Alcohol consumption patterns among men who have sex with men in major cities of Myanmar: A cross-sectional study.

Background: Alcohol consumption patterns vary widely across the regions of the world. Although previous studies have focused on the sexual risk behaviours among men who have sex with men (MSM), studies regarding binge alcohol drinking among MSM in Myanmar are scarce. Methods: A cross-sectional study was conducted to identify the alcohol consumption patterns among MSM aged over 18 years in two major cities of Myanmar where the MSM population is higher than other regions. Purposive sampling was applied and sampling was made through Myanmar MSM network. Face-to-face interviews were conducted using a structured questionnaire. Patterns of alcohol consumption were described as frequency/percentage and mean/median as appropriate. Bivariate analysis was also done to find out the association between types of MSM and binge drinking. Results: A total of 256 MSM included in the study (mean age, 27.33±7.7 years). Of 256 participants, 225 MSM had the experience of alcohol consumption in their lifetime (225/256, 87.9%). Among ever drinkers, 152 MSM consumed alcohol within three months (152/225, 67.6%). Regarding beer consumption, the highest proportions of MSM from both groups (42.8%, 36.8%) consumed 1-3 times per week. Overall, 57.2% of young MSM and 41.2% of adult MSM consumed beer together with their friends. Nearly 34% of young MSM and nearly 38% of adult MMS consumed beer at gatherings of friends. At different time periods, higher proportions of Thange (partners of MSM) had experienced of binge drinking than apwint (open) and apone (hidden) (p<0.05). Conclusions: The current study identified the alcohol consumption patterns in terms of type, amount, frequency at different time periods among MSM in major cities of Myanmar. It is suggested to develop and implement alcohol control policy for MSM since the proportion of current drinkers as well as binge drinking higher among these groups.

Young key affected population in Myanmar: are there any challenges in seeking information and care for HIV/sexually transmitted infections and reproductive health?

Background: Unmet needs and barriers in seeking HIV/STI and RH information and care are present especially among young key affected population (YKAP). Therefore, the study was conducted to determine the health seeking behaviors of YKAP regarding HIV/STI and RH, and challenges in seeking health information and care. Methods: A cross-sectional, mixed-methods study was conducted at two large cities in Myanmar. Face-to-face interviews were conducted with YKAP aged 15-24 years. In-depth interviews and key informant interviews were done with YKAP and health care providers. Descriptive statistics and bivariate analyses were done for quantitative data and thematic analysis was applied for qualitative data. Results: A total of 119 young men who have sex with men (YMSM) and 123 young female sex workers (YFSW) included in the study. Mean age of YMSM and YFSW were 20.9±2.4 and 21.7±2.2 years. Over 30% of YMSM and 49.3% of YFSW had experience of any STI symptom. Particularly, 17% of YMSM and 10% of YFSW had genital ulcer, and majority sought health care at NGO clinics. About 37% of YMSM and 40% of YFSW visited Drop-in-center (DIC) within one to six months. Over 13% of YMSM and 14.6% of YFSW had challenges in seeking HIV/STI and RH information.  YMSM/YFSW type and age of YMSM were associated with visit to DIC. Lesser proportions of Tha-nge (43.5%), younger age YMSM (66.7%), brothel-based YFSW (47.9%) visited DIC than others (p<0.05). Challenges and unmet needs expressed by YKAP were reluctance in asking health information, worry for future fertility, consequences of anal sex and contraception. Challenges expressed by providers were limited time during outreach service and difficulty in reaching entertainment-based sex workers. Conclusions: Special attention in provision of health information should be paid to YKAP since there is a considerable proportion of YKAP with unmet need in seeking HIV/STI/RH information and care.

Engagement of public and private medical facilities in tuberculosis care in Myanmar: contributions and trends over an eight-year period.

