Bhutan Health Journal Khesar Gyalpo University of Medical Sciences of Bhutan en-US Bhutan Health Journal 2413-2993 Quality in universal health coverage Jayendra Sharma ##submission.copyrightStatement## 2018-11-06 2018-11-06 4 2 I II Barriers to self-injection of insulin among patients attending the diabetes clinics at the three referral hospitals in Bhutan: a cross-sectional study <p><strong>Introduction:</strong> Insulin, despite its increasing cost, is prescribed to selected cases of diabetes patients with an aim to achieve good glycaemic control. However, many on insulin do not achieve glycaemic control. We, therefore, studied the possible factors that may act as barriers to effective self-injection of insulin among diabetes patients at the three referral hospitals in Bhutan.</p> <p><strong>Methods:</strong> This was a cross-sectional study, conducted from January-June 2017, involving all patients on insulin therapy for more than three months duration. Convenience sampling was used. Respondents’ basic details and self-reported barriers to insulin therapy under various domains were collected using an interviewer-administered questionnaire. Ethics approval was granted by the Research Ethics Board of Health, Bhutan.</p> <p><strong> Results:</strong> There were 207 respondents on insulin therapy. The mean age of the sample was 55 years (±13.8 years) and the mean duration of diabetes was 10.6 years (± 7.8 years). Injection dexterity was an issue in 77 respondents (37.2%) while 37 respondents (17.8%) reported that they would miss their insulin shots if their caregiver were unavailable. Insulin regimens were burdensome and interfered with their daily activities (80; 38.7%) and meal timings (64; 30.9%). Although the majority (179; 86.4%) knew why insulin was indicated for them, 149 (72.0%) found that the healthcare personnel’s demonstration on the use of insulin was inadequate and 50 respondents (24.2%) felt that they did not receive enough information on how<br>to inject insulin.</p> <p><strong> Conclusions:</strong> Barriers to self-injection are common among insulin users and coordinated efforts are needed to overcome them.</p> Thinley Dorji Pempa Lhamo Tshering Tshering Lungten Zangmo Kencho Choden Deki Choden sang Namgyal ##submission.copyrightStatement## 2018-11-06 2018-11-06 4 2 1 5 Community action to reduce harmful use of alcohol: a pilot study in the remote villages of eastern Bhutan <p><strong>Introduction:</strong> As per the Annual Health Bulletin, 2017, alcohol related liver disease is the leading cause of death in Bhutan. There were 190 deaths due to harmful use of alcohol in 2016 and alcohol liver disease (ALD) incidence was 46 per 10,000 people. Community action to reduce harmful use of alcohol in the communities is one of the strategies being implemented in Bhutan. However, the impact of such community action is not assessed in the country. Therefore, this pilot study was conducted in two gewogs (sub-district) of Trashiyangtse dzongkhag to assess the short-term effects of this community action to reduce alcohol use.</p> <p><strong>Methods:</strong> This pilot study involved one intervention and one control community. The interventions were developed and implemented in consultation with the community by empowering them for monitoring to ensure effectiveness of the intervention. The data were collected pre and post-intervention in both the gewogs through repeated cross-sectional surveys.</p> <p><strong> Results:</strong> The practice of offering tshogchang decreased from about 99% to about 50% after the intervention. Practice of children drinking alcohol decreased by 6.83%. The average monthly spending on alcohol reduced from about Nu. 418 to about Nu. 97, and the amount of grains used for brewing decreased from about 34 Kg to 18 Kg, after the intervention.</p> <p><strong>Conclusion:</strong> This study found that the community action is effective in bringing positive impacts in reducing harmful use of alcohol in community. Therefore, expansion of such community action in other communities in Bhutan with similiar context is strongly recommended..</p> Dil K. Subba Mongal S. Gurung Diki Wangmo Mindu Dorji Tashi Tobgay ##submission.copyrightStatement## 2018-11-06 2018-11-06 4 2 6 14 Health-related quality of life and co-morbidities among older adults in Bhutan <p><strong>Introduction:</strong> Health-related quality of life (HRQoL) is a multi-dimensional construct that assesses an individual’s and group’s perceived physical and mental health over time. Measurement of HRQoL is an important medical outcome study and its study among older adults in Bhutan is limited.</p> <p><strong>Methods:</strong> This is a cross-sectional study aimed to assess HRQoL and its sociodemographic and health correlates, among older adults in Bhutan. Data for this study was collected from the four major towns of Thimphu, Phuntsholing, Gelephu, and Samdrupjongkhar, Bhutan, from November 2014 - February 2015, using structured questionnaire with face-to-face interview. A total of 337 Bhutanese older adults participated in this study. Statistical analysis was performed using statistical package for social science version 21.0.