14 respondents. Qualitative data served a content analysis, while quantitative data facilitated a simple descriptive analysis using frequencies only. Key Findings: The construct of a national surveillance system comprises of: (a) disease prioritization including criteria, prioritization process, and prioritization outcomes ; (b) surveillance capacity which includes case detection, case registration, case reporting, data analysis, and feedback; and (c) partnerships and networks which includes inter-sector collaborations and data sharing. The need assessment revealed the following: (a) diseases prioritization: none of the respondents were aware about what’s involved on the disease prioritization process; (b) surveillance capacity was challenged by having only main health facilities functioning as data generating points and field-based manual operation systems making it impossible to employ interactive data analysis. As a result feedback was slow and became outdated with no follow-up mechanisms in place; (c) only one third of the respondents are aware of inter-sectoral collaborations, whereas half of the respondents did not share information because of technical and/or political barriers. Discussion and Conclusion: Priority setting in disease surveillance follows donor funding in Myanmar at the risk of overriding actual needs. Although sporadic inter-sector collaboration did exist, it was not a routine practice which is necessary across all relevant sectors and all functional levels. To improve health equity for

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remote and resource poor communities through expanding surveillance coverage, health policy should promote the integration of all health facilities into the national surveillance system. Rapid assessment findings of this study call for future in-depth and larger scale studies. Myanmar’s communicable disease surveillance system’s core capacity is challenged in terms of disease prioritization, surveillance capacity, and partnerships and networking.

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Sustainable Change Through Socially Responsive Design Istvan Rado1 1 School of Global Studies, Thammasat University, Pathumthani, Thailand, [email protected]

ABSTRACT A number of recent publications in the field of social design/social innovation argue that in solving many community issues, design teams should act as enablers and facilitators rather than primary problem-solvers. This suggests that community members take the lead in solving their own problems based on assets and skills endogenous to the community. Such processes are expected to lead to sustainable change of economic realities. In this context, the term “sustainability” primarily refers to the continuation of the change process as community members develop a sense of ownership and feel invested in its outcomes. Based on ethnographic research undertaken in January 2012 about an alternative farmers’ network in Northeastern Thailand, this paper aims to illustrate what such a “strengths-based” human-centered design approach could look like. At the same time, and following the insights from the empirical case study, it will be argued that problem-based research and respective methods continue to be valuable alongside strengths-based methods, namely when the research process is intended to result in the creation of a social enterprise.

INTRODUCTION Human-centered design (HCD) is an action research methodology with the objective to directly contribute to social change building on the research findings. In most cases the HCD process is highly participatory, involving affected community members as informants or even as co-researchers and co-creators of the research outcome (IDEO, n.d.). However, there are limits to the extent to which community members are involved due to the very orientation of most HCD initiatives: The research process is meant to respond to a central need or problem faced by the community; accordingly, the objective is to find a solution or service to adequately serve this need. Recent publications in the field of “social impact design” or “socially responsible/responsive design” have pointed out that this orientation depicts the community in terms of what it lacks and in need of outside help (Thorpe & Gamman, 2011; Manzini & Rizzo, 2011, p. 201; Campbell, 2013). The social designer is thereby from the beginning assigned a “savior” role (Peters, 2011). The authors point towards emerging trends within the related field of community development, in which action research is oriented towards the identification of community strengths (resources and skills). Since these are resources available to community members this orientation puts them in the driver’s seat in the social innovation process. The role of the design team is here to facilitate a process, in which community members are guided towards project ownership. As community participants are personally invested in the project and responsible for its outcomes, the likelihood of the success of the project is increased. This paper will explore the potentials of this “strengths-based” approach for social innovation by outlining the activities of the Inpaeng network, the largest network of alternative farmers in Thailand. The data will then be analyzed for what a strengths-based HCD process can look like and how it relates to and complements problem-based social innovation.

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THE INPAENG NETWORK: BACKGROUND AND ACTIVITIES Most information in this section has been collected over a two week field research period in January 2012. During that time the author conducted fifty random household interviews in the village of Ban Bua, eleven expert interviews with Inpaeng leaders from four provinces, and participated in two network meetings and a village ceremony. During the time of the research, few sources on the network were available both in English or Thai. The sources available did not go into depth about core network activities, but either provided some historical background with only general info on network activities (see Tosakul et al., 2005; UNDP, 2007), were authored by an institution engaged in a project with the network (Samek et al., 2011), or focused on social determinants of health (Sutee, 2010). The present research had the purpose of systematically capturing how the network has operated. The Inpaeng network started out as a small group of villagers, who sought to expand their knowledge on local strengths, such as traditional products and skills. Inpaeng can therefore be characterized as primarily a learning network. In 1986, a bachelor student and NGO member came to join the village for a year to conduct ethnographic research on livelihoods in rural Sakon Nakhon. After presenting his findings to two influential village elders, the small group sought ways to make the local community understand the value of traditional knowledge and local biodiversity, including fruits and herbs unique to the region (Pho Lek, personal interview on 17 January 2012). At that time farmers mainly grew cassava for agribusiness companies, which made them dependent on cash income. Since almost every household grew the same cash crop, sales prices were very low and private debt was on the rise in the village (see Tosakul et al., 2005, p. 12). These founding members shared an understanding that most villagers underestimated their own capacities to improve their lives. The initial activities of the group consisted of excursions throughout the region to collect seeds and to learn from alternative farmers. They experimented with new techniques in their own fields. One member left to earn a diploma in traditional medicine in Khon Kaen province, likewise applying this knowledge upon returning back home. From various government institutions Inpaeng moreover acquired techniques to increase their agricultural output; these skills included making fertilizer from local ingredients or the manufacture of water-pumping windmills, which is an important innovation in an area in which fields are predominantly rain fed. As is the case for herbal medicinal use or the organic fertilizer, only the know-how to construct these windmills comes from outside the communities, whereas the building materials are locally available. In fact, it can be said that the single most important outside resource making many Inpaeng projects possible is information and expertise. Inpaeng readily shares this knowledge with the wider community. In 1988, a learning center was established for training and for exchanging knowledge (Sutee, 2010, p. 23). Some resource persons provide training to others in the use of medicinal herbs, whereas others are teaching local farmers how to construct windmills for irrigation purposes. Network activities have gradually extended beyond matters of farming and biodiversity conservation into the creation of social enterprises. For instance, the group has acquired know-how from a state research institute to process local fruits, especially Makmao berries, into juice and wine. Today, the Inpaeng center in Ban Bua hosts two community enterprises: one producing traditional medicine and the other Makmao juice (Rado, 2013, p. 185). Local strengths combined with modern techniques and know-how thus provided unique opportunities for community development. Illustrating this through successful examples and spreading this knowledge among regional farmers became a central concern for network members.

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Since the early 1990s the Inpaeng network has expanded first within Sakon Nakhon province and then throughout the remote Northeast by word of mouth and collaborative projects with government institutions. Today it is present in five provinces. Most activities involve the wider communities of Inpaeng members, including people beyond the network. The Makmao factory in Ban Bua, for instance, buys the berries from local farmers at a stable price with a guarantee to purchase any quantity. It moreover provides seasonal labor for about a dozen villagers. This and similar enterprises operated by network members serve to illustrate that money can be made based on local resources. Other cooperatives, such as a fertilizer enterprise in Udon Thani province, respond to local weaknesses or needs: following a study undertaken by Inpaeng it has been found that local households in a district in Udon Thani spend more than 10% of their income on fertilizer (Chamnan, personal interview on 22 January 2012). This cooperative meets this demand by producing an organic alternative for a quarter of the market price. These ventures illustrate that Inpaeng products may target both outside and local markets, but in each case are meant to serve local communities. If community enterprises target external consumers they are profit-oriented and provide local communities with revenue and employment. If local households are targeted as buyers, then enterprises work on a non-profit basis aimed at lowering the expenses of local householders. In this latter case the cooperative responds to a specific problem or need but serves this need through local resources. In the case of the fertilizer company the ingredients are obtained from local inputs, freely available to any farmer who knows how to reproduce this product. In sum, the Inpaeng network identifies weaknesses alongside strengths, but seeks ways to respond to these needs through locally available means instead of solutions that consolidate dependence on external assistance.