BACKGROUND: As part of the WHO End TB strategy, national tuberculosis (TB) programs increasingly aim to engage all private and public TB care providers. Engagement of communities, civil society organizations and public and private care provider is the second pillar of the End TB strategy. In Myanmar, this entails the public-public and public-private mix (PPM) approach. The public-public mix refers to public hospital TB services, with reporting to the national TB program (NTP). The public-private mix refers to private general practitioners providing TB services including TB diagnosis, treatment and reporting to NTP. The aim of this study was to assess whether PPM activities can be scaled-up nationally and can be sustained over time. METHODS: Using 2007-2014 aggregated program data, we collected information from NTP and non-NTP actors on 1) the number of TB cases detected and their relative contribution to the national case load; 2) the type of TB cases detected; 3) their treatment outcomes. RESULTS: The total number of TB cases detected per year nationally increased from 133,547 in 2007 to 142,587 in 2014. The contribution of private practitioners increased from 11% in 2007 to 18% in 2014, and from 1.8% to 4.6% for public hospitals. The NTP contribution decreased from 87% in 2007 to 77% in 2014. A similar pattern was seen in the number of new smear (+) TB cases (31% of all TB cases) and retreatment cases, which represented 7.8% of all TB cases. For new smear (+) TB cases, adverse outcomes were more common in public hospitals, with more patients dying, lost to follow up or not having their treatment outcome evaluated. Patients treated by private practitioners were more frequently lost to follow up (8%). Adverse treatment outcomes in retreatment cases were particularly common (59%) in public hospitals for various reasons, predominantly due to patients dying (26%) or not being evaluated (10%). In private clinics, treatment failure tended to be more common (8%). CONCLUSIONS: The contribution of non-NTP actors to TB detection at the national level increased over time, with the largest contribution by private practitioners involved in PPM. Treatment outcomes were fair. Our findings confirm the role of PPM in national TB programs. To achieve the End TB targets, further expansion of PPM to engage all public and private medical facilities should be targeted.

International non-governmental organizations' provision of community-based tuberculosis care for hard-to-reach populations in Myanmar, 2013-2014.

BACKGROUND: National tuberculosis (TB) programs increasingly engage with international non-governmental organizations (INGOs), especially to provide TB care in complex settings where community involvement might be required. In Myanmar, however, there is limited data on how such INGO community-based programs are organized and how effective they are. In this study, we describe four INGO strategies for providing community-based TB care to hard-to-reach populations in Myanmar, and assess their contribution to TB case detection. METHODS: We conducted a descriptive study using program data from four INGOs and the National TB Program (NTP) in 2013-2014. For each INGO, we extracted information on its approach and key activities, the number of presumptive TB cases referred and undergoing TB testing, and the number of patients diagnosed with TB and their treatment outcomes. The contribution of INGOs to TB diagnosis in their selected townships was calculated as the proportion of INGO-diagnosed new TB cases out of the total NTP-diagnosed new TB cases in the same townships. RESULTS: All four INGOs implemented community-based TB care in challenging contexts, targeting migrants, post-conflict areas, the urban poor, and other vulnerable populations. Two recruited community volunteers via existing community health volunteers or health structures, one via existing community leaderships, and one directly involved TB infected/affected individuals. Two INGOs compensated volunteers via performance-based financing, and two provided financial and in-kind initiatives. All relied on NTP laboratories for diagnosis and TB drugs, but provided direct observation treatment support and treatment follow-up. A total of 21 995 presumptive TB cases were referred for TB diagnosis, with 7 383 (34%) new TB cases diagnosed and almost all (98%) successfully treated. The four INGOs contributed to the detection of, on average, 36% (7 383/20 663) of the total new TB cases in their respective townships (range: 15-52%). CONCLUSION: Community-based TB care supported by INGOs successfully achieved TB case detection in hard-to-reach and vulnerable populations. This is vital to achieving the World Health Organization End TB Strategy targets. Strategies to ensure sustainability of the programs should be explored, including the need for longer-term commitment of INGOs.

Correlates of Forced Sex Among Young Men Who Have Sex With Men in Yangon and Monywa, Myanmar.

Forced sex at an early age is associated with a variety of negative factors including increased illness, high-risk sexual and substance-use behaviors, and mental and psychological stress. These sequelae may be compounded for men who have sex with men (MSM), especially young MSM and those with feminine gender identity and expression. This survey examined the prevalence and associations of forced sex among young MSM in two cities in Myanmar. In 2013-2014, surveys using respondent-driven sampling collected data on 200 young MSM in Yangon and 200 in Monywa. One quarter of young MSM in Yangon and 21 % in Monywa reported ever experiencing forced sex. In a multivariable model, having problems with family members and having any MSM friends with many partners had higher odds of experiencing forced sex. Having maternal acceptance of same-sex attraction (compared to acceptance by both parents) and becoming aware of their same-sex attraction at or above the age of 16 had lower odds of experiencing forced sex. Focused research is needed to understand the family and other social dynamics affecting vulnerability to forced sex, as well as specific sexual risks associated with forced sex among young MSM, including HIV acquisition and transmission risks.

Effectiveness of Mindfulness Intervention on Psychological Behaviors Among Adolescents With Parental HIV Infection: A Group-Randomized Controlled Trial.

