bluuebunny/crossref_metadata_2025_split huggingface dataset:
Prevalence, determinants and outcomes of unplanned pregnancy and perspectives on termination of pregnancy among women in Nganglam, Bhutan
Authors: Choden Jigme , Pem Rinzin , Pathak Abhijeet 
Published: December 2020

Introduction: The objectives of this cross sectional study were to determine prevalence, determinants, and outcomes of unplanned pregnancy among women in Nganglam, a town in southeastern Bhutan. It also gauged opinions of women and healthcare providers towards abortion.
Methods: A total of 683 women attending health clinics were consecutively interviewed using a semi-structured questionnaire. The core group for analysis was 490 women who indicated their recent pregnancy as planned or unplanned. Percentages, x2 tests, and multivariate logistic regression analyses were used to determine prevalence and differences in unintended pregnancy by demographic characteristics.
Results: The prevalence of unplanned pregnancy was 20.2%. Higher education, employed status of partner, higher parity, and non-use of contraceptives significantly increased the odds of unplanned pregnancy. Over half (58.4%) of the women said they knew someone to have crossed Indian borders to avail abortion services. Overall, 23% women supported legal abortion but majority (64%) were ambivalent. Given specific circumstances, both participants and health care providers supported some scenarios (life of mother, severe anomaly in fetus, rape and incest, maternal mental health) and opposed some circumstances as reasons for abortion (desired number of children met, contraception failure, not wanting to marry,poverty).
Conclusions: One in five women in our setting in Bhutan experienced unplanned pregnancy. Programs to romote family planning are required among populations most at risk for unplanned pregnancy. Awareness programs are required to encourage use of effective contraceptive methods among Bhutanese women.
Prevalence and socio-cultural determinants of domestic violence among married women in Thimphu, Bhutan
Authors: Wangmo Kencho 
Published: December 2020

Introduction: Domestic violence is a public health problem all over the world, yet its prevalence is under-reported in a pervasive “culture of silence”. Bhutan is not likely to be an exception; however, data on the prevalence, forms and determinants of domestic violence are scant. The purpose of this study is to measure the prevalence and characterize factors associated with domestic violence among women in Thimphu, Bhutan’s capital.
Methods: A population-based, household cross-sectional survey was conducted in January-May, 2012. A multistage sampling method was used to obtain a representative sample of 300 married women. The chi-square test was used to identify factors associated with increased likelihood of experiencing the four forms of domestic violence.
Results: The overall prevalence of any domestic violence was 44%. By type of violence, the most common was emotional (36%), followed by control (30%), physical (20%) and sexual (14%). Sexual violence was reported more often by young adolescent women. Women from urban areas reported more emotional violence compared to women from rural areas. Women agreed with many situations in which force might be used by their husbands and with many of the traditional roles of women in society. Nonetheless, many women objected to the use of force in many situations and rejected certain constraining roles of women.
Conclusions: This study supports the importance of advocacy for education and programs to prevent and mitigate harm from domestic abuse experienced by women in Bhutan.
Pediatric tele-echocardiography in the diagnosis of congenital heart diseases in a regional referral hospital in eastern Bhutan
Authors: Bhandari Purushotam , Morawakkorala Ruwan 
Published: December 2020

Introduction: Congenital Heart Diseases are the commonest birth defects and the most common reason for out-country referral of pediatric patients in Bhutan.Without any qualified pediatric cardiologists in the country, early diagnosis and appropriate care of pediatric cardiac patients is often delayed or inappropriate. Collaboration through telemedicine between general pediatrician and pediatric cardiologist can improve the diagnosis of congenital heart diseases in Bhutan.
Methods: Pediatric patients clinically suspected to have congenital heart diseases underwent Echocardiography at Mongar regional referral hospital. The Echocardiograms, performed by general pediatrician, were e-mailed to Pediatric Cardiologist working in UK, who gave the diagnosis after viewing the Echo-loops. This was compared with the final diagnosis made at tertiary cardiac centre in India.
Results: 30 echocardiograms performed by general pediatrician at Mongar Hospital in eastern Bhutan were mailed to Pediatric Cardiologist working in UK. Of the thirty cases, 20 required no immediate referral and were put on medications and follow up plans. 10 of the 30 cases requiredearly referral to tertiary care hospital in India. There was excellent concordance between the diagnosis made through tele-echocardiology and the final diagnosis made at tertiary cardiac centre.
Conclusions: Tele-echocardiography between a general Pediatrician and a Pediatric Cardiologist can greatly enhance the diagnosis of congenital heart diseases in children.
Incidence of congenital heart diseases in children born at Eastern Regional Referral Hospital, Monggar
Authors: Bhandari Purushotam , Wangmo Kezang 
Published: December 2020