LESSONS FOR HUMAN-CENTERED DESIGN INTERVENTIONS The activities of the Inpaeng network provide important insights not only about the advantages of development approaches based on local strengths, but also on the design of these approaches. As the above illustration shows, a strengths-based project could start with an identification of resource persons, or natural leaders, especially those who need little convincing about the merits of place-based development alternatives. Not only do such leaders share this understanding, but usually already command respect in the community, which ensures that the project is met with a higher degree of openness and acceptance. Also, it is they, together with later recruits within the community, who will increasingly own the project. A primary network activity consisted in gathering data on local biodiversity and traditional know-how. Practitioners and researchers in the field of community development have devised methods to structure such explorations of local resources, namely asset-mapping and appreciative inquiry (see Kretzmann & McKnight 1993; Cameron & Gibson 2001; Whitney & Trosten-Bloom 2010). Both of these methods involve close interaction with community members through in-depth interviews, focus groups, and workshops. Since these interactions emphasize the capacities of the interviewees or participants, this process also serves the build-up of positive emotions and self-confidence (see Whitney & Trosten-Bloom, 2010, p. 147/48; Seri, 2001). After all, it is community members themselves who are the primary innovators and their creative capacities depend to a large degree on the extent to which they are “energized” for the project. In contrast to strengths-based approaches, Inpaeng resource persons not only explore local assets, but also problems and needs: The fertilizer cooperative in Udon Thani has clearly been created for the purpose of serving a particular need, which is the demand for affordable fertilizer in a low-income rural district. Proponents of strengths-based approaches typically oppose development ventures meant to serve particular

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problems; however, as the examples in section 2 show, Inpaeng seems to treat such problems as opportunities to come up with solutions based on local resources. This approach again reinforces the idea among community members that they possess the capacities to solve their own issues. Problems and weaknesses thus serve to foster the same positive attitude, which strengths-based projects are meant to evoke. HCD initiatives already make use of SWOT-analyses in community development projects (see Peters, 2011, p. 58), capturing not only strengths, but also weaknesses, opportunities, and threats in a single table. Proponents of asset-based community development, on the other hand, are mostly critical of this tool, because placing positives next to negatives is seen as inviting people to focus on the latter (see Gibson, 2010). The Inpaeng approach could provoke us to reconsider this interpretation and view weaknesses and threats as another kind of opportunity instead. In the above examples, these weaknesses have induced network members to seek additional know-how. Once the techniques to create organic fertilizer or windmills have been acquired, they become part of a growing knowledge commons increasingly strengthening the resilience of Inpaeng communities in the region. This treatment of problems as triggers of new strengths has wider ramifications for a discussion of the relationship between community strengths and weaknesses. For instance, the way Inpaeng members had conducted research leading up to the establishment of the fertilizer cooperative resembled a conventional HCD approach more than a strengths-based approach. However, this cooperative is part of the community, inserted in the district through ongoing relationships with local households. In this case, people native to the region created the social enterprise, but we can see how external actors can play an equally productive role in a community through social enterprises serving a particular need. This approach can likewise be sustainable the more the enterprise becomes an interdependent part of the community economy. The more it relies on local resources, including labor, resources, or personal relationships the more it becomes a resource or asset of the community.

CONCLUSION This paper has provided a brief examination of economic activities of the Inpaeng network, with an emphasis on ventures, which provide clues about what a strengths-based HCD project could look like. Not only has it been shown that design teams continue to play an important role as project initiators and enablers; the tools and orientations in problem-based action research may as well remain productive, if the project is not intended as an intervention with a deadline; this means projects, in which design teams come up with a “successful” solution for a design challenge and then withdraw, expecting community members to continue with the innovation. Such projects resemble community development projects and as such need to be owned by the community through asset-based approaches. However, if the purpose of the action research process is the creation of a social enterprise, which adds new and ongoing activities to the life of the community, then problem-based research remains a promising strategy.

REFERENCES Cameron, J. & Gibson, K. 2001. Shifting Focus: Pathways to Community and Economic Development: A Resource Kit. Latrobe City Council and Monash University, Victoria. Campbell, A. 2013. “Designing for development in Africa: a critical exploration of literature and case studies from the disciplines of industrial design and development studies.” Gaborone International Design Conference: Design Future: Creativity, Innovation and Development (GIDEC 2013)

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Gibson, K. 2010. Community Partnering for Local Development. http://communitypartnering.info/ (last accessed on 1 April 2016) IDEO. n.d. Human-centered design toolkit. https://yali.state.gov/wp-content/uploads/sites/4/2015/07/ IDEO_HCD_ToolKit.pdf (last accessed on 1 April 2016) Kretzmann, J. P., & McKnight, J. 1993. Building communities from the inside out. Northwestern University, Evanston, IL: Center for Urban Affairs and Policy Research, Neighborhood Innovations Network Manzini, E. & Rizzo, F. 2011. “Small projects/large changes: Participatory design as an open participated process.” CoDesign 7(3-4), 199-215. Peters, S. 2011. Design for Enabling Sustainable Livelihoods in Disadvantaged Communities: A Case Study in Amphoe Phrapradaeng, Samut Prakran Province in Thailand. RMIT University, Melbourne Rado, I. 2013. “Sustainable Community Development in Northeastern Thailand. The Inpaeng Network.” In Brennan, Linda; Lukas Parker; Torgeir Aleti Watne; John Fien; Duong Trong Hue & Mai Anh Doan (eds): Growing Sustainable Communities: A Development Guide for Southeast Asia. Tilde University Press, 177-194 Samek, Jay H.; David L. Skole; Usa Klinhom; Chetphong Butthep; Charlie Navanugraha; Pornchai Uttaruk & Teerawong Laosuwan (2011): “Inpang Carbon Bank in Northeast Thailand: A Community Effort in Carbon Trading from Agroforestry Projects.” In Kumar, B. Mohan & P.K.Ramachandran Nair (eds): Carbon Sequestration Potential of Agroforestry Systems: Opportunities and Challenges, Springer, 263-280 Seri Phongphit (2001): People’s Development. A Community Governance Tool. UNDP Southeast Asia HIV and Development Project, Bangkok Sutee Suksudaj (2010): The Thai Social Capital as a Social Determinant of Oral Health; Phd dissertation, University of Adelaide, Australia Thorpe, Adam, and Lorraine Gamman. “Design with society: why socially responsive design is good enough.” CoDesign 7.3-4 (2011): 217-230. Tosakul, R.; Benjasaph, J.; Phromduang, P. Wittaporn, S.; Juemmi, S. & Phaireephinat, S. 2005. Duen thi la kao kin khao thi la kham: phumpanyaa nai kanjadkan khwamru khong chaoban [Walk One Step at a Time, Eat One Bite at a Time: Wisdom in Knowledge Management of Villagers]. Khon Kaen, Thailand UNDP. 2007. Thailand Human Development Report 2007. Sufficiency Economy and Human Development. Bangkok, Thailand Whitney, D. & Trosten-Bloom, A. 2010. The power of appreciative inquiry: A practical guide to positive change. Berrett-Koehler Publishers

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Case Studies from Ethiopia and Nepal-What Variants in Social Determinants Make Girls Vulnerable to Trafficking for Sexual Exploitation? Elin, M. Longard1 1 School of Global Studies, Thammasat University, Pathumthani, Thailand

ABSTRACT Background: Human trafficking is the fastest growing criminal industry in the world. Trafficking of girls is on the rise, and many of these girls are trafficked for sexual exploitation. High numbers of girls seem to be trafficked to the Middle East from Ethiopia and Nepal. Methodology: A literature review based on analysis of secondary data was conducted. Materials produced by governments, United Nations agencies, international- and local non-governmental organizations were collected. The Boolean search strategy was used, using “AND”, “OR”, “NOT” along with key terms such as Ethiopia, Nepal, social determinants, vulnerability, girls, sexual exploitation and human trafficking. Inclusion criteria were studies or reports on girls under the age of 18 years, girls from either Nepal or Ethiopia, and papers covering the years of 2006-2016. Twenty four reports, academic papers, governmental documents, non-governmental documents and documents by United Nation were selected. Findings: Social determinants that are making Ethiopian and Nepali girls vulnerable to trafficking for sexual exploitation could be identified through analysis of secondary data. Ethiopia and Nepal shared determinants of female gender, lack of education, poverty and employment opportunities. In addition, determinants of personal insecurity of being an orphan, early marriage and prostitution were identified for Ethiopia, and for Nepal, determinants of the caste system and lack of birth certificates. Discussion: The similarities of the determinants helps in understanding factors behind the more global patterns of vulnerability. Conversely, differences help in understanding a more country specific context of trafficking. The findings could provide helpful guidance in terms of policy implementation or actions with intention to mitigate or combat trafficking of girls. However, these social determinants are structured in a complex, versatile and deep-rooted manner. Therefore, more thorough research is needed in order to get a deeper understanding of how these determinants affect vulnerability among girls. Keywords: Human trafficking, sexual exploitation, girls, vulnerability, Ethiopia, Nepal, social determinants.

INTRODUCTION Human trafficking is the fastest growing criminal industry in the world and is seen as a modern form of slavery (The Global Slavery Index, 2014). As presented in Table. 1, the vast majority of trafficking victims are women and under-aged girls. United Nations Office on Drugs and Crime (UNODC, 2014), states that these women and girls are mainly trafficked for the purpose of sexual exploitation. As Table 2 shows, the proportion of detected girls has increased significantly in recent years, and as presented in table 3, children

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account for more than 60 per cent of trafficked victims in Africa and the Middle East (ibid.). Furthermore, table 4 shows that an estimated 53 per cent of trafficked victims in Africa and the Middle East, are trafficked for sexual exploitation. Most of the victims are trafficked from East Asia, South Asia, Africa and the Middle East itself. High numbers of trafficked children that end up being sexually exploited are reported to come from countries like Nepal and Ethiopia (ibid.). Because of these increasing numbers of trafficked girls from source countries such as Ethiopia and Nepal, it becomes important to understand what social determinants make the girls vulnerable to trafficking for sexual exploitation. Social determinants of health ultimately affect a girl’s vulnerability to exploitation (WHO, 2008). Therefore, variants of these social determinants are essential to explore, as it can help to successfully mitigate or combat trafficking of girls for sexual exploitation, either nationally or globally.

