J-AMSA Vol. 6, AMSC 2016 Issue

ISSN: 2226-3403 Vol. 6, AMSC 2016 Issue September 2017 Research Paper Competition Research Poster Competition Photography Competition

Published by Asian Medical Students’ Association International Journal of Asian Medical Students’ Association National Yang Ming University No. 155, Sec. 2, Linong Street, Taipei, 112 Taiwan (ROC) j-amsa@amsa-international.org

John Kenneth V. Gacula (PH) EDITOR-IN-CHIEF Rabia Noureen (PK) Rio May Llanes (PH) ASSOCIATE EDITORS Lavisha S. Punjabi (SG) MANAGING EDITOR Chiraphat Boonnag (TH) Davin Caturputra Setiamanah (ID) Fadhian Akbar (ID) Fatima Khawar (PK) Hilda Nadhila Hasbi (ID) Luqman Munawar Khan (PK) Muhammad Junaid Khan (PK) Nadya Johanna (ID) Novita Oktaviana (ID) Nur Syifa Fikri (ID) Sehrish Nadeem (PK) Tanat Yongpisarn (TH) Tonmoy Biswas (BD) EDITORS Akhil Deepak Vatvani (ID) Aninditya Verinda Putrinadia (ID) Chandrika Dasgupta (BD) Edwin Setyawan (ID) Fenska Seipalla (ID) Ismi Masyithah (ID) Josevaldo Bagus Pratomo (ID) Keisha Deandra Christie (ID) Maria Nouren (PK) Muhammad Umar (PK) Prio Wibisono (ID) Raksheeth Agarwal (ID) Steven Philip (ID) Valensa Yosephi (ID) STUDENT REVIEWERS Fatiha Nasreen (BD) Yudisitra Wardana (ID) CHAPTER REPRESENTATIVES

RESEARCH PAPER COMPETITION Preliminary Findings on the Association between Migrant Status and Mental Well-Being and Depressive Symptoms in Hong Kong Ethnic Differences in Enforced Compulsory Admissions for Psychiatric Disorders in the UK: A Meta-Analysis The role of social determinants of health in alcohol consumption and diabetes mellitus among Mongolian population Systematic Review: Effectiveness of interventions for shift-workers in improving outcomes of low mood and depression Evaluation of market-based interventions to reduce the prevalence of avian influenza viruses: a systematic review Social Determinants Affecting Menstrual Hygiene Relation between Usage of Indonesia’s National Health Insurance (Badan Penyelenggara Jaminan Nasional for Health) and Patient-Reported Treatment Outcome in Breast Cancer Patients who Undergo Mastectomy Community initiatives in preventive medicine - Saku, Japan Do Universiti Sains Malaysia Medical Students Burn Out? The Impact of Housing on the Health and Wellbeing of Older Chinese Migrants in New Zealand Factors Affecting the Acquisition of Health Insurance Acquirement among Migrant Factory Workers: Pilot study

Preliminary Findings on the Association between Migrant Status and Mental Well-Being and Depressive Symptoms in Hong Kong

Jacqueline Chak Lam Fung, Xue William, Pias Hoi Kiu Tang, Gabriel Chun Hei Wong, Agnes Pei Xi Yip, Andrew Man Kwun Li, Dong Mei Li Keywords: migration, mental well-being, Chinese Background of the Study In 2015, 244 million people, or 3.3 per cent of the world's population, lived outside their country of origin (UNFPA, 2016). In Asia, particularly, there has been a rapid increase in migration in the last two decades (Chen, 2011; Lu 2008; Yeoh, Huang & Lam, 2005). Past studies have shown that cultural, language, legal and economic barriers limit migrants’ access to healthcare services, and therefore hinder their health (Murray & Skull, 2005). Thus, migrants are a potentially vulnerable population. In addition, the substantial life changes and stress associated with migration makes the mental health well-being of migrants a particular concern. Hong Kong has traditionally been a major centre for immigration, with up to 40% of the local population foreign born (Census and Statistics Dept., 2012). Among them are a large number of 'new immigrants' from Southern China, who have lived in Hong Kong for less than 7 years (Census and Statistics Dept., 2012).

With internal migration within countries on the rise (UNFPA, 2016), Hong Kong’s unique blend in population composition makes it the ideal setting to study potential health determinants related to immigrant status. Current literature focuses mainly on the effect of international migration between different ethnicities and cultures in a Western context.

Hence, the measured outcomes include both the effect of migration and of cultural assimilation (Vanasse et al., 2015; Lu & Qin, 2014). Also, past studies on immigrants’ mental health usually base their discussion on health records, rather than selfperceived mental health. However, studies have shown that usage of the healthcare system is significantly lower in migrant communities, suggesting that studies utilising only health records do not fully reflect the true health status of immigrant communities (Gimeno-Feliu et al., 2013).