Introduction: Congenital heart diseases are the commonest birth defects worldwide. While the true incidence of congenital heart diseases is known in many countries, it has not been studied in Bhutan.
Methods: Neonates born at the Eastern Regional Referral Hospital, Monggar in the year 2010 were screened for congenital heart diseases at birth by echocardiography and clinical examination including pulse oximetry.
Results: The majority of the study subjects were natives of eastern districts of Bhutan. The incidence of congenital heart diseases was found to be 68 per 1000 live births, with Atrial Septal Defect being the commonest lesion.
Conclusions: The overall incidence of congenital heart disease is higher than what is reported in other countries although the incidence of serious lesions was similar to what is reported elsewhere.
Incidence and pattern of leukemia in Bhutanese population: a retrospective analysis of eight years (January 2008 to December 2015)
Authors: Dorji Kuenzang , Sharma Krishna Prasad , Jamtsho Rinzin , Samal Puja Devi , Wangchuk Dorji , Rai Pratap 
Published: December 2020

Introduction: The burden of haematological malignancies in developing countries is on the rise. This burden may be further aggravated in Bhutan due to the aging population and rapid modernization of the nation. Despite this, there is a paucity of information about the incidence and pattern of leukemia in the Bhutanese population. In this retrospective study, we aim to investigate the incidence and pattern of leukemia in Bhutan using a database of leukemia diagnosed at Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan from January 2008 to December 2015.
Methods: The diagnoses and classification of leukemias were based on the morphology of blood cells on peripheral blood and bone marrow smears. The data was analyzed with descriptive statistics. The age-standardized incidence rate per 100,000 populations and its 95% confidence interval was calculated to assess the statistical significance.
Results: In total 118 patients were diagnosed with leukemia over the period of eight years. Leukemia was found to be more frequent in male (51.69%) compared to female (48.30%) with a male to female ratio of 1.1:1. Acute leukemia accounted for 66.95% of all leukemia case diagnosed, whereas chronic leukemia accounted for only 33.05% of the cases. The average, annual, age-standardized incidence rate of leukemia per 100,000 population was 2.30 (95% CI: 1.87-2.73).
Conclusions: The incidence and pattern of leukemia in the Bhutanese population is similar to other published literature. Leukemia is not uncommon in the Bhutanese population, thus additional studies on risk factors for leukemia in the Bhutanese population is necessary.
Serotypes and antibiotic susceptibility of Streptococcus pneumoniae in the Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan: a preliminary finding
Authors: Tshokey Tshokey , Yangzom Deki , Sharma Ragunath , Tshering Nima 
Published: December 2020

Introduction: Streptococcus pneumoniae cause life-threatening infections, mostly affecting children under five years in developing countries. Several countries in South Asia have incorporated a pneumococcal vaccine in their immunization schedule. Bhutan is currently considering the introduction of a vaccine, although no studies in the country to date have characterized the serotypes of S.pneumoniae to gauge the potential vaccine coverage. We, therefore, characterized pneumococcal serotypes isolated from patients in the Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), Thimphu.
Methods: Four hospitals attempted to study S.pneumoniae from various clinical specimens from January 2014 to December 2015, although only the JDWNRH was able to isolate pneumococci. Isolates were tested for antibiotic susceptibility and serotyped at a reference laboratory in India.
Results: Thirtyseven isolates were preliminarily identified as S. pneumoniae at the JDWNRH. At the reference laboratory, two isolates could not be revived and 14 were identified as non-pneumococcal streptococci. From the remaining 21 isolates, 15 different serotypes were identified. The Bhutanese serotypes were more comparable to those of India than Bangladesh or Nepal. Current vaccines would cover 26.7% (Prevnar, 7-valent), 40.0% (Synflorix, 10-valent), and 53.3% (Prevnar, 13-valent and Pneumovax23, 23-valent) of these serotypes. All isolates were sensitive to penicillin, chloramphenicol, and ceftriaxone; 9.5% were resistant to erythromycin and 38.1% to cotrimoxazole.
Conclusions: For the first time, we characterized serotypes of S. pneumoniae in Bhutan. However, the findings need to be interpreted cautiously due to small numbers of isolates from one referral hospital. A larger study is needed to validate the findings and guide selection of an appropriate vaccine.
Anemia and risk factors among children 6 months to 59 months old: a hospital-based prospective study
Authors: Chhetri Kalpana , Mynak Mimi L. , Pedon Kuenley 
Published: December 2020