Distribution and trends among detected trafficking victims METHODOLOGY A literature review based on analysis of secondary data was conducted. Data was collected through search engines such as Medline, PubMed and ScienceDirect. Materials produced by governments, United Nations agencies, international- and local non-governmental organizations were collected by using Google and Google Scholar. The Boolean search strategy was used, using “AND”, “OR”, “NOT” along with key terms such as Ethiopia, Nepal, social determinants, vulnerability, girls, sexual exploitation and human trafficking. Inclusion criteria included studies or reports on girls under the age of 18 years, girls from either Nepal or Ethiopia, and papers covering the years of 2006-2016. Twenty four reports, academic papers, governmental documents, non-governmental documents and documents by United Nation were selected as they related directly to the research question.

FINDINGS Ethiopia Ethiopia is considered to be a source country for men, women and children for forced labour and sex trafficking (UNODC, 2014). It is estimated that Ethiopia has more than 389,700 people living in modern slavery (Global Slavery Index, 2014). Up to 20,000 children, some only 10 years old, are being sold by their parents domestically each year for around USD 120 to USD 240 (Peebles, 2012). Some of these girls are being trafficked across borders, primarily to Djibouti, South Sudan and to the Middle East (UNODC, 2014). Girls are being trafficked cross borders for either domestic service or sexual exploitation. Social determinants identified with girl’s vulnerability to trafficking for sexual exploitation were female gender, lack of education, poverty, search for employment opportunities, personal insecurity of being an orphan (often related to HIV and AIDS), early marriage and prostitution. More detailed descriptions of the identified social determinants that are creating vulnerability among girls in Ethiopia are presented in table 1

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Table 1: Variants of Social Determinants in Ethiopia

Social Determinant Female Gender

Lack of Education

Poverty

Employment Opportunities

Description Gender discrimination is still rife in parts of Sub-Saharan Africa, placing girls at a higher risk of being exploited. This places girls at higher risk of modern slavery (Global Slavery Index, 2014). Females in Ethiopia suffer from low social status and lack of social support networks, which make them more vulnerable to sexual exploitation (UN, 2013). The attainment rate of girls (aged 25+) to primary education was 14% (37% for boys). The pattern of low attainment rates for girls worsens through secondary education, with 8% of the girls attaining (Global Gender Gap Report, 2015). Young girls, most with only primary education, are becoming victims of trafficking to the Middle East (US Department of State, 2013). People living in parts of Sub-Saharan Africa are particularly vulnerable to modern slavery due to limited economic opportunities (Global Slavery Index, 2014), Children from poor families in Ethiopia are the most vulnerable to child trafficking (The Forsaken Children, 2013). 400 employment agencies in Ethiopia use of both legal and illegal recruitment of girls to countries, which are said to have better employment opportunities (UNODC, 2014)

Brokers bring in children from poor families from the rural to the urban areas with false promises of work and education. These children then become highly vulnerable for sexual exploitation and child trafficking cross borders (ECPAT, 2007a). Personal Insecurity by Being Ethiopia Health and Nutrition Research Institute (EHNRI, 2012) an Orphan (often related to reports that there are 3,700,000 orphans in Ethiopia. 800,000 out HIV or AIDS) of these children were orphans due to HIV and AIDS, 300,000 were estimated to be double orphans. Children affected by this crisis will face stigmatization and discrimination from the society, and consequently forced to find their own way to meet their daily need for food, shelter, security and other basic human needs (Worldrenew, 2015). Children orphaned and made vulnerable by HIV or AIDS in Ethiopia are at greater risk of exploitation, abuse and neglect (Unicef, 2014a).

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Social Determinant Early Marriage

Description The median age at first marriage in Ethiopia is 17.1 (Ethiopian Demographic Health Survey, 2011). Early marriage is a deep-rooted phenomenon in the Ethiopian society and is prevalent throughout Ethiopia (ECPAT, 2007a). When the marriage collapses, the girls often migrate to urban areas as they are no longer welcome within the family and community. Most victims of commercial sexual exploitation that are found in Addis Ababa was married below the age of 15 (ECPAT, 2007a).

Prostitution

Numerous children are escaping the rural areas because of early marriages, only to become sexually exploited in the urban areas or trafficked across borders (ECPAT, 2007b). Child prostitution and trafficking of children are inextricably linked (O’Connor & Healy, 2006; Pebbles, 2012). Child prostitution is growing at an alarming rate in both urban and rural areas of Ethiopia (ECPAT, 2007b). A significant number of girls in Ethiopia are victims of sexual exploitation and prostitution (Humanium, 2012).

Nepal Nepal is considered to be a source, transit and destination for forced labour and sex trafficking (Stallard, 2013). Child trafficking in Nepal is on the rise, with up to 20,000 children trafficked from Nepal each year, many forced to work within the commercial sex industry (ibid.). Girls in Nepal are often being sex trafficked both domestically within Nepal and across borders to India, the Middle East, China and South Korea (ibid). The identified social determinants of why Nepali girls are being trafficked for sexual exploitation were female gender, lack of education, poverty, search for employment opportunities, identification as lower caste, and systems creating lack of birth certifications and citizenship. More detailed descriptions of the identified social determinants that are creating vulnerability among girls in Nepal are presented in Table 2.

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Table 2: Variants of social determinants in Nepal

Social Determinant Female Gender

Lack of Education

Description Nepal is largely considered to be a patriarchal society, with discrimination against women and girls highly institutionalized (Stallard, 2013). Low value of women and girls in families and society contributes to making girls more vulnerable to trafficking (McGregor and McEwing, 2013). High drop-out rates from school make girls more vulnerable to trafficking (Stallard, 2013). The easiest children to traffic and manipulate are the girls with the lowest levels of education (Unicef, 2009). Girls are often dropping out early from school because of poverty (ibid.).

Poverty

When children are out of school they are more likely to be trafficked (Stallard, 2013). Sometimes the family is in debt, and because of that debt, the family is forced to send their daughters away to repay the debt (The Global Slavery Index, 2014). Families sometimes send their children away in hope that they will be able to be provided with basic needs such as food (UNOCD, 2011).

Employment opportunities

Most girls who are being trafficked come from poor families where they are lured by promises of employment or education (UN, 2014). Poverty can function as a factor pushing or pulling children into seeking other economic opportunities, leading to vulnerability to trafficking (The Global Slavery Index, 2014). It is also likely that a girl will choose to leave a domestic environment in order to make a life for herself elsewhere (Stallard, 2013). Young women and girls especially are often lured by men who promise them marriage, a good life, work or money, and then become duped into prostitution or domestic servitude (Stallard, 2013). Girls who leave their community to look for work run the risk of being denied access to basic services, including schools and health services, putting them in a vulnerable position for trafficking (Unicef, 2012).

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Social Determinant Caste system

Lack of birth certificates and citizenship

Description Traffickers also typically target low-caste groups or those who are marginalised in Nepal. They are often left unprotected by weak legal and policy frameworks, making them much more vulnerable to being trafficked (Stallard, 2013). Dalit (low caste) women and girls are particularly vulnerable to violence and discrimination (International Dalit Solidarity Network, 2015). Often women and girls from caste-affected communities face multiple forms of violence including sexual violence, trafficking, abduction and abuse as well as forced and bonded labour and slavery (ibid). Birth registration in Nepal is extremely low with only 42% of children under the age five years registered (Stallard, 2013). Close to 1 million children in Nepal do not have birth certificates and are therefore stateless, which make them more vulnerable to trafficking (Preiss & Pragati, 2015). A child who is not registered at birth is in danger of being shut out of society (Unicef, 2014b). The children without birth certificates/citizenships miss out on a whole range of rights such as education, health care, participation and protection (ibid). With no proof of age and identity, children may lack the most basic protection against abuse and exploitation. An unregistered child will be a more attractive ‘commodity’ to a child trafficker (Unicef, 2014b).

DISCUSSION As presented in table 3, Ethiopia and Nepal both shared social determinants with variants of culturally defined female gender roles, lack of education, poverty and the search for employment opportunities. Identified determinants that the countries did not share to the same extent were, for Ethiopia: personal insecurity from being an orphan (which often was related to HIV or AIDS), early marriage and prostitution. For Nepal: belonging to a particular lower caste, and lack of birth certificates and citizenship.