This study aims to identify the effectiveness of mindfulness intervention on the psychological behaviors of adolescents with parental HIV infection and its associated factors in Myanmar. A total of 80 adolescents from 2 intervention townships and 80 adolescents from 2 control townships were enrolled in a group randomized controlled trial with assessments at baseline and 6 months follow-up. The mindfulness intervention involved monthly group sessions for 3 consecutive months led by an experienced mindfulness trainer. Three domains of psychological behaviors-namely, emotional, conduct, and social behaviors-were assessed at baseline and compared after 6 months. Multilevel regression analysis was used to determine the effectiveness of the intervention and associated factors for psychological behaviors. The intervention significantly improved emotional and conduct behaviors at 6 months (P < .001) but had no effect on social behavior. The significant effect of the intervention existed after adjusting for gender, family type, child age, and orphan status.

Correlates of male involvement in maternal and newborn health: a cross-sectional study of men in a peri-urban region of Myanmar.

BACKGROUND: Evidence suggests that increasing male involvement in maternal and newborn health (MNH) may improve MNH outcomes. However, male involvement is difficult to measure, and further research is necessary to understand the barriers and enablers for men to engage in MNH, and to define target groups for interventions. Using data from a peri-urban township in Myanmar, this study aimed to construct appropriate indicators of male involvement in MNH, and assess sociodemographic, knowledge and attitude correlates of involvement. METHODS: A cross-sectional study of married men with one or more children aged up to one year was conducted in 2012. Structured questionnaires measured participants' involvement in MNH, and their sociodemographic characteristics, knowledge and attitudes. An ordinal measure of male involvement was constructed describing the subject's participation across five areas of MNH, giving a score of 1-4. Proportional-odds regression models were developed to determine correlates of male involvement. RESULTS: A total of 210 men participated in the survey, of which 203 provided complete data. Most men reported involvement level scores of either 2 or 3 (64 %), with 13 % reporting the highest level (score of 4). Involvement in MNH was positively associated with wives' level of education (AOR = 3.4; 95 % CI: 1.9-6.2; p < 0.001) and men's level of knowledge of MNH (AOR = 1.2; 95 % CI: 1.1-1.3; p < 0.001), and negatively correlated with number of children (AOR = 0.78; 95 % CI: 0.63-0.95; p = 0.016). CONCLUSIONS: These findings can inform the design of programs aiming to increase male involvement, for example by targeting less educated couples and addressing their knowledge of MNH. The composite index proved a useful summary measure of involvement; however, it may have masked differential determinants of the summed indicators. There is a need for greater understanding of the influence of gender attitudes on male involvement in Myanmar and more robust indicators that capture these gender dynamics for use both in Myanmar and globally.

Threat of HIV/AIDS in children: social, education and health consequences among HIV orphans and vulnerable children in Myanmar.

BACKGROUND: There is very limited information available on HIV related orphans and vulnerable children (HIV-OVC) in Myanmar. Hence, the objective of this study was to identify and compare the social, education and health consequences among HIV-OVC and children from the families not related to HIV in the same neighbourhoods (neighbouring children). MATERIALS AND METHODS: A cross-sectional, comparative survey was carried out in three geographical locations. Face-to-face interviews were conducted with guardians and children using a pretested structured questionnaire including Strength and Difficulties Questionnaire (SDQ) for behavioural problems. Outcome measures were compared using Chi-squared test or 't' test or 'Rank-sum' test. RESULTS: A total of 300 HIV-OVC and 300 neighbouring children were included. A greater number of HIV-OVC than their neighbouring children have experienced family displacement from their original homes (27% and 1%), child/sibling displacement (20% and 2.7%) and family dispersion (20.3% and 1.3%) (P < 0.001). More guardians of HIV-OVC reported that the disease affected their children's education (28.2% and 16.3%; P < 0.05). Fifteen per cent of HIV-OVC and 10.5% of neighbouring children had to work for their families (P < 0.05). Psychological condition was assessed on emotional, conduct, hyperactivity/inattention, peer relationship and prosocial behaviour. A greater number of HIV-OVC were noted in the abnormal category with regard to hyperactivity and prosocial behaviours (P < 0.05). CONCLUSIONS: Higher incidence of social and psychological consequences among HIV-OVC call for more community support programmes and creation of job opportunities to minimize social impact in the affected families. Future programmes should focus on counselling of HIV-OVC and providing psychological support.

Predictors of contraceptive use among married youths and their husbands in a rural area of Myanmar.

This study aimed to determine the predictors of contraceptive use among married female youths and their husbands using the behavioral theory of the Health Belief Model (HBM). A community-based survey was conducted in a rural area of Myanmar in 2008. A total of 444 respondents (222 couples) were interviewed separately using a pretested, structured questionnaire. Significant predictors of contraceptive use were determined by univariate and multivariate analysis. Wife's HBM perception was a highly significant predictor of contraceptive use in married youths (adjusted odds ratio = 10; 95% confidence interval = 2.7, 37.6). Wives aged 20 to 24 years and having their own income, experience of spousal communication, and shorter distance from home to health center were also significant predictors of contraceptive use. A poor agreement on HBM perception between wife and husband was noted. This study highlights the importance of HBM perceptions, wife's income, spousal communication, and geographic barriers in contraceptive use among married youths in rural Myanmar.