Background: Anemia is a major public health problem and the most common nutritional issue in many parts of the world, especially in developing countries. The objective of the study was to determine the prevalence of anemia and factors associated with anemia among children 6 to 59 months old admitted in Pediatric ward of National Referral Hospital, Thimphu.
Methods: A hospital-based descriptive cross-sectional study. All children 6 months to 59 months old admitted in Pediatric ward of National Referral Hospital, Thimphu were included in the study. A total of 353 children were included in the study. Data was analyzed using STATA 12.
Results: The prevalence of anemia was 58.4%. Mild, moderate and severe anemia was 65%, 22.8% and 12.2% respectively. Anemia was more common in children less than 2 years old. The majority of the children had microcytic hypochromic anemia with low serum iron. The risk factors associated with moderate to severe anemia were malnutrition [p-value 0.001, OR 32.1, 95% CI (9.10-118.8)], low education level of caregiver [p value 0.0019, OR 5.10, 95% CI (1.66-15.68), monthly family income less than 5000/month [p-value 0.0004, OR 4.6 , 95% CI (1.89-11.54)] and chronic illness [p value 0.030, OR 2.43, 95% CI (1.08-5.47)].
Conclusion: This study found a high prevalence of anemia in under-5 children, with iron deficiency accounting for the majority of the cases. Children under 2 years were affected more.
Breastfeeding problems: an analysis of secondary data from Lactation Management Unit at the national referral hospital in Bhutan from 2014 to 2016
Authors: Zangmo Kencho , Wangmo Diki , Tobgay Tashi , Gurung Mongal S. 
Published: December 2020

Introduction: Breastfeeding is one of the most natural and best forms of preventive medicine for the newborns. Lack of optimal breastfeeding contributes to about over million preventable child deaths every year. Despite numerous benefits of breastfeeding and continuous efforts to improve breastfeeding practices, breastfeeding rates are far from optimal. Problems faced by lactating mothers while breastfeeding are main reason leading to non-exclusive breastfeeding or early termination of breastfeeding. This descriptive study is aimed at examining breastfeeding problems among women visiting Lactation Management Unit [LMU] at Bhutan’s national referral hospital in Thimphu.
Methods: Data of all 2751 women-infant pair visiting Lactation management unit of Jigme Dorji Wangchuck National Referral Hospital with breastfeeding problems were double entered into Epi Data (version 3.1). Using STATA, descriptive statistical analyses were carried to examine common breastfeeding problems among the lactating mothers. Exclusive breastfeeding rates were also examined among the group.
Results: The commonest types of breastfeeding problem were nipple sore (60.8%), incorrect breastfeeding techniques (12.9%), and nipple problems (8.2%). Teenage, first timers, caesarean delivery, preterm infants, underweight infants, and mothers with full time paid job were more likely to suffer from breastfeeding problems.
Conclusion: Breastfeeding interventions for timely correction of breastfeeding techniques early in postnatal units could warrant prevention of up to 73.7% breastfeeding problems and thus, promoting exclusive breastfeeding and preventing early termination of breastfeeding.
Positioning Nurses in Primary Health Care in Bhutan
Authors: Wangmo Diki , Windosr Carol , Clark Michele 
Published: December 2020

Introduction: Nursing in Bhutan had its beginning in the early 1960s, approximately 20 years prior to the Alma Ata Conference. From basic nursing care and housekeeping roles, Bhutanese nurses have now occupied central place in nursing service, administration and management and education. Nursing education has progressed from certificate level in the 1960s to bachelor, master and PhD levels in 2014. Although nurses have been closely associated with Primary Health Care development in Bhutan, apart from the role of the Auxiliary Nurse Midwives, nurses have rarely been explicitly associated with this area of practice. Therefore, the objective of this study was to find out the role of Bhutanese Nurses in PHC.
Methods: qualitative case study method was used to carry out focus group and in-depth interviews with 66 respondents that included policy makers, planners, educators, regulators and implementers. Data were analyzed through manifest and latent content analysis.
Results: The centrality of the nursing role in the area of PHC has not been realized. Discharge of the PHC role was identified more in terms of the place of work and by title or designation of the nurses. Primary Health Care momentum appeared to have slowed down and nurses differed in their understanding of PHC concept.
Conclusion: Although Nursing in Bhutan has made much progress, the uneven development of the nurses’ role in PHC in Bhutan and globally suggests a need to identify and implement strategies such as standardizing, role profiling, curricula review and leadership improvement to ensure progress in this area.
Relying on Widal test alone could lead to over diagnosis of typhoid fever: Findings from a records review of febrile patients at Damphu Hospital, Bhutan, 2011-2012
Authors: Nepal Tej Nath , Dorji Tshering , Tsheten Tsheten , Tenzin Karma , Pelzom Dorji , Gurung Mongal S. , Rinchen Namgay , Wangchuk Sonam 
Published: December 2020