Therefore, our study uniquely focuses on internal migration within a Chinese population. Cultural assimilation is mitigated due to shared cultural similarities, so that the relationship between migration and mental well-being can be better understood. With Hong Kong’s recent history of socioeconomic development, the findings of this study are of great relevance to not only the local context, but also global urban populations currently experiencing similarly rapid economic development (Leung et al., 2015).

To address these issues, our study sought to assess the association between migration and the mental well-being of Mainland Chinese migrants in the context of Hong Kong.

Methods Study Population The sample was drawn from the FAMILY Cohort, a prospective population-based cohort study described in detail elsewhere (Leung et al., 2015). From 2009 to 2014, the FAMILY Cohort conducted in-house interviews of 2891 households consisting of 7645 individuals who reside in New Towns (Tung Chung, Tin Shui Wai and Tseung Kwan O). These towns are in relatively remote locations and have higher concentrations of mainland Chinese immigrants. Data collection consisted of two waves on the same individuals: Wave 1 data was collected from March 2009 to April 2011, and Wave 2 data was collected from August 2011 to March 2014. Immigrant status was categorized into immigrants residing for less than 7 years, immigrants residing for 7 years or more, and natives. Age, gender, education level, and marital status were assessed during Wave 1 as potential confounders. Mental well-being and depressive symptoms were assessed using the Short Form 12 Mental Component Summary (SF-12 MCS) and Patient Health Questionnaire (PHQ-9), respectively, during Wave 2.

Statistical Analysis One-way ANOVA was used to examine associations between immigrant status and SF-12 MCS and PHQ-9. Multiple linear regression was used to assess the adjusted association of immigrant status and mental health outcomes. We handled missing data using complete case analysis. All analyses were performed using IBM SPSS Statistics Version 23.

Results Study Sample 5408 individuals from the three new towns successfully completed the Wave 1 and Wave 2 phases. Amongst this group, 4265 individuals were evaluated for their mental well-being using the SF-12 MCS and PHQ-9. 4221 of these individuals provided data on their age, gender, education level, and marital status. They consisted of 160 immigrants residing for less than 7 years, 1898 immigrants residing for more than 7 years, and 2163 natives. Analyses were ASIAN MEDICAL STUDENT CONFERENCE 2016 | MANILA, PHILIPPINES

immigrants residing for less than 7 years and natives. Immigrants residing for more than 7 years were omitted because they would have obtained Hong Kong permanent resident status. Gaining permanent resident status would place such immigrants in a social and healthcare context more similar to that of natives.

Mental Well-Being One-way ANOVA comparing SF-12 MCS between immigrants residing for less than 7 years (M = 52.22, SD = 7.61) and natives (M = 52.72, SD = 7.54) was found to be not significant (F(1, 2177) = 0.662, p = 0.416). A multiple linear regression was adapted to assess the association between immigrant status and mental well-being, adjusting for age, gender, marital status, and education level on SF-12 MCS. Immigrant status (Beta = -0.006, p = 0.795) was not directly associated with the mental well-being of individuals in our sample.

Depressive Symptoms One-way ANOVA comparing PHQ-9 scores between immigrants residing for less than 7 years (M = 1.13, SD = 0.33) and natives (M = 1.41, SD = 0.28) was not significant (F(1, 2177) = 2.576, p = 0.109).

A multiple linear regression was adapted to assess the association between immigrant status and depressive symptoms, adjusting for age, gender, marital status, and education level on PHQ-9 scores. Immigrant status (Beta = -0.036, p = 0.088) was not directly associated with depressive symptoms.

Discussion We found that immigrant status was not associated with mental well-being and depressive symptoms in our sample.

The comparable mental well-being status of immigrants and natives might be explained by the healthy migrant and salmon bias hypothesis (Lu et al., 2014). The healthy migrant effect states that those who migrate usually have better health in the first place, while the salmon bias hypothesis suggests that after migrating to Hong Kong, individuals with better health are more likely to stay while those with poorer health tend to return home. Immigrants are exposed to considerably higher stressors than natives, such as potential social exclusion and insufficient medical support due to mild but valid cultural differences (Modesti et al., 2014). Since migration will not necessarily lead immigrants with poorer health to a better living environment, such individuals may tend to return to their hometown, leaving only healthier immigrants in Hong Kong (Lu et al., 2014). This postulated phenomenon may explain our preliminary finding that the mental well-being of new immigrants was similar to that of natives.

Recommendations and Role of Medical Students Despite our findings suggesting similar levels of mental well-being amongst immigrants and natives, it is difficult to corroborate its validity. Further studies must be performed to validate these findings. With this in mind, it is important to take into account the fact that previous studies have shown migrants in general to be less inclined in making use of healthcare services (Sandhu et al., 2012; Gimeno-Feliu et al, 2013). Thus, the government should consider reducing potential barriers to utilisation of health services among new immigrants.