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Table 3: Variations of Social Determinants between Ethiopia and Nepal

SOCIAL DETERMINANTS CREATING VULNERABILITY AMONG GIRLS IN ETHIOPIA Female Gender Lack of Education Poverty Employment Opportunities Personal Insecurity by Being an Orphan (often related to HIV or AIDS) Early Marriage Prostitution

SOCIAL DETERMINANTS CREATING VULNERABILITY AMONG GIRLS IN NEPAL Female Gender Lack of Education Poverty Employment Opportunities Belonging to a particular Caste System Lack of Birth Certificates (Citizenships)

There are similarities in the variants of social determinants that are making girls more vulnerable to human trafficking for sexual exploitation. These similarities help in understanding the determinants behind the more global patterns of vulnerability among girls, such as female gender, lack of education, poverty and employment opportunities. However, even if the overall definition of the social determinant is similar between two countries, the deeper analysis of them show variations and nuances of those determinants.

CONCLUSION Differences between the country-specific determinants help in understanding the more country specific contexts of trafficking. This could provide helpful guidance in terms of policy implementation or other actions with intentions to mitigate or combat trafficking of girls. For example, to mitigate child sex trafficking in Ethiopia, one must consider the vulnerability of orphan girls (especially the ones who have been affected by HIV or AIDS), and the factors of early marriage and prostitution. Likewise, when planning actions towards mitigating or combating child sex trafficking in Nepal, one must take into consideration identification as lower caste, or that the lack of birth certificates and citizenship is making girls more vulnerable to trafficking for sexual exploitation. Social determinants are often structured in complex, intertwined, versatile and deep-rooted manners. Therefore, more thorough research is needed in order to get a deeper understanding of how these determinants affect vulnerability among girls, globally as well as country-specifically.

REFERENCES ECPAT. (2007a). Global Monitoring Report on the Status of Action Against Commercial Sexual Exploitation of Children. http://www.ecpat.net/sites/default/files/Global_Monitoring_Report-ETHIOPIA. pdf [access date: 23.02.2016] ECPAT. (2007b). International Linkages between the Commercial Sexual Exploitation of Children and HIV/AIDS in Africa. http://www.ecpat.net/sites/default/files/confronting_csec_eng_0.pdf. [access date: 24.02.2016]

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EHNRI. (2012). HIV related estimates and projections for Ethiopia Addis Ababa, Ethiopia. Ethiopia Health and Nutrition Research institute. Ethiopia Demographic Health Survey. (2011). http://www.unicef.org/ethiopia/ET_2011_EDHS.pdf. [access date: 21.02.2016] Global Slavery Index. (2014). http://www.globalslaveryindex.org/ [access date: 22.02.2016] Global Gender Gap Report. (2015). http://reports.weforum.org/global-gender-gap-report-2015/economies/ [access date: 22.02.2016] International Dalit Solidarity Network. (2015). http://idsn.org/wp-content/uploads/2015/06/Caste-Gender-and-Modern-Slavery1.pdf [access date: 24.02.2016] Humanium. (2012). Children of Ethiopia. http://www.humanium.org/en/africa/ethiopia/ [access date: 23.02.2016] McGregor, K., & McEwing, L. (2013). How do Social Determinants affect Human Trafficking in Southeast Asia and What Can We do About IT? Health and Human Rights Journal, 15(2). O’Connor, M., & Healy, G. (2006). The Links between Prostitution and Sex Trafficking: A Briefing Handbook. http://www.turnofftheredlight.ie/wp-content/uploads/2011/02/The-links-between-prostitution-and-sex-trafficking.pdf [access date: 23.02.2016] Peebles, G. (2012). Stolen Childhoods: Child Prostitution And Trafficking In Ethiopia. http://www.eurasiareview.com/26032012-stolen-childhoods-child-prostitution-and-trafficking-in-ethiopia/ [access date: 22.02.2016] Preiss, D., & Pragati, S. (2015). When Nepali Women are Victims of Sex Trafficking, their Kids Pay the Price too. Broadly. https://broadly.vice.com/en_us/article/when-nepali-women-are-victims-of-sex-trafficking-their-kids-pay-the-price-too [access date: 24.02.2016] Stallard, R. (2013). Child trafficking in Nepal: Causes, consequences and education as prevention. https://www. google.co.th/search?q=Stallard%2C+R.+(2013).+Child+trafficking+in+Nepal%3A+ Causes%2C+consequences+and+education+as+prevention.&oq=Stallard%2C+R.+(2013).+Child+trafficking+in+Nepal%3A+Causes%2C+consequences+and+education+as+prevention.&aqs=chrome..69i57.3487j0j9&sourceid=chrome&ie=UTF-8 [access date: 22.02.2016] The Forsaken Children. (2013). http://theforsakenchildren.org/tfcs-plan-to-help-prevent-child-trafficking-in-ethiopia/ [access date: 23.02.2016] UN. (2013). Leave no Women Behind. http://www.unwomen.org/mdgf/B/Ethiopia_B.html [access date: 22.02.2016] UN. (2014). UNICEF reports 7,000 Nepali women and girls trafficked to India every year. Global Initiative to Fight Human Trafficking. http://www.ungift.org/knowledgehub/en/stories/September2014/ unicef-reports-7-000-nepali-women-and-girls-trafficked-to-india-every-year.html [access date: 22.02.2016] Unicef. (2009). Child Trafficking in East and South-East Asia: Reversing the Trend. http://www.unicef.org/ eapro/Unicef_EA_SEA_Trafficking_Report_Aug_2009_low_res.pdf [access date: 25.02.2016] Unicef. (2012). A Child-Rights Approach on International Migration and Child Trafficking: A Unicef Perspective. http://www.un.org/en/development/desa/population/events/pdf/3/P06_UNICEF.pdf [access date: 23.02.2016] Unicef. (2014a). Child Protection. http://www.unicef.org/ethiopia/ECO_Child_Protection_BN.pdf. [access date: 24.02.2016]

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Unicef. (2014b). Child Protection fro Violence, Exploitation and Abuse. http://www.unicef.org/protection/57929_58010.html [access date: 24.02.2016] UNODC. (2011). Responses to Human Trafficking in Bangladesh, India, Nepal and Sri Lanka: Legal and Policy Review. http://www.unodc.org/documents/humantrafficking/2011/Responses_to_Human_ Trafficking_in_Bangladesh_India_Nepal_and_Sri_Lanka.pdf UNODC. (2014). Global Report on Trafficking in persons. https://www.unodc.org/documents/data-and-analysis/glotip/GLOTIP_2014_full_report.pdf [access date: 24.02.2016] US. Department of States. (2013). http://www.state.gov/j/tip/rls/tiprpt/2013/. [access date: 22.02.2016] WHO. (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. http://www.who.int/social_determinants/final_report/media/csdh_report_wrs_en.pdf [access date: 22.02.2016] Worldrenew. (2015). Ethiopia Orphans and Vulnerable Children. http://www.worldrenew.net/what-we-do/ projects/ethiopia-orphans-vulnerable-children [access date: 23.02.2016]

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The Role of Traditional Life and Colonial Authority in the Formulation of Post-Colonial Identity for Women in Cameroon Amanda J Pierz1-2, Leonie N Dapi3 1 Faculty of Health, Medical, and Life Sciences, Maastricht University, The Netherlands 2 Santa Barbara, California 93110 USA, [email protected] 3 Department of Public Health, Clinical Medicine, Epidemiology, and Global Health, Umeå University, Umeå, Sweden, [email protected]

ABSTRACT Background: In contemporary academic research, the politics of belonging and identity in post-colonial Cameroon have become blurred in the process of shifting paradigms between traditional society, opposing colonial institutions, and the process of contemporary post-colonial development. For women in particular, the notions of identity development are not only entrenched in the context of their treatment during the rule of colonial empires, but also within their traditional gender roles. Objective: This study investigated the role of traditional life and colonial authority in the construction of post-colonial identity for women in Cameroon, Africa. To date, no study has dealt with the analysis of post-colonial identity for women in Cameroon using narratives from native women about the influence of traditional life and colonial authority on personal identity construction. There is a need for further analysis utilizing a female ideology in which native women are able to construct, develop, and vocalize their own perceptions of personal identity. This study served as a pilot study in which our preliminary results will motivate further research with focus groups involving women from other cities and ethnic groups. Further research will be used to gather data to prepare educational discussions and booklets for schools and women’s organizations in Cameroon as part of concentrated programs to promote, engage, and mobilize women and girls in reducing gender inequities and participating in national development efforts. Methods: Focus group discussions were conducted with female participants aged 55 and older from Yaoundé urban areas, in order to collect a range of opinions on women’s identity in Cameroon. The participants in this study were found through purposeful sampling with the use of local contacts as part of a women’s organization in Yaoundé. Content analysis was used in the study to discover theoretical constructs to increase understanding of identity formulation for women in post-colonial Cameroon. Findings: Five themes emerged from the study: gender role division, education as a reinforcement of gender roles, social control and compliance, maltreatment and discrimination, and movement for equality in contemporary Cameroon. The participants explained that women’s primary role “was to go to the market to buy food and cook dinner and to carry around babies all day.” These values were instilled to the participants through traditional gender role division in which women maintained the domestic sphere and familial responsibilities. This concept was signif-