Introduction: The Widal test is widely used in hospitals in Bhutan for diagnosis of typhoid fever. The right test with high sensitivity and specificity supplements clinical judgement and contributes to correct diagnosis of disease. This study focuses on the contribution of the Widal test in the diagnosis of typhoid fever.
Methods: Data was collected from records of patients who presented to Damphu hospital from March 2011 to June 2012 with clinical suspicion of typhoid fever. Blood samples were collected from patients and tested at Damphu Hospital, Tsirang and the Royal Centre for Disease Control, Thimphu. Seventy records were used for the study.
Results: There was no growth of Salmonella typhi on blood cultures from patients who had tested positive in the Widal test. There were 20 (28.57%) samples which tested positive for scrub typhus; among these Widal test was positive in 10 (50%) samples. Thirty four out of 36 (94.44%) patients had duration of illness less than seven days and among them 26 (74.47%) had positive Widal test results.
Conclusion: None of the samples that tested positive by Widal test gave a definite diagnosis of typhoid fever with blood culture. Clinical judgement may be more challenging because patients with other febrile illnesses like Scrub typhus also have positive Widal test result. We conclude that it is best not to rely on the Widal test alone for the diagnosis of typhoid fever and this test should be replaced by more accurate ones.
To study the effect of Triamcinolone injection for low back pain due to lumbar disc herniation
Authors: Wangchuk Tashi , Wangmo Kunzang P. , Norbu Thinley 
Published: December 2020

Introduction: Low back pain is one of the most common complaints in the general population which represents a significant public health problem. Epidural Steroid Injection is being considered as a simple, effective and minimally invasive treatment modality for lumbar disc herniation. However, most studies only find a short-term benefit. In Bhutan, till date, no study has been done in Bhutan on this subject. The objective of our study was to find the effect of epidural steroid injection for low back pain due to lumbar disc herniation.
Methods: An observational one-year-period study completed in Jigme Dorji Wangchuck National Referral Hospital. Symptomatic and positive Magnetic Resonance Imaging patients with lumbar disc herniation were included in our study. Pain scores were collected using Numeric Rating Scale at three different points of study. We also included patients’ age, weight and trauma history as some of the independent variables to study their associations with pain scores. The data obtained were analyzed using the Stata software program. One way repeated measures ANOVA was used to assess the significant difference in pain score.
Results: Out of 100 participants recruited for the study, 91 of them completed demographic data and only 81 patients completed follow-up till 4 weeks post-treatment for demographic analysis and analytical analysis, respectively. There was a significant difference in pain scores in all three different points of study (p <0.01). No significant difference was observed in the pain scores amongst different age groups, gender, occupation and trauma history (p >0.05) at all three points of study.
Conclusion: Our study observed a significant short-term benefit from epidural Triamcinolone injection for symptomatic lumbar disc herniation.
Community action to reduce harmful use of alcohol: a pilot study in the remote villages of eastern Bhutan
Authors: Subba Dil K. , Gurung Mongal S. , Wangmo Diki , Dorji Mindu , Tobgay Tashi 
Published: December 2020

Introduction: 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.
Methods: 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.
Results: 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.
Conclusion: 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..
Incidence and clinicopathological profile of gestational trophoblastic disease in tertiary care centre
Authors: Tamang Tshering , Tshomo Ugyen 
Published: December 2020

Introduction: 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.
Method: A prospective and retrospective observational study was conducted over a period of 18 months.
Results: 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(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 (> 100,000 mIU/ml) and larger uterine size (> 14 weeks).
Conclusions: 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.
Methodology and criteria for setting national health research priorities in Bhutan: a workshop report
Authors: Humphries Debbie L. , Ingber Hannah , Gurung Mongal Singh , Khoshnood Kaveh 
Published: December 2020

The Bhutanese health system is committed to providing health services for all citizens and is interested in strengthening the country’s health research capacity. The objectives of this workshop were to understand the range of health research activities in Bhutan; to formulate a prioritized research agenda for the Ministry of Health (MoH); to share challenges, gaps and opportunities in health research; and to provide insights for future prioritization exercises. The MoH partnered with Khesar Gyalpo University of Medical University of Bhutan and USA-based facilitators to develop and pilot a methodology for health research priority setting. The Bhutan priority setting process was adapted from the Combined Approach Matrix and the Essential National Health Research methods. The methodology proved successful in the systematic creation of a list of health research priorities. Future priority setting processes will build on this workshop, continuing to refine and strengthen the priority setting process in Bhutan.