Challenges faced by skilled birth attendants in providing antenatal and intrapartum care in selected rural areas of Myanmar.

BACKGROUND: In Myanmar a large proportion of antenatal and intrapartum care in rural areas is provided by skilled birth attendants (SBAs), this study assessed the coverage by these health workers of all births, their adherence to service guidelines, and community opinion on the antenatal and delivery care they give in two rural health centres in Pathein Township, Ayeyarwaddy Region to identify the challenges and improve antenatal and intrapartum service delivery provided by the SBAs. METHOD: A structured questionnaire was used to interview 304 women who had infants under one year of age, and in-depth interviews were held with 12 SBAs and 10 community members. RESULTS: Of the 304 pregnancies, 93% had received antenatal care (ANC); 97% of these were covered by SBAs at an average 15 weeks' gestation. The average frequency of ANC visits was 9. Rates of home and hospital deliveries were 84.5% and 13.8% respectively. Among home deliveries, use rate of SBA was 51.4%, while for postnatal care, 31.3% was given by unskilled providers (traditional birth attendants (TBAs) 17.5%, auxiliary midwives (AMWs),13.8%). Multivariate analysis showed that interviewees aged 30 years and below (OR=0.468, P=0.046), with an education at primary level and below that of husband (OR=0.391, P=0.007) or not residing in the village of the rural/station health centre (OR=0.457, P=0.011) were significantly less likely to use SBAs. The categories of supervision, referral, and health education activities of SBAs were not in line with service guidelines. The main reasons were lack of access and community acceptance of TBAs. CONCLUSION: Heavy workload, geographical location, transportation and financial concerns were major challenges for SBAs, along with community compliance and mutual coordination. Good communication and service management skills were important to overcome these challenges.

Public and/or private health care: tuberculosis patients' perspectives in Myanmar.

BACKGROUND: Tuberculosis is a major public health problem in Myanmar as in other developing countries. About 73% of TB patients seek care at private general practitioners' clinics before presenting to the public TB centre, raising questions about how best to prevent transmission and maintain treatment regimens. METHOD: The study was conducted in two townships in Yangon Division in Myanmar in 2004, and examined treatment seeking behaviour of TB patients and their views towards public and private health care services. This was an exploratory descriptive study. Both quantitative and qualitative research methods were employed in data collection from TB patients, health care professionals, and members of various agencies involved in TB Control Programme. RESULTS: A considerable delay was found between the onset of symptoms of TB and seeking treatment (five days - two months). General practitioners were the first point of contact in all cases. Old TB patients influenced the treatment seeking behaviour and choice of treatment clinics of new TB patients. Most patients viewed the public health sector as a place to obtain free treatment and the private sector as a fee-paying, convenient and better place to seek treatment. CONCLUSION: The involvement of private general practitioners is crucial for effective TB control in Myanmar. The selection of GPs for partnership with the public sector is vital to the success of public-private partnership in controlling TB.

Women's awareness, knowledge and perceived magnitude regarding common female cancers in Yangon, Myanmar.

Early detection and diagnosis can greatly increases the chances for successful treatment particularly relevant for common female cancers like cancer breast and cervix. Increased awareness of the possible warning signs of these cancers among general public is a necessity. A community-based, cross-sectional study was conducted with the objectives of assessing the women's awareness and knowledge on common female cancers and estimating the perceived magnitude and survival of these cancers. A total of 400 women were interviewed using a pre-tested, structured questionnaire. Mean age of women was 48.4 years and majority were married, dependent and primary school passed. Almost all (99.3%) were aware of breast cancer and only (69.5%) were aware of cervical cancer. Breast lump was considered as a condition that will later develop into cancer by (38.8%) and (41.5%) mentioned that it was painless in early stage. Abnormal bleeding per vagina and white discharge were mentioned as main symptoms of cervical cancer (76.3%, 63.3%). Regarding the risk of cervical cancer, female hygiene was indicated by (88.5%) and number of sexual partners by (77.0%). Almost all of them said that both diseases can be cured at early stage. Cancer breast, uterus and cervix were mentioned as the most common female cancers according to their perceived magnitude. Although cervical and breast cancer were perceived as common female cancers, health education activities regarding risk factors and early warning signs of these cancer still need to be promoted.