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icant over the course of the participants’ formal education, which prioritized women’s commitment to family over their education because “school for girls was nothing.” The participants noticed a clear difference between their education and that of their male peers as “they only wanted boys to be in school.” For women that did not adhere to the social pressure of their families and education systems, they were met with various compliance techniques ranging from “fear,” “forced confinement,” and “forbidden to eat good things” to rape and domestic violence. The participants of this study indicated “there are many maltreated women in Cameroon” and still face significant violence “especially for sexual intercourse.” However, the majority of participants report that conditions for women have improved since national independence in 1960 due to increased school participation and regulations as well as an influx of Discussion: The influence of traditional social hierarchy and gender role division plays the largest role in the development of post-colonial identity. The participants indicated that their identity formulation was based on traditional gender roles of caretaker, housewife, and mother. These identity constructs are formulated early in development through family pressure and social compliance techniques. The role of colonial education was also largely influential to the post-colonial formulation as they reinforced gender roles and limited social mobility for women in Cameroon. This preliminary data will be utilized by the researchers to formulate new interview guides for further focus group discussions, in order to continue interviewing Cameroonian women to identify historical and social causes of gender inequity. We will use the culminated data to prepare discussion guides to be utilized in workshops, presentations, and community discussions aimed at giving safe spaces for women to explore and formulate the weight of gender inequity on their personal lives as well as identifying the root cause(s) of these injustices. This will be done to encourage participation in local, regional, and national development efforts, so that women can become more engaged and involved in dismantling systems, policies, and notions that were developed with oppressive colonial and patriarchal elements. Keywords: post-colonial identity, women, focus group discussions, gender roles, Cameroon

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Hidden in Plain Sight: Community-Based Research on Undocumented Children Living along the Thai-Myanmar Border Amanda Mowry1, Therese Caouette2, Treasure Shine3 1 School of Global Studies, Thammasat University, Pathumthani, Thailand 2 Partners Asia, 220 Second Ave S., Seattle, WA 98104 3 Meeeain Shin Development Foundation, Pathumthani, 12130, Thailand

ABSTRACT Background: Dual non-citizenship occurs when a person is not able to prove citizenship in their country of origin or the country they are currently residing. All across the world, it is the duty of acting governments to ensure access to basic human rights for its citizens. When a person is undocumented, they do not have a governing body to guarantee rights such as health care, education, and freedom to travel and are at high risk for exploitation. Objectives: The aim of this research is to understand the vulnerability to and possible risks for children who are dual non-citizens along the Thai-Myanmar border and identify the barriers to and opportunities for citizenship. In order to achieve the study’s aim, the Research Team will attempt to realize the following objectives: 1) To understand the extent undocumented children along the Thai-Myanmar border. 2) To develop recommendations for pilot projects to reduce dual non-citizenship along the Thai- Myanmar border. 3) To present the voices of mobile populations and their concerns of dual non-citizenship to a national and international level. Methods: The study population includes children and families of mobile populations along the Thai-Myanmar border with no documentation of citizenship; participants will be selected through snowball sampling. Using Participatory Action Research, community-based organizations will conduct semi-structured interviews with dual non-citizens and findings will be supported with documentary review. In the Pilot Phase, qualitative research was conducted in Kanchanaburi Province and the Bangkok Metropolitan Region with a sample size of 20 households. In Phase 2, site selection will be expanded to Chiang Mai and Mae Hong Son Province with a total anticipated sample size of 80 households. Discussion: In considering causes for dual non-citizenship amongst research participants in the Pilot Phase, two major factors were prominent: people were unaware of how to apply for documentation or their documents were lost or missing. These causes for dual non-citizenship, and their impact on wellbeing and access to basic human rights will be further analyzed in the next phase of research.

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Inclusiveness of Disability Practice for Children with Disabilities in Nepal Lina Brandt1 1 Maastricht University, Netherland

ABSTRACT Although the recognition of disability issues has increased and evolved, children with disabilities in Nepal have been shown to continuously experience obstacles in their enjoyment of basic human rights and their inclusion in society. Disability practice has recently shifted toward a rights-based approach, which enables bottom-up, long-term solutions for disabled children. Nonetheless, the concept of inclusiveness is mainly used as an overall goal, rather than being tangibly incorporated into daily activities. Despite positive changes in the Nepalese disability movement, structural barriers within and between organizations hinder the successful implementation of inclusive practice. Most notably, measures should be taken against the complexity of engaging stakeholders, the gap between policy and practice as well as heterogeneous perceptions and beliefs towards disabled children. Even though the rights-based approach has been shown to offer new powerful perspectives to tackle the issues faced by disabled children and advance their societal inclusion, substantiations to address disability by a more holistic, integrative approach are strong. To become an effective approach, the concept of inclusiveness requires a change from an idealistic desire towards an everyday practice. In other words, inclusiveness needs to be clearly defined within the Nepalese context and translated into concrete, feasible measures for disability organizations. This effort will help to provide more homogenous, inclusive disability practices in Nepal.

INTRODUCTION Inclusiveness is considered to be key to social development, promoting equal opportunities and fair participation for everyone in a community. However, children with disabilities (CWD) in Nepal encounter different forms of exclusion that create barriers to the enjoyment of their basic human rights and to their inclusion in society (UNICEF, 2007). While CWD have the potential to play meaningful roles in their communities, they are denied access to social services, the chance to attend school, and opportunities for employment later in life (UNICEF, 2013b, Mol, et al., 2014, Kuper, et al., 2014). Since the available statistics vary substantially depending on definitions and measures used, estimates of the prevalence of disability in Nepal range from 0.5% to 25%, comprising both disabled children and adults (HRW, 2011). Nepalese disability organizations have started to use the concept of inclusiveness to achieve equal opportunities and to reduce inequities. As outlined by UNDESA (2009, p.3), inclusiveness can be realized through “a process by which efforts are made to ensure equal opportunities for all, regardless of their background, so that they can achieve their full potential in life.” Yet, the conceptualization of inclusiveness in the Nepalese context and its implications for disability practice have remained unexplored. Therefore, this analysis strives to evaluate how disability practice has used the concept of inclusiveness in interventions to address the challenges at stake. The underlying research question is: What is the role of the concept of inclusiveness in disability practice in Nepal today?

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METHODS This study combines two qualitative research methods to integrate theoretical conceptualizations of inclusiveness with real life experiences. Firstly, an analysis of the problem representation within disability practice at the Karuna Foundation was conducted. The ‘What’s the problem represented to be’ (WPR) approach by Carol Bacchi was used to evaluate the Inspire2Care program. This program was chosen because it represents one important example of a disability practice that seeks to contribute to societal inclusion for CWD and uses inclusiveness as part of the project itself. The WPR approach provides insight into how and with what consequences inclusiveness has been framed in disability practice (Bacchi, 2009). This research method does not intend to analyse processes or the effectiveness of project implementation per se, but rather focuses on the underlying problem representation. This approach is based on the assumption that disability practice is established within certain paradigms and belief systems (Thissen & Walker, 2013). As illustrated in Table 1, the WPR approach is directed by six questions. Table 1: Categories for the Practice Analysis based on the WPR-approach by Bacchi (2009) Question 1. What’s the problem represented to be in the disability practice? 2. What presuppositions or assumptions underlie this representation of the problem? 3. How has this representation of the problem come about? 4. What is left unproblematic in this problem representation? Where are the silences? Can the problem be thought about differently? 5. What effects are produced by this representation of the problem?

6. How/where has this representation of the problem been produced, disseminated and defended? How could it be questioned, disrupted and replaced?

Categories Problem representation: definitions, explanations or reasons for disability/societal inclusion Presuppositions/Assumptions: binaries, key concepts, categories for disability/societal inclusion Genealogy: developments, decisions, processes, events in the discourse on disability/societal inclusion Silencing: criticism, gaps, limitations, simplifications in the discourse on disability/societal inclusion Effects: perspectives, opinions on disability/societal inclusion; situation, conditions, behavior, positions, relations for disabled children and the society they live in Origination: explanations, elaborations on the disability discourse

Secondly, semi-structured interviews with disability experts, including staff members from the Karuna Foundation in Nepal, were conducted to gather detailed information from experts in the field. These interviews were analysed by means of a conventional, qualitative content analysis to deepen the understanding of Nepalese disability practice (Hsieh & Shannon, 2005). Snowball sampling was used to identify potential participants, taking the professional network of the Karuna Foundation as a starting point (Browne, 2005). In total, six interviews were conducted with experts currently working in international and national non-governmental organizations (NGOs), being representatives of or advocates for disabled children (see Table 2).

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Table 2: Detailed information about conducted interviews Interviewee Representative of a Nepalese Disabled People’s Organization (female) Program director of an international NGO in Nepal (male) Community Based Rehabilitation expert working in an INGO (female) Program director of an international NGO in Nepal (male) Advocate for disabled people through journalism and work in NGOs (male) Program director of an international NGO in Nepal (male)

Method type Skype (due to internet connection both calling and chatting) Skype

Interview length 46 min

Date 03.07.2015

37 min

14.07.2015

Skype

58 min

22.07.2015

Skype

33 min

31.07.2015

Telephone

37 min

31.07.2015

Skype

53 min

05.08.2015

RESULTS The following analysis is structured according to the previously presented research steps and provides an analysis of the most relevant information gained about inclusiveness within disability practice for CWD in Nepal.