We, as medical students, also have a role to play. Social determinants of health are often overlooked in the eyes of the general public and healthcare professionals. Therefore as budding facilitators of health in society, medical students should play a role in reminding the public the intimate correlation between social factors and individual health through educational and mass media campaigns. Medical students can play the important role of advocates by aiding and encouraging immigrants to seek health services, particularly preventive health services. This can be conducted by organizing health education, community-inclusion programs, and immigrant focus groups. Additionally, to improve understanding of immigrant health, medical students can conduct qualitative questionnaires and interviews on behalf of research initiatives.

Limitations and Future Directions Several factors limit our results. First, a more careful identification of appropriate confounders using a causal inference approach (e.g. Directed Acyclic Graphs) must be performed. Several demographic factors, such as income or occupation were omitted from regression analysis due to their role as potential mediators rather than confounders, which would have blocked the association between immigrant status and mental health. Second, this study is susceptible to selection and response bias, resulting in selection of better-functioning immigrants in our analytic sample. This may explain the lack of significant association found between immigrant status and mental well-being. As such, findings presented in this paper can only be deemed preliminary and require further analyses before full interpretation of results.

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Conclusion This Hong Kong-specific study provided preliminary findings into the association of immigrant status and mental health in an ethnically homogenous population.

The role of key mitigating factors, including resilience and cultural characteristics, on this relationship should also be further explored. Regardless, it is important to emphasize that medical students can facilitate deeper understanding of immigrant mental health by serving as immigrant advocates and research aids through organising education and communityinclusion initiatives.

References Chen, J. (2011). Internal migration and health: Re-examining the healthy migrant phenomenon in China. Social Science & Medicine, 72(8), 1294-1301.

Gimeno-Feliu, L. A., Magallón-Botaya, R., Macipe-Costa, R. M., Luzón-Oliver, L., Cañada-Millan, J. L., & Lasheras-Barrio, M. (2013). Differences in the Use of Primary Care Services Between Spanish National and Immigrant Patients. Journal of Immigrant and Minority Health, 15(3), 584–590. http://doi.org/10.1007/s10903-012-9647-x Hong Kong (China), Census and Statistics Department. (2012). 2011 Population Census Summary Results. Hong Kong: Census and Statistics Dept. Retrieved May 25, 2016, from http://www.census2011.gov.hk/pdf/summary-results.pdf Kirmayer, L. J., Narasiah, L., Munoz, M., Rashid, M., Ryder, A. G., Guzder, J., Hassan, G., Rousseau C., & Pottie, K. (2011).

Common mental health problems in immigrants and refugees: general approach in primary care. Canadian Medical Association Journal, 183(12), E959-E967.

Leung, G. M., Ni, M. Y., Wong, P. T., Lee, P. H., Chan, B. H., Stewart, S. M., Schooling, C. M., Johnston, J. M., Lam, W. W. T., Chan, S. S. C., McDowell, I., & Lam, T. H. (2015). Cohort Profile: FAMILY Cohort. International journal of epidemiology, dyu257.

Lu, Y., & Qin, L. (2014). Healthy migrant and salmon bias hypotheses: A study of health and internal migration in china.

Social Science & Medicine, 102, 41-48.

Lu, Y. (2008). Test of the ‘healthy migrant hypothesis’: a longitudinal analysis of health selectivity of internal migration in Indonesia. Social science & Medicine, 67(8), 1331-1339.

Modesti, P. A., Bianchi, S., Borghi, C., Cameli, M., Capasso, G., Ceriello, A., ... & Novo, S. (2014). Cardiovascular health in migrants: current status and issues for prevention. A collaborative multidisciplinary task force report.

Journal of Cardiovascular Medicine, 15(9), 683-692. Murray, S. B., & Skull, S. A. (2005). Hurdles to health: immigrant and refugee health care in Australia. Australian Health Review, 29(1), 25-29.

Sandhu, S., Bjerre, N., Dauvrin, M., Dias, S., Gaddini, A., Greacen, T., Ioannidis, E., Kluge, U., Jensen, N. K., Lamkaddem, M., Puigpinos i Riera, R., Kosa, Z., Wihlman, U., Stankunas, M., Strassmayr, C., Wahlbeck, K., Welbel, M., & Priebe, S. (2012). Experiences with treating immigrants: a qualitative study in mental health services across 16 European countries. Social Psychiatry And Psychiatric Epidemiology, 48(1), 105-116. http://dx.doi.org/10.1007/s00127-012-0528-3 UNFPA - United Nations Population Fund. (2016). Migration. Retrieved May 25, 2016, from http://www.unfpa.org/ migration Vanasse, A., Courteau, J., Orzanco, M. G., Bergeron, P., Cohen, A. A., & Niyonsenga, T. (2015). Neighbourhood immigration, health care utilization and outcomes in patients with diabetes living in the Montreal metropolitan area (Canada): a population health perspective. BMC health services research, 15(1), 1.

Yeoh B. S. A., Huang S., & Lam T. (2005). Transnationalising the ‘Asian’ Family: Imaginaries, Intimacies and Strategic Intents. Global Networks, 5(4):307–315. doi: 10.1111/j.1471-0374.2005.00121.x.