</p> <p><strong>Results:</strong> The overall mean score for the HRQoL among older adults in this study was 0.67 (SD: 0.13) significantly different between the gender (p-value&lt;0.001). A significantly low scores in<br>the areas of role limitations (p&lt;0.05), pain (p&lt;0.01), mental health (p&lt;0.001), and vitality (p&lt;0.05) of the HRQoL was observed for the female gender. Frequent back pain (67.1%), memory decline (60.5%), depression (46.0%) mobility impairment (45.4%), insomnia (42.1%), and problem affecting breathing (31.8%) were common health problems and were significantly higher among the female gender. Better health conditions was positively related with better HRQoL (p-value&lt;0.001).</p> <p><strong>Conclusions:</strong> Low HRQoL was reported higher among female gender and was linked to multiple and cumulative health morbidities. Members of the family, community and healthcare providers could incorporate holistic approach to foster positive health outcomes and HRQoL of the older adults.</p> Nidup Dorji Michael P. Dunne Charrlotte Seib Sibnath Deb ##submission.copyrightStatement## 2018-11-06 2018-11-06 4 2 15 24 Incidence and clinicopathological profile of gestational trophoblastic disease in tertiary care centre <p><strong>Introduction:</strong> Gestational trophoblastic disease (GTD) arises from abnormal proliferation of placental trophoblastic tissue. The aim of this study was to determine the incidence and clinicopathological profiles with treatment outcome of gestational trophoblastic disease in Jigme Dorji Wangchuck National Referral Hospital, a tertiary hospital in Bhutan.</p> <p><strong> Method:</strong> A prospective and retrospective observational study was conducted over a period of 18 months.</p> <p><strong>Results:</strong> A total of 121 cases of gestational trophoblastic disease were diagnosed with an incidence rate of 19.7 per 1000 deliveries. Majority comprised hydatidiform moles<br>(115);of which, 30 (26.1%) were complete and 85(73.9%) partial moles. The mean gestational age at diagnosis of hydatidiform mole was 9.8± 1.6 weeks and the most common symptom being vaginal bleeding (72.8%). Nine (7.8%) of these progressed to gestational trophoblastic neoplasia and was strongly associated with high pre-evacuation beta-hCG level (&gt; 100,000 mIU/ml) and larger uterine size (&gt; 14 weeks).</p> <p><strong>Conclusions:</strong> This study revealed a high incidence of gestational trophoblastic disease in national referral hospital. Further in-depth research and instituting a GTD registry can be useful to validate these findings and find the true incidence. A substantial number of molar pregnancies can progress to GTN, and thus requires strict follow-up.</p> Tshering Tamang Ugyen Tshomo ##submission.copyrightStatement## 2018-11-06 2018-11-06 4 2 25 29 Patients’ knowledge and practices on the drug regimens prescribed at the National Traditional Medicine Hospital: a call for a systematic approach to drug information services <p><strong>Introduction:</strong> The World Health Organisation estimates that only half of all medicines dispensed are used appropriately. The Bhutanese Traditional Medicine (BTM) system is no exception. Objectives: We studied the patients’ knowledge on the usage of traditional medicine regimens prescribed to them, their medication adherence and possible adverse events.</p> <p><strong>Methods:</strong> This was a cross-sectional study conducted using an interviewer-administered questionnaire at the National Traditional Medicine Hospital, Thimphu in 2017. A simple random sampling was used. Ethical approval was sought from Research Ethics Board of Health, Thimphu.</p> <p><strong> Results:</strong> A sample of 402 patients were studied. The mean age of the respondents was 45 years (±15 years) and 333 (82.8%) were old cases presenting to the hospital. The knowledge on the correct timing of the medicine, how to take the medicine and what to avoid while on those medicines were understood only by 62.7%, 34.6% and 22.9% respectively. Only 351 (87.3%) patients received verbal information on the usage of drugs from the dispensers, of which 119 (29.6%) said the information was not clear or not adequate. Failure to take medicines on time was reported by 224 (67.3%) among old cases. Undesirable events reported while using BTM were giddiness, vomiting, skin irritation, diarrhoea and fainting episodes.</p> <p><strong> Conclusions:</strong> The drug information system and monitoring of medication adherence and adverse drug events require adoption of more effective tools<br>and methods.</p> Kinga Jamphel Dorji Gyeltshen Sherab Tenzin Thinley Dorji ##submission.copyrightStatement## 2018-11-06 2018-11-06 4 2 30 34 Stillbirth rate in Bhutan: a retrospective facility-based study <p><strong>Introduction:</strong> Stillbirth is an important public health concern; yet there is no reliable stillbirth rate for Bhutan. Hence the aim of this study was to estimate the stillbirth rate for Bhutan.</p> <p><strong>Methods:</strong> A retrospective study was carried out for live and stillbirths recorded in delivery registers of all 253 health facilities across the country for a period of one year commencing 1st January till 31st December 2015.</p> <p><strong>Results:</strong> There were a total of 11,126 live births and 108 stillbirths documented in delivery registers. The stillbirth rate from this data set was 10 per 1000 live births.</p> <p><strong> Conclusions:</strong> The stillbirth rate for Bhutan from this study is 10 per 1000 live births lower than 16 per 1000 live births estimated in Lancet Series 2015. In order to find the true burden of stillbirths in the country, a surveillance may be instituted which can facilitate the prevention efforts while at the same time enable to strengthen information system.</p> Pema Lethro Kinga Jamphel Vandana Joshi Chandralal Mongar Lobzang Tshering Tashi Tshomo ##submission.copyrightStatement## 2018-11-06 2018-11-06 4 2 35 38 Situation of maternal health in Bhutan 2018 <p><strong>Introduction:</strong> Bhutan has opened up to modernization in 1961s and since then good progress has been made in social sectors.<br>Providing free health service and education has the top priority from the beginning to this day. With humble starting from almost<br>bare grounds, the situation of maternal health has improved. Until the start of the Safe Motherhood program in 1994, health<br>programs were not streamlined. The maternal mortality ratio (MMR) was 380 per 100000 livebirths in 1994. A lot of efforts<br>with different programs have been implemented by the reproductive health program of Ministry of Health to improve maternal<br>health. Main challenge has been with health human resource from the very beginning and it still stands to this day as number one<br>challenge. With the inputs of various programs to improve maternal health and development in non-health sectors, the MMR has<br>come down to 89 per 100000 livebirths in 2017.</p> Phurb Dorji Pema Lethro Lobzang Tshering Tashi Tshomo ##submission.copyrightStatement## 2018-11-06 2018-11-06 4 2 39 42 Hypotension, bradycardia and reversible conduction defect induced by prescription of Bhutanese traditional medicines <p><strong>Introduction:</strong> Aconite is widely used in both Chinese and Ayurvedic medications and therefore often used within the Himalayan<br>Kingdom of Bhutan. Despite its use in traditional medicine, because of its narrow therapeutic index, significant cardiotoxic and<br>neurotoxic events are documented due to both intentional and unintentional ingestion. In this case series we present 2 cases of<br>bradycardia, hypotension and reversible conduction defects caused by prescribed aconite-based Bhutanese traditional medicines,<br>for different therapeutic goals, who suffered cardiac dysrhythmias.</p> Ugyen Tshering Shankar LeVine Melanie Watts ##submission.copyrightStatement## 2018-11-06 2018-11-06 4 2 43 45 Taking action on prevention and control of noncommunicable diseases in Bhutan by strengthening gross national happiness <p><strong>Introduction:</strong> Noncommunicable diseases (NCDs) are major public health problem in Bhutan, accounting for 68% of total deaths.<br>The growing epidemic of NCDs threatens the achievement of Gross National Happiness (GNH). NCDs are the results of complex<br>interaction of social and economic risk factors and change in diet and lifestyle. Effective action to prevent and control these<br>diseases requires a whole-of-government approach.In this paper we review new evidence to support political priority for NCDs<br>in Bhutan. One third of the Bhutanese are overweight (33%) and hypertensive (35.7), and 6.4% are diabetic. The prevalence of<br>modifiable risk factors is also very high. We also present the analysis of strategic policy opportunities for health sector to integrate<br>the ‘Multisectoral national action plan for the prevention and control of NCDs, 2015-2020’ into policies across all relevant<br>sectors. Our analysis has identified three specific opportunities for the health sector to engage strategically to strengthen action on<br>NCDs and GNH, concurrently: 1) raising priority actions on NCDs within the existing GNH multisectoral committee, to achieve<br>both health and happiness objectives; 2) identifying shared agenda between NCDs and GNH to achieve both health and happiness<br>objectives; and 3) identifying shared GNH determinants between NCDs and GNH to enhance action on NCDs. Addressing NCDs<br>aligns with the optimization of Gross National Happiness. It is imperative that the Government of Bhutan recognize that action<br>on NCDs is an integral element for achieving GNH.</p> Gyambo Sithey Anne Marie Thow Jayendra Sharma Karma Lhazeen Mu Li ##submission.copyrightStatement## 2018-11-06 2018-11-06 4 2 46 50 Estimation of serum creatinine in biochemistry department, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan Sonam Chhoden R Kuenzang Chhenzom Jigme Tenzin ##submission.copyrightStatement## 2018-11-06 2018-11-06 4 2 51 52 Medical Education Centre for Research, Innovation and Training (MECRIT) Tashi Norbu ##submission.copyrightStatement## 2018-11-06 2018-11-06 4 2 53 54