The Inspire2Care Program of the Karuna Foundation Karuna Foundation Nepal has been engaged in projects for people with disabilities since 2007 (Karuna Foundation, n.d.). In the intervening years, different initiatives have been implemented to improve the situation of disabled children in Nepal. One central program that has been developed is the ‘Inspire2Care’ program which addresses the need to empower communities and vulnerable groups to develop and strengthen their own capacities (Karuna Foundation, 2014a). The program was launched in 2011 and was first implemented in two districts in Nepal: Sunsari and Rasuwa. The implementation is effected within government structures by means of the integration of all disability-related actors. The aim of the project is to “improve the quality of life of 2000 children with disability” and simultaneously decrease the incidence of disabilities due to birth defects (Karuna Foundation, 2013). As illustrated in Figure 1, the Inspire2Care model comprises both prevention-related activities and community-based rehabilitation strategies (Vaughan, 2015; WHO, 2010).

Figure 1: Operation areas of the Inpsire2 Care model (Karuna Foundation 2014b)

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The Karuna Foundation represents the problem of disability as grounded in local structures, referring to the existing attitudes and commitment in families and communities. The assessment of local resources and practices is central to the project process (Karuna Foundation, n.d.). The Karuna Foundation tries to deliver understanding of the fundamental community structures by taking the attitude of the people into account, which is crucial for successful implementation. The willingness and capability of community members are important factors that must be accounted for in order to successfully implement disability projects in communities because negative attitudes towards disabled persons are associated with discrimination and stigmatization (WHO, 2010). The improvement of existing health systems and the empowerment of communities and vulnerable groups are means to increase the space and capacity for disabled children to claim and exercise their rights. The binary responsible/irresponsible representation used by the Karuna Foundation illustrates the focus of the project. CWD are not held responsible for their situation, but rather the community or family they live in are. The problem representation is further based on the painstaking process needed to achieve attitude change and sustainable development. As Cornielje (2012) states, negative attitudes persist in Nepalese communities. In contrast, Maudslay (2014) holds that traditional opinions often coexist with other perceptions on disability. She points out that, on the one hand, Nepalis may still be exposed to the strong belief that children become disabled due to sins of a past life; on the other hand, some families with a disabled child tend to provide biomedical explanations for their child’s disability. Hence, the situation of disabled children in Nepal is at risk of oversimplification and should be approached carefully by also not assuming negative perceptions per se as implied by the Karuna Foundation’s problem representation. Sometimes it is not the attitude that needs to be changed, but other local structures, such as financial resources or the infrastructure which limits disabled children in their enjoyment of a good quality of life. Low resource settings may lack the means to implement suggested objectives which results in communities being left responsible for providing these resources. Since they are often already living with scarce resources, this may become an obstacle in setting up sustainable projects. The Karuna Foundation therefore addresses capacity building, which has the discursive effect of putting the discussion into the development paradigm. Since Nepal is one of the poorest countries in the world, inclusion of the development discourse opens up new means for decreasing negative conditions for disabled children. For instance, the development discourse promotes the eradication of poverty and achievement of primary education inclusively for disabled children, even though disability was not included as a specific objective in the Millennium Development Goals from the start (Mattioli, 2008; Griffiths, Mannan, & MacLachlan, 2009).

Expert Perspectives on Disability Practice in Nepal “We are trying to make inclusiveness in each and every activity. In the village from the initial day. And when we go to the village to steer our project we invite all the persons with disabilities as well as other persons of the community like political leaders, social leaders, government representatives, school teachers; we do not only talk with the children or person with disability but we also equally pay focus on other parts of the society. Why? Because we consider that the issue of disability is not only with the person with disability.” (Program director of an international NGO in Nepal) For the interview respondents, inclusiveness meant that CWD have equal opportunities and rights to enjoy a life in dignity, respect and confidence. Non-discrimination was a central concept and was especially applied to health and education issues. Moreover, opportunity to be involved in decision-making and general participation in any community activity was emphasized. Interview participants elaborated on different challenges that they experience in everyday work. There are a variety of different agencies engaged in the disability sector: international and national NGOs, disabled people’s organizations, governmental organi-

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zations, among others. These agencies have different mandates and do not all cooperate with each other. In some cases there is a clash of interests between the government officials, policy makers and advocacy organizations or NGOs who are all trying to improve the situation for CWD, but who have different approaches and areas of focus. Therefore, collaboration takes time, and it is difficult to reach a consensus. One reason for this is the distinguished understanding of inclusiveness among government authorities and NGOs. There seems to be a gap between the interpretation and implementation of inclusivity by NGOs and the government. Organizations are very limited in their resources and are dependent on funding. Hence, the social and financial support and strong commitment from communities and families becomes central to creating successful interventions for CWD. “If the other parts of the community including persons with disability would realize the problem of these groups and they invest their resources to make a change in the life of the children with disability, take their time, society will reach an ideal situation and every person can get benefit of that development” (Program director of an international NGO in Nepal) Empowerment was pointed out to be vital to better the lives of disabled children because they are not sensible of their potential to lead a dignified life. They have to raise their demands and claim their rights. In so doing, it is very important to create meaningful participation, such as involvement in decision-making processes for health or school facilities. The responsibility to empower CWD was ascribed explicitly to the community. Interviewees claimed that the community has the powerful ability to impart knowledge of rights and opportunities on to disabled children. It was presented as being inevitable that community members without disabilities take the lead in changing conditions. For example, the realization of a disability-friendly environment is not only beneficial for CWD, but also for all other community members, because empowerment of all community members can bring constructive development to society. To achieve this, participatory action was suggested to provide sustainable sensitization of all stakeholders. Community members’ own identification and involvement with disability practice was seen as part of a greater “civilization process” of the community. This change could only come from within, making integration from the start of any initiative central to successful development. To facilitate this process, information has to be provided to both persons with and without disabilities and support must be given for making consolidations between stakeholders. Hence, inclusiveness was seen as vital to the achievement of effective disability practice.

CONCLUSION Disability practice has recently shifted toward a rights-based approach, which enables bottom-up, longterm solutions for disabled children. Nonetheless, the concept of inclusiveness is mainly used as an overall goal, rather than as part of daily activities. Despite positive changes in the Nepalese disability movement, structural barriers within and between organizations hinder the successful implementation of inclusive practice. Most notably, measures should be taken against the complexity of engaging stakeholders, the gap between policy and practice as well as heterogeneous perceptions and beliefs towards disabled children. This study has shown that the discourse on disability in Nepal is complex. The unique and distinctive aspects of context-specific realities have shaped the evolving conceptualizations of disability in Nepal. To become an effective measure, the transition from theoretical ideal to everyday practice can be achieved by realizing the ideas of experts in the field. Substantiations to address disability by a more holistic, integrative

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approach are strong. In other words, inclusiveness needs to be clearly defined within the Nepalese context and translated into concrete, feasible measures for disability organizations. The interview participants as well as the analysed project of the Karuna Foundation offer confident approaches to be taken into account. This effort will help to provide more homogenous, inclusive disability practices in Nepal.

REFERENCES Bacchi, C. (2009). Analysing Policy: What’s the problem represented to be? Australia: Pearson Australia. Browne, K. (2005). Snowball Sampling: Using Social Networks to Research Non-heterosexual Women. International Journal of Social Research Methodology. Cornielje, H. (2012). Karuna Foundation Nepal: Evaluation of the Community Based Rehabilitation Projects in Nepal. Alphen aan den Rijn: Enablement. Griffiths, M., Mannan, H., & MacLachlan, M. (2009). Empowerment, Advocacy and National Development Policy. In M. MacLachlan, & L. Swartz, Disability & International Development (pp. 105 - 118). New York: Springer. HRW. (2011). Futures Stolen - Barriers to education for children with disabilities in Nepal. Human Rights Watch. Hsieh, H.-F., & Shannon, S. E. (2005). Three Approaches to Qualitative Content Analysis. Qualitative Health Research, 15(9), 1277 - 1288. Karuna Foundation. (2013). Karuna background and long term vision. Karuna Foundation. (2014a). From Pilot Towards Impact - Karuna Foundation First Phase in Nepal (2007 - 2013). Karuna Foundation. (2014b). Towards a disability movement in Nepal. Retrieved March 30, 2015, from http://www.karunafoundation.nl/nieuws/378_uk.html. Karuna Foundation. (n.d.). Principles Inspire2Care. Karuna Foundation. Kuper, H., Monteath-van Dok, A., Wing, K., Danquah, L., Evans, J., Zuurmond, M., & Gallinetti, J. (2014). The Impact of Disability on the Lives of Children. PLOS, 9(9), 1 - 11. Madden, R. H., Dune, T., Lukersmith, S., Hartley, S., Kuipers, P., Gargett, A., & Llewellyn, G. (2014). The relevance of the International Classifiation of Functioning, Disability and Health (ICF) in monitoring and evaluating Community-based Rehabilitation (CBR). Disability and Rehabilitation, 36(10), 826 - 837. Mattioli, N. (2008). Including Disability into Development Cooperation. Analysis of Initiatives by National and International Donors. University of Madrid. Maudslay, L. (2014). Inclusive education in Nepal: Assumptions and reality. Childhood, 1 - 7. Mol, T. I., van Brakel, W., & Schreurs, M. (2014). Children with Disability in Nepal: New Hopw Through CBR? Disability, CBR and Inclusive Development, 25(1), 5 - 20. National Planning Commission/UNICEF/New Era. (2001). A situation analysis of disability in Nepal. Thissen, W. A., & Walker, W. (2013). Public Policy Analysis. Springer. UNDESA. (2009). Creating an Inclusive Society: Practical Strategies to Promote Social Integration. United Nations. UNICEF. (2007). Promoting the Rights of Children with Disabilities. Denmark: Innocenti Research Centre. UNICEF. (2013b). Children and Young People with Disabilities Fact Sheet. UNCEF. UNICEF. (2013c). The State of the World’s Children - Children with Disabilities. UNICEF.

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USAID. (2015). About Nepal. Retrieved May 14, 2015, from http://www.usaid.gov/nepal. Velema, J. P., Ebenso, B., & Fuzikawa, P. (2008). Evidence for the effectiveness of rehabilitation-in-the-community programmes. Leprosy Reviews, 79, 65-82. Watson, N. (2012). Theorising the Lives of Disabled Children: How Can Disability Theory Help? Children & Society, 26, 192 - 202. World Health Organization (WHO). (2010). Community-based rehabilitation: CBR guidelines. Malta: WHO.

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Effects of Motivational Interviewing on Treatment Adherence of Tuberculosis Patients in the Philippines Ritzmond Loa1,2 1 University of Santo Tomas, College of Nursing, Manila, Philippines, 1015, [email protected] 2 Faculty of Nursing, Thammasat University, Pathumthani, Thailand, [email protected]

ABSTRACT Background: The WHO reported that 9.6 million of the world’s population was infected with Tuberculosis (TB). Though curable, 1.5 million died due to TB (WHO Report, 2015). Non-adherence remained as one of the barriers in eliminating TB in the Philippines. Adherence declined due to lack of patient’s motivation to complete treatment (Pagulayan, 2008). Motivation affects self-efficacy of patients to treatment adherence (Treasure, 2004). Hence, modification on the patient’s behavior can enhance treatment adherence (Dela Cruz, 2002). This study aims to evaluate the effects of a nurse delivered Motivational Interviewing (MI) as adjunct to standard health education to enhance treatment adherence of TB patients in the health center. Methods: The study utilized an experimental, pre-posttest design. Thirty newly diagnosed tuberculosis patients were randomly assigned to control and experimental groups using multistage cluster sampling. The experimental group received four (4) sessions of 30-minutes nurse delivered adjunct MI weekly for one month, while the control group received standard health education. MI is a counseling style that used specific questions to direct behavior change by expressing empathy, developing discrepancy, rolling with resistance and supporting self-efficacy. Adherence was measured through the use of Medication Adherence Self-Efficacy Scale and Sputum AFB microscopy before the intervention and 2 weeks after the intervention. A panel of experts reviewed the questionnaire to ensure face and content validity, and the instrument was subjected to internal consistency with a Cronbach alpha of 0.80. Results: Independent T-test revealed there was a significant difference in the medication adherence self-efficacy scores (p=0.036) and sputum AFB count (p=0.047) between two groups before and 2 weeks after the intervention. The mean pre and posttest medication adherence self-efficacy scores of the experimental group (2.32, 2.97) is higher compared to the control group (2.31, 2.32). Moreover, the mean pre and posttest sputum AFB count of the experimental group (1.6, 0.07) is lower compared to the control group (1.61, 0.4). Discussion: Knowledge about the disease and its treatment combined with motivation can increase self-efficacy of TB patients to treatment adherence (Ngamvitroj & Kang, 2007). Motivational Interviewing as an adjunct to the standard health education is effective in enhancing treatment adherence of tuberculosis patients in the health center (Riekart, Borreli, et al, 2011). Consequently, decreasing the number of M. tuberculosis in the sputum microscopy. Moreover, studies have shown that MI has significant psychological (75%) and physiological (72%) effect to diseases (Rubak, Sandbaek, et.al ; 2005).

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Mothers’ Behaviors in Preventing Diarrhea in Children Aged 1 - 5 Years and its Related Factors in Buol District, Indonesia Helmi Rumbo1, Susheewa Wichaikull 2, Boosaba Sanguanprasit2 1 Kasetsart University, Bangkok 10900, Thailand, [email protected] 2 Boromarajonani College of Nursing Nopparat Vajira, Bangkok, 10230, Thailand, [email protected]

ABSTRACT Diarrhea is unceasingly threatening children’s health, particularly in poor rural areas. Diarrhea causes severe dehydration and can be fatal if left untreated. Factors affecting diarrhea in children include biological factors, behavioral factors, and environmental factors. This study aims to identify the relationship between educational background, self-efficacy and mothers’ behaviors in preventing diarrhea in children aged 1 to 5 years. A cross-sectional study design was carried out from October to November 2015. This study used multistage sampling techniques. A total of 300 mothers were selected from six villages. The mothers were interviewed by using a structured questionnaire. The results show 65.6 % of the mothers had completed the nine-year compulsory education, and two thirds of them had good behaviors regarding preventing diarrhea. By using the Chi-square test, this study found a significant relationship between educational background (p < 0.05), perceived self-efficacy (p < 0.01) and mothers’ behaviors in preventing diarrhea in children. Findings indicate that educational level could help a person with decision-making, and that confidence in ability reflects on a mother’s behavior in preventing diarrhea. Keywords: Mothers’ behaviors, Prevent diarrhea, Children aged 1 – 5 years.

INTRODUCTION Diarrhea is one of the leading killers for all people around the world. Diarrhea occurring in children under 5-years may manifest other symptoms like a cough, loss of appetite, decreased skin-elasticity or dryness, fever, and vomiting. The stool may appear to be large in volume, light or dark in color, slimy in size or even tainted with blood droplets (McKinney E.S et al. 2013). Diarrhea among children has increasingly become a health problem, particularly in economically poor regions and among the populations of less-developed countries. According to the statistics, 6.5 million deaths of children under 5-years occurred in 2012, and 9% of these deaths were caused by diarrhea. Moreover, in the Southeast Asian region, 10% of the 1.7 million deaths of children under 5-years were due to diarrhea. In Indonesia, deaths caused by diarrhea accounted for 6% of the 151,000 deaths of children under 5-years (WHO, 2014). Diarrhea causes severe dehydration and depletes nutrients due to decreasing nutritional intake resulting in malnutrition in children. Furthermore, it can reduce immunity and deficiency of micronutrients. Diarrhea can also lead to a fatal outcome if dehydration is left untreated, and there are insufficient amounts of body-fluids (WebMD, 2015). The major causes of diarrhea are viruses, bacteria, and parasites. The patho-

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gens spread easily through contaminated food or drinking water, and can be transmitted through person-to-person contact (McKinney E.S et al. 2013). Other factors are behavioral and environmental. Behavioral factors that put children at risk are often unhygienic behaviors, with daily routines like not washing their hands with soap before having their meals, not washing hands with soap after defecation, reusing any cutleries after dropping them on the ground without cleaning them, drinking unclean tap water and drinking un-boiled water, and cleaning utensils and cutleries using unclean water / well water. Environmental factors involve poor sanitation such as a household without a toilet, a household without any sewage and drainage facilities as well as the presence of animal feces in the yard, and no access to clean water (WHO, 2013). Traditionally, the mother has a central role as decision maker, educator, counselor, and caregiver in the house. During the prime period of growth and development in children, the mothers’ role in disease prevention is an important factor for preventing or limiting the risks to a child’s health (Friedman M, 2003). Factors influencing a mothers’ health behaviors include intra-personal factors, inter-personal factors, and social-environment factors, which form the “ecological perspective”. Intra-personal factors focus on individual characteristics such as age, knowledge, educational level, beliefs, and motivation (Becker, 1974 & Pender et al. 2011). Previous studies found some gaps of knowledge related to diarrhea prevention behaviors, and identified the different factors that influence this gap. Educational background could be the factor that changes people’s behaviors. Therefore, this study aims to identify the relationship between educational background, self-efficacy, and mothers’ behaviors in preventing diarrhea in children aged 1 to 5 years.

Statement of Problem In 2012, only 24.2% of Buol people performed hygienic practices and practiced a healthy life style (DinKesSul-Teng, 2012).

MATERIALS AND METHODS This study was conducted from 24th October to 22nd November 2015 in Buol District, Central Sulawesi, Indonesia. This study was approved by the Ethical Review Board of BCNNV on 6th October 2015. This study used a cross-sectional survey design, with multistage sampling techniques. The population was stratified into two groups based on area; lowlands and highlands. Simple random sampling was used to select sub-district / villages: four villages from the lowlands, and two villages from the highlands. A total of 300 mothers were selected by using purposive sampling method, within the following criteria: • Able to write, read, and speak in Bahasa Indonesia. • Have children aged 1 to 5 years. • Providing care to their children aged 1 to 5 years. • Those unable to perform daily activities by themselves were excluded (physical disabilities and mental disorders). Each participant was interviewed directly by the researcher using a structured questionnaire. The researcher visited the participants’ houses to collect data.