Yu, X., Tam, W. W., Wong, P. T., Lam, T. H., & Stewart, S. M. (2012). The Patient Health Questionnaire-9 for measuring depressive symptoms among the general population in Hong Kong. Comprehensive psychiatry, 53(1), 95-102.

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Ethnic Differences in Enforced Compulsory Admissions for Psychiatric Disorders in the UK: A Meta-Analysis Cai WY, Chan P, Cheng A, Fujitake E, Li YM, Koo JM, Mollier J, Rahman A, Teh J

Key words: ethnicity; psychiatric; compulsory admission; prejudice; stigma; detainment Introduction Compulsory admission is the mandated admission of a patient in the UK to hospital after a formal mental health assessment under the UK's Mental Health Act 1983 (Salize, Dreßing, & Peitz, 2002). It is postulated that particular minorities experience more difficulty in being conventionally admitted for mental conditions, therefore present later with more severe symptoms necessitating compulsory admission.

This study delivers insight to the underlying biological and social determinants within the field of mental health, and assist in building pathways to improve equal treatment of ethnicities in the UK. This meta-analysis aims to determine the relationship between compulsory admissions and ethnicity based on 32 studies in the United Kingdom. Meta-analysis shows that Asian patients are 0.95 times as likely as White patients to be compulsorily admitted, whereas Black patients are 2.04 times more likely than White patients to be compulsorily admitted.

Methodology Literature search Search strategies focused on specific questions: is there variation between ethnic groups in (a) compulsory hospital admission and detention; (b) patterns of psychiatric service use; and (c) source of referral and help-seeking.

The search was confined to studies published in 1983 to 2016. Pubmed was used as the primary bibliographic database and Medical Subject Headings (MeSH) terms were combined and the grouped search terms included: (a) GREAT BRITAIN, HOSPITALISATION, ETHNIC GROUPS; (b) MENTAL HEALTH, ETHNIC GROUPS, GREAT BRITAIN; (c) COMMITMENT OF MENTALLY ILL, GREAT BRITAIN, ETHNIC GROUPS; (d) GREAT BRITAIN, HOSPITALISATION, ETHNIC GROUPS, PSYCHIATRY; (e) GREAT BRITAIN, INDIGENOUS GROUPS, HOSPITALISATION; (f) COMMITMENT OF MENTALLY ILL, (ETHNICITY or ETHNIC GROUPS or MINORITIES), (GREAT BRITAIN or UNITED KINGDOM).

Our exclusion criteria were: non-related topic, no access, non-primary data, insufficient data, non-UK study, and no comparison group. The flowchart (Figure 1) demonstrates the selection of searched papers.

Quality ratings We assessed the quality of published studies using the criteria adapted from an older study that evaluated ethnic variation in pathways to specialist care (Bhui et al., 2003) (Table 1). The criteria focused on three domains: sample source and size; adjustment for confounding variables; and quality of method of ethnic group classification.

The quality scores were divided into low (0–3), medium (4-7) and high (8–11). Each published study was RESEARCH PAPER COMPETITION

independently evaluated by two reviewers in order to improve the reliability of inclusion and data-extraction. Where differences existed, consensus was achieved by means of discussion.

Data analysis Meta-analysis and figures were generated using Review Manager 5.3 to pool odds ratio for compulsory admission.

When heterogeneity (I2) was greater than 0.5, the random-effects model was used. When heterogeneity (I2) was less than 0.5, the fixed effects model was used.

Results and Analysis Primary studies Preliminary search terms returned 294 hits, of which 215 were unique articles. 32 studies were objectively included with inclusion and exclusion criteria. Studies were rated on size of the sample (3 maximum), adjustment for confounding factors (5 maximum) and appropriate classification of ethnic groups (3 maximum). Studies were categorized into high-rated (8-11), medium rated (4-7) and low rated (0-3).

Compulsory admissions From the 32 included studies, 15 studies (5 high-rated, 9 medium-rated and 1 low- rated) found that black patients are more likely to be compulsorily admitted. Some studies discussed how blacks are often perceived as more violent by staff and police. Our meta-analysis of 7 studies (Figure 3) suggest black patients are 2.04 more likely to be compulsorily admitted than White patients.

Most studies suggest Asian patients are less likely admitted compared to White patients (2 high-rated, 2 moderatelyrated), while 1 moderately-rated study found that Asian patients are more likely to be compulsorily admitted. Our metaanalysis of 3 studies (Figure 4) suggest Asian patients are 0.95 times as likely as White patients to be compulsorily admitted.

One primary study found that minorities (Asian and Black patients) experience more difficult paths to conventional admissions for psychiatric conditions. The study linked that it could potentially deter patients from seeking help earlier which result in unattended mental disorders.

Our meta-analysis of studies that compared compulsory admissions of non-White patients compared to White patients presented a large pooled odds-ratio suggesting non-White patients are over 3 times as likely as White patients to be compulsorily admitted (Figure 2). This could be due to the heavily weighted study by Coid.

Do the different detentions reflect prevalence of mental disorders?

When comparing regular GP admissions and prescription data, results varied whether psychotic conditions are more or less prevalent amongst minority groups in the UK. 3 high-rated and 1 medium-rated study concluded that psychotic-based admissions or prescriptions were not different to the White population. However, 4 low-rated and 2 medium-rated studies found that psychotic conditions were more frequent among the black population.

Similarly, there was no consensus for the Asian minority in the UK. Among the medium- rated studies, 1 found Asians experienced psychotic conditions less, 1 found that prevalence among Asians and Whites were non-significant and 3 found prevalence to be higher amongst Asians.

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prevalence to be higher amongst Asians.

Discussion The inequality in compulsory admissions rates in different ethnicities could be attributed to a variety of reasons.

Stigma Social stigma against those with mental health, present within ethnic groups, may affect the number of compulsory admissions observed. Anglin et al suggested that this can be the case for the ‘Self-Identified-African’ group, which has a higher odds-ratio than other ethnic groups for compulsory admissions. This can be attributed to the belief, within the AfricanCaribbean group, that those with mental health disorders are dangerous (Anglin, Link, & Phelan, 2006). Such perception within the ethnic group can lead to people with mental health problems in the African-American group (e.g. psychosis) restraining him/herself from voluntarily seeking help, in order to avoid labelling, prejudice and segregation from their own ethnic/social groups (Corrigan, Edwards, & Green, 2001; Corrigan, Green, & Lundin, 2001). Reduced help seeking may worsen an individual’s mental disorders, and increase the likelihood of an event triggering compulsory admission (e.g. violence) (Morgan et al., 2005a) However, results show that the ‘Asian’ group has a lower odds-ratio than other minorities for mental illnesses, despite evidence that members of this ethnic group perceive individuals with mental health disorders to be ‘dangerous (Whaley, 1997). This suggests that stigma does not have a consistent effect on different ethnic groups’ rates of compulsory admissions, suggesting other sociological factors in play.

Ethnic disposition to compulsory admissions-related conditions Inherent differences in prevalence between ethnicities could influence varying rates of compulsory admissions observed between ethnicities. Members of the African- Caribbean group in the UK were consistently reported in studies carried out in the past decades to have higher rates of schizophrenia than White Caucasian members (Bebbington, Hurry, & Tennant, 1981; Cochrane & Bal, 1989; McGovern & Cope, 1987), which are consistent with our findings. The root cause of this increased prevalence of schizophrenia is non-definite. Studies on rates of schizophrenia in first generation and second generation African-Caribbean people have shown that there is little variation between parents and siblings of first generation African-Caribbean people and White Caucasian people in the UK, whilst there is a greater morbid risk for schizophrenia in second generation African-Caribbean, suggesting environmental factors act on second generation African-Caribbeans (Hutchinson, Takei, Fahy, & Bhugra, 1996). The higher rates of schizophrenia can be attributed to social factors - that more African-Caribbean children experience such as living in a one-parent family and being in foster care or children’s homes, which are associated with increased risk of developing a psychiatric disorder later in life (Cox, 1977; Maughan, 1989). In addition to these social factors, there is evidence that proportionally more African-Caribbean experience factors in later life which lead to social exclusion, such as living alone, being imprisoned and unemployed (Bhugra, Leff, Mallett, & Der, 1997; Cox, 1977; Maughan, 1989), as well as experiencing racism, which can all contribute to poorer health (Tomas, 1998; Nazroo, 1998) and increased risk of developing schizophrenia.

Ethnicity as a boundary leading to unmet need Lack of easy access to mental health support can postpone patients in seeking help earlier. This can cause patients to present at a later stage or necessitate compulsory admissions. Ethnic minorities often live in less prosperous areas where mental health facilities may not be readily available (Wells, Klap, Koike, & Sherbourne, 2001).

Ethnic minorities may have subtly different presentations, which are missed by unprepared clinicians (Borowsky & Rubenstein, 2000). A study found that English proficiency to be a significant contributing factor to unmet healthcare needs especially in mental health which rely on verbal communication. This relationship was more significant between English speaking minorities and non-English speaking minorities (Sentell, Shumway, & Snowden, 2007). A detailed re-examination of the cracks in the mental health system and more culturally conscious training appears necessary to tackle the unmet needs among minorities.

Potential causes of error Limitations arising from Classification The statistical conclusions on racial disparities is influenced greatly by data collection methods. This study used the racial categories CAUCASIANS, BLACKS (African- Caribbean), and ASIANS to enable a statistical comparison of different ethnic groups, with unique biological and historical characteristics that distinguish each group. However, inclusion and exclusion to each category widely vary in different societies (and consequently different studies), hence masking heterogeneity within every group (Cohen, Bulatao, & Anderson, 2004). In addition, such categories evolve from social constructs which are inconsistent, and based largely on subjective classification based on geopolitical divides.

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Self-identification and its influence on data All studies in this meta-analysis rely on self-identification of ethnicity by the individual. While this approach is a conventional and safe approach in social demographic analyses, the presiding identification of ethnicity in genetic analyses stems from an individual’s ancestry informative markers (AIMs), which are based on genomic data. Mersha et al show that self-reporting African Americans can have drastically varying African and European ancestries. There is little proof that a similar deviation may not be prevalent in the UK. Hence, associations between data and genetic disposition are heavily limited (Mersha & Abebe, 2015).

Scope of Study Selection The studies used in this analysis were obtained from PubMed©, which includes the MEDLINE© database. This could contribute to fewer relevant studies. In the meta- analysis between Whites and non-Whites (Figure 2) only 4 studies were included. And only 3 studies were included in the meta-analysis between Asians and Whites (Figure 4). This can contribute to skewing of data and inaccurate results. More search terms and databases should be utilized to obtain more relevant studies.

Follow up studies could analyse additional databases (EMBASE (medical and pharmacologic database by Elsevier publishing), CINAHL (cumulative index to nursing and allied health literature), CANCERLIT (cancer literature research database), and the Cochrane Collaborative), allowing for a wider net of studies to reaffirm the conclusions derived from this analysis.

Variation in study sources It can be noted that all studies can be attributed to different research groups. While this suppressed the effects of potential selection bias across the datasets, it enhanced methodological heterogeneity. A point-scoring system was included in data processing to minimise data skews introduced by his heterogeneity.

Conclusion The meta-analysis determined that likelihood of compulsory admission is more likely in order of ethnicity: Black, White then Asian. Finally, studies suggest Asian and Black patients have more difficult paths to admission for psychiatric conditions.

In conjunction with supporting data and studies, these inequalities have been associated with stigma, ethnicity as a boundary to unmet need, and ethnic disposition to disorders. Further investigation is needed to establish the role of these contributing factors for these inequalities.

This study shows a clear presence of ethnic inequalities in unmet needs and compulsory admissions rates for psychiatric disorders. Our concerning findings advocate the necessity for (a) more culturally conscious training for clinicians to provide better care to minorities, (b) progress in reducing stigma of mental disorders in minorities and (c) increasing and facilitating access to healthcare in communities with less access.

References Ali, S., Dearman, S., & McWilliam, C. (2007). Are Asians at greater risk of compulsory psychiatric admission than Caucasians in the acute general adult setting? Medicine, Science and the Law, 47(4), 311–314.

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Bhui, K., Stanfield , S., Hull , S., Priebe , S., Mole , F., & Feder , G. (2003). Ethnic variations in pathways to and use of specialist mental health services in the UK. The British Journal of Psychiatry, 182(2), 105–116.

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Chang, S., Steeg, S., & Kapur, N. (2015). Self-harm amongst people of Chinese origin versus ASIAN MEDICAL STUDENT CONFERENCE 2016 | MANILA, PHILIPPINES

Chang, S., Steeg, S., & Kapur, N. (2015). Self-harm amongst people of Chinese origin versus White people living in England: a cohort study. BMC psychiatry, 15(1), 1.

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The role of social determinants of health in alcohol consumption and diabetes mellitus among Mongolian population Enkhjin G, Lkham-Erdene B, Tumenjargal T, Tamir L, Suvd B, Mandukhai G, Davaalkham D Background Since the beginning of human recorded history alcohol has played an important role in culinary, social and religious practices in every cultural tradition. Expanding industrialization of alcohol production and rapid globalization of its marketing however have unduly increased alcohol consumption and its related harms worldwide. Analysis of the 2010 Global Burden of Disease (GBD) study reported that from 1990 to 2010 alcohol climbed from 8th to 5th rank on the list of global risk factors1.

Relative to other countries using 2010 WHO data, Mongolia is right in the middle of the pack, just above the worldwide average of 6.2 liters of “pure alcohol” per person per year. But today’s alcoholism in Mongolia is reaching epidemic levels, driven by cheap liquor and wrenching social and economic change.

Social determinants of health components, such as gender, age, location of residence and socioeconomic gradients, exert varying impacts on alcohol consumption and related chronic conditions. Age shapes the impact of drinking patterns on chronic disease, with lifetime accumulative alcohol volume driving the likelihood of chronic diseases – accordingly, greater affect should occur with age.2 Lower socioeconomic populations experience greater impact of alcohol- attributable disease, with significantly higher alcohol-attributable hospitalizations3 and deaths4-6. In part, drinking patterns may explain this differential. Higher socioeconomic groups tend to drink more often, with the majority of occasions involving light to moderate consumption7.

While lower socioeconomic groups generally drink less often, such occasions are more likely to involve high volume drinking sessions8. This means, that for a set consumption volume, lower socioeconomic groups experience disproportionally higher levels of alcohol- related acute and chronic disease than that of higher socioeconomic groups.

Diabetes mellitus is a metabolic disorder of multiple etiologies characterized by chronic hyperglycemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action, or both9.