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The Instrument The questionnaire was tested by three experts to determine clarity and relevance of content. After the content validity process was completed, the questionnaire was translated into Bahasa Indonesia, and re-translated into English. The questionnaire was tested with 30 mothers in one village in Buol District.

Operational Definition Mothers’ behaviors in preventing diarrhea refer to mothers’ practices in caring to protect their children from acute diarrhea in the last one month. The behavior consists of safe drinking water, proper disposal of feces, personal hygiene, and safe food preparation and feeding practices.

Site of Study

Figure 1: (a) Stilt house at riverside / seaside; (b) Inland area

RESULTS The results show mothers’ age range to be 18 to 48 years and the mean to be 29.9 years. Two thirds of the mothers had completed the nine-year compulsory education. The data reveals that 46.7% of the children had experienced acute diarrhea within one month prior to interview (within diarrhea period less than 14 days). The distribution shows that 68.3 % of the mothers performed good behaviors in preventing diarrhea in children, including providing safe drinking water, proper disposal of children’s feces, practice personal and domestic hygiene, and safe food preparation. However, 31% of the mothers responded that they did not always provide boiled drinking water to the child, and 32.3% of the mothers did not use a clean spoon to feed the child. The results show that 30% of the mothers never defecate in the latrine (open defecation was practiced). And only 38.3% of the mothers always disposed their child’s feces into the latrines.

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Table 1: Number and percentage of general characteristics of mothers (n = 300) General Characteristics

Frequency

Percentage

11 221

3.7 73.7

68

22.7

292 8

97.3 2.7

5 98 91 81 25

1.7 32.7 30.3 27 8.3

160 140

53.3 46.7

160 140

53.3 46.7

Mothers’ Age < 20 years ≥ 20 – 35 years ≥ 36 – 48 years Marital Status Unmarried Married Widowed Education None Primary School Junior High School Senior High School Diploma and Bachelor Child’s Age < 36 months 36 – 60 months Episode of Diarrhea (in last one month) No Yes

Table 2: The relationship between independent variables and dependent variable. Variables Behaviors needs Educational level PS or below 42 JHS or above 53 Perceived self-efficacy Low-Fair 92 High 3 PS = Primary school JHS = Junior High School

Good

Total

61 144

103 197

118 87

χ² 6.0

p 0.014

Phi 0.142

47.6

0.000

0.399

210 90

In addition, this study also found a significantly positive relationship between educational level and perceived self-efficacy for diarrhea preventing behaviors (p < 0.001).

DISCUSSION Educational level showed a significant positive relationship with mothers’ behaviors to prevent diarrhea. Similarly, another finding identified that those who had completed the compulsory education were more

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likely to be better at preventing diarrhea (Liu, 2009 & Chowdhury, 2010). According to this study, the level of education could determine behaviors because education could affect the manner of thinking and motivation. Educational background is an indicator associated with a person’s level of resources, which could also lead a person to perform better health behaviors (Barkey, 2008). This study also found that those who had an educational background up to Junior High School or above had perceived higher self-efficacy for diarrhea prevention than those who had educational backgrounds only up to Primary School or below. Perceived self-efficacy had a significant positive relationship with mothers’ behaviors. This was similar to another finding that revealed that mothers who had highly perceived self-efficacy for diarrhea prevention behaviors were more likely to be better at preventing diarrhea (Morgan, 2014). According to this study, perceived self-efficacy for diarrhea prevention behaviors would determine mothers’ behaviors. A person, who believed in her ability to succeed in performing an action, was more likely to perform healthy behaviors. In other words, she had confidence to implement the action for reducing the threat of the disease (Pender et al., 2011).

CONCLUSION AND RECOMMENDATIONS Educational background was a factor that influenced decision-making among mothers. Confidence in one’s ability reflected on behaviors in preventing diarrhea. To sustain the healthy behaviors, mothers require motivation from others, facilities to maintain their healthy behavior, and accessibility to health information/ services.

Acknowledgement The highest appreciation for the thesis advisors, Dr. Susheewa Wichaikull, RN, MNS., and Asst. Prof. Boosaba Sanguanprasit, M.P.H, Ph.D. Big thanks to participants who have been willing as the volunteers in this project. A very special thanks to parents, siblings, and a few close friends who always tried to find a solution when the researcher was not able to focus on thought.

REFERENCES Becker, M. H. 1974. The health belief model and personal health behavior. San Francisco: Society for public health education. Barkley G.S. 2008. Factors influencing health behaviors in the national health and nutritional examination survey, III (NHANES III). Social work in health care, 46:4, 57-79. DOI: 10.1300/J010v46n04_04. Badan Pusat Statistik (BPS). 2013. Kabupaten Buol Dalam Angka. BPS Kabupaten Buol. Chowdhury F. 2010. Diarrhea preventive practice among caregivers of 1 to 5 years children at urban slum area in Chittagong, Bangladesh. M. Sc. Thesis, Mahidol University. Dinas Kesehatan Sulawesi Tengah (DinKes Sul-Teng). 2012. Profil kesehatan provinsi, kota Palu, Indonesia. http://www.depkes.go.id/resources/download/profil/PROFIL_KES_PROVINSI_2012/25_Profil_Kes.Prov.SulawesiTengah_2012.pdf [access date: 30.01.2015] Dinas Kesehatan Kabupaten Buol (DinKes Kab. Buol). 2014. Profil kesehatan Kabupaten Buol. DinKes Kab. Buol Sulawesi Tengah, Indonesia. Friedman M.R., V.R. Bowden and E. Jones. 2003. Family nursing research theory and practice 5th edition. Pearson education, Inc. Upper Saddle River, New Jersey.

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Htay W.Y.A., B. Keiwkarnka and N. Hongkailert. 2010. Diarrhea preventive behavior of Myanmar immigrant caregivers with children under-five years in Muang District, Samut Sakhon province, Thailand. http://www.aihd.mahidol.ac.th/sites/default/files/images/new/pdf/journal/janapr2011/ 1.pdf [access date: 01.07.2015] McKinney E.S, S.S. Murray, J. Ashwill, S.R. James, and K. Nelson. 2013. Maternal-child nursing 4th edition. Saunders, Elsevier Inc. Morgan M.S. 2014. Diarrhea preventive behavior among the caregivers of children under-five years old in the Tonle Sap great lake floodplains, Siem reap, Cambodia. M. Sc. Thesis, Mahidol University. Pender N.J, C.L Murdaugh and M.A Parsons. 2011. Health promotion in nursing practice, 6th edition. Pearson education, Inc. Upper saddle river, New Jersey. Strina, A, S. Cairncross, M.L. Barreto, C. Larrea and M.S. Prado. 2002. Childhood diarrhea and observed hygiene behavior in Salvador, Brazil. American journal of epidemiology http://aje.oxfordjournals. org/content/157/11/1032.full.pdf+html [access date: 09.05.2015] Walker C.L.F., J. Perin, M.J. Aryee, C.B. Pinto and R.E. Black. 2012. A systematic review: diarrhea incidence in low- and middle-income countries in 1990-2010. http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3323412/pdf/1471-2458-12-220.pdf [access date: 01.07.2015] WebMd. 2015. Digestive disorders health disease. http://www.webmd.com/digestive-disorders/ digestive-diseases-diarrhea [access date: 11.01.2015] WHO. 2012. Health statistics and information system, estimates 2000-2012 disease burden. http://www. who.int/healthinfo/global_burden_disease/estimates/en/index2.html [access date: 01.07.2015] WHO and UNICEF. 2013. Ending preventable deaths: global action plan for prevention and control of pneumonia and diarrhea (GAPPD). WHO library cataloguing-in-publication data. WHO. 2014. Indonesia health profile. http://www.who.int/gho/countries/idn.pdf?ua=1 [access 14.02.2015]

date:

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Working Group

192

1. Dr. Uma Langkulsen

Chairman

2. Mrs. Chanjira Khanphan

Member

3. Ms. Sirada Sahaimitr



Member

4. Ms. Rungtip Intapeng



Member

5. Ms. Samittra Pornwattanavate

Member

6. Mr. Anusorn Phonboon

Member

7. Ms. Porjai Klinsrisuk

Member

8. Mr. Watchai Phothong

Member

9. Ms. Sunisa Wangta

Member

10. Ms. Kuntiwa Wutisanit

Member

11. Mr. Kittisak Nimklad

Member

12. Mr. Athikom Nunbhakdi

Member

13. Mr. Piriya Tipkongka

Member

14. Ms. Usa pongjitsai



Member

15. Ms. Fueangfa Sudmee

Member

16. Mrs. Viparnit Phothong

Member/Secretary



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Mahidol University

Faculty of Public Health

PUBLIC HEALTH INSTITUTE

PHS

PUBLIC HEALTH SOLUTIONS. LIMITED Consultants in International Public Health