There were 96,000 cases of diabetes in Mongolia in 2015 according to the International Diabetics Federation (IDF) and it demonstrates that people aged over 60 in Mongolia have greater prevalence of diabetics in comparison with world average.

Alcohol is a risk factor for many cardiovascular diseases and cancers and has both beneficial and detrimental effects on diabetes and ischemic cardiovascular diseases, depending on the amount of alcohol consumed and the patterns of consumption10.

Moderate alcohol consumption protects against type 2 diabetes and cardiovascular disease. But Mongolian populations have polymorphisms of the alcohol metabolizing enzyme11. This means protective effect of alcohol consumption for diabetes could be altered in the Mongolian population. Thus it is essential to identify the role of social determinants in alcohol consumption and the relationship with diabetes among the Mongolian population.

Methods

Study population and sampling procedure This study was conducted in two stages. In the first stage a cross-sectional baseline study was designed using multistage random sampling method for 2,280 people over the age of 40 in Ulaanbaatar, Central, Western, Eastern and Khangai regions from March 2009 to August 2009. It was carried out to determine alcohol consumption. The second stage utilized a prospective cohort study design that will follow-up with participants at 5, 10, and 20 year intervals, to determine the incidence of diabetes mellitus morbidity or mortality and associated social determinants of health and alcohol consumption.

Data collection Prior to conducting the study, informed consent was obtained from all participants. All blood samples were collected in the morning following 8 hours of fasting. Subsequently, fasting blood glucose was measured. Data was collected using a standardized questionnaire that included questions on socioeconomic status and alcohol use of participants.

Alcohol consumption was estimated by “standard drinking” which easily estimates ethanol. “Binge drinking” was evaluated as drinking five or more drinks in one sitting for men, and four or more for women.

Statistical Analysis The collected information then was analyzed using different descriptive and analytic methods with the use of the SPSS software version 20. Univariate and multivariate regression analyses were developed using SPSS to determine risk association. In all the analyses, a P value less than 0.05 was considered significant.

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Ethical Consent The study ethical approval was obtained with Ethical Review Committee at the Health Sciences University of Mongolia and the informed consent form was introduced and distributed to each study participant.
 RESULTS A total of 2280 individuals aged 40 years old and above participated in this study. 37.3% of study participants were male, 62.7% of them were female. Khalkh ethnicity was predominant in the study participants (92.9%). As seen in Figure 3, of the total participants, 55.6% were living in Ulaanbaatar city, and the remaining 44.4% resided in rural areas (14.3% in province center , 30.1% in other rural areas).

Alcohol consumption was estimated by age group and there was a decreasing trend by age group of drinking in the past 12 months (67.0% in the 40-44 age group and 45.1% in the over-60 age group). In contrast, the binge drinking rate increased by age group (Fig. 4).The mean income (323207 Mongolian tugrugs) of people who consumed alcohol in the last 12 months was higher than the income of those who did not consume (188750 Mongolian tugrugs, p=0.0001).

Alcohol consumption was increasing by education level (Fig. 5). Alcohol consumption was 27.7% in those who did not have education and 75.4 % in people who had master and higher degree. This may be associated with their income.

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Alcohol consumption in the past 12 months was higher in people who were a clerk or herdsman, while binge drinking was higher in clerks (Fig. 6). The distilled vodka and airag (horse milk) consumption was higher in herdsman.

The mean standard of alcohol was 5.3Âą4.3 and mean standard for men was 1.5 times higher than for women (p=0.001). Mean standard and binge drinking mean was higher in people living in the Khangai region.

The prevalence of diabetes is different among urban and rural people. The prevalence of diabetes was 8% of total participants (n=2280) and 9.8% in Ulaanbaatar city, 6.4% in province center, 5.5% in rural soum, which means diabetes was higher in the centralization region. Accordingly, the regional diabetes prevalence was lower in the western and eastern regions, and higher in Ulaanbaatar, central and Khangai regions (p=0.012). Hyperglycemia in fasting blood (normal blood glucose level 5.6-6.1 mmol/l) was 6.7% in urban and 8.3% in rural areas.

The prevalence of hyperglycemia and diabetes were 7.6% and 8.3% in men, 7.2% and 7.8% women, respectively.

Hyperglycemia was higher in men than in women, but not significantly (p=0.676) (Fig. 7).

The overall mean fasting blood glucose level was 5.03 mmol/l and5.11 mmol/l in men and 5.00 mmol/l in women.

Diabetes prevalence increased by education level as it was 6.2% in people without education, but 9.2% in people who had higher education. Prevalence of diabetes was about two times higher in people who live apartments rather than people who live ger (traditional Mongolian home, p=0.048). Diabetes prevalence was 8.7% in elderly people, 9.6% in unemployed people and 11.3% in disabled people. The movement and family income was not related to diabetes prevalence.

One of two persons with previously diagnosed diabetes had alcohol consumption. Two of three people with newly diagnosed diabetes had alcohol consumption. This means alcohol consumption is lower in people with previously diagnosed diabetes than in people with newly diagnosed diabetes.

Binge drink was 24.4% in men and 22% in women with diabetes and 50% in men and 23.6% in women with hyperglycemia. Standard drink was 5.29 in healthy people, 5.45 in people who previously diagnosed diabetes, 5.86 in people who newly diagnosed diabetes. This means all study participants have higher alcohol consumption.

Conclusion 1. Alcohol consumption varies by location, age group, gender, occupation and education level.

2. Diabetes prevalence increases with age, education, living environment and also is higher in females. The movement and family income was not related to diabetes prevalence.

3. Diabetes mellitus and alcohol consumption are more likely to be related (p< 0.001). â&#x20AC;¨

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References 1. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. The Lancet. 2013; 380:2224-60.

2. Schmidt LA, Makela P, Rehm J, Room R. Alcohol: equity and social determinants. In: Blas E, Kurup AS, editors. Equity, social determinants and public health programmes. Switzerland: WHO; 2012.

3. Mäkelä P, Keskimäki I, Koskinen S. What underlies the high alcohol-related mortality of the disadvantaged: high morbidity or poor survival? Journal of Epidemiology and Community Health. 2003;57:981-6 4. Makela P. Alcohol-related mortality as a function of socioeconomic status. Addiction. 1999;94(6):867-86.

5. Hemstrom O. Alcohol-related deaths contribute to socioeconomic differentials in mortality in Sweden. European Journal of Pubic Health. 2002;12(4):357-69.

6. Harrison L, Gardiner E. Do the rich really die young? Alcohol-related mortality and social class in Great Britain, 1988-1994. Addiction. 1999;94(12):1871-80.

7. Marmot M. Inequities, deprivation and alcohol use. Addiction. 1997;92(S1):S13-S20.

8. Knupfer G. The prevalence of various social groups of 8 different drinking patterns, form abstaining to frequent drunkenness: analysis of 10 US surveys combined. British Journal of Addiction. 1989;84:1305-18.

9. WHO – Definition and Diagnosis of Diabetes Mellitus and Intermediate Hyperglycaemia 10. Kevin D. Shield MHSCP, Ph.D.; and Jürgen Rehm, Ph.D. Focus On: Chronic Diseases and Conditions Related to Alcohol Use. Alcohol Research: Current Reviews. 2014; 35.0 11. Ki-Woong Kim,Bayanbileg Shinetugs, Kyung-Hwa Heo, Yong Lim Won, Tserenkhuu Lkhagwasuren. Polymorphisms of alcohol metabolizing enzyme and cytochrome P4502E1 genes in mongolian population. 2009

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Systematic Review: Effectiveness of interventions for shift-workers in improving outcomes of low mood and depression

SRINIVASAN, Vivek, YU, Angela, MASON, Emma, LEE, Marco, ARORA, Anisha, TSAKISIRIS, James, MCKENNA, Chloe, ONG, Ru Min, JAMIESON, Nathan, PERERA, Nadia Background of the Study With the rise of a 24-hour society, employment hours have changed towards longer and non-standard hours, leading to concerns about work-life balance and negative health impacts. Workers at particular risk of adverse health outcomes are shift- workers, who make up 16% of Australia’s working population (Australian Bureau of Statistics, 2010). Shift-work refers to a workday that lasts longer than the usual eight hours, and up to 24 hours (Stevens, Hansen, Costa, Haus, Kauppinen, Aronson & Straif, 2011). Shift-work can disrupt endogenous circadian rhythms resulting in a ‘jet lag’ experience entailing fatigue, irritability, poor digestion and reduced performance efficiency (Moon, Lee, Lee, Lee & Kim, 2015). In the long- term, it has been associated with increased incidence of chronic illnesses including cardiovascular disease (Baagild, 2000), diabetes (Wang, Armstrong, Cairns, Key & Travis, 2011) gastrointestinal disorders (Knuttson & Boggild, 2010) and depression (Driesen, Jansen, van Amelsvoort & Kant, 2011).

Depression is a major contributor to long-term sickness absence and disability in the working population (Lexis, Jansen, van Amelsvoort, van den Brandt & Kant, 2009), resulting in high costs for society (Utsun, Chatterji, Mathers & Murray, 2004). Significantly, shift-workers were found to have a higher prevalence of depressed mood (11.6%) than day workers (6.8%) in a prospective cohort study comparing 2452 shift-workers and 6438 day workers (OR: 1.39) (Driesen et al., 2011). Similarly, a survey of 659 hotel workers found that night workers had 3.46 times greater odds of depressive outcomes than day workers (Moon et al., 2015). While reduced quantity and quality of sleep and circadian desychronisation may directly increase the risk of depression, shift-work can also affect social and domestic role patterns, compounding its detrimental effect on mental health.

Given this strong evidence linking shift-work and depression, there is a need for interventions that can be implemented both in and outside of workplaces. A 2008 systematic review (Bambra, Whitehead, Sowden, Akers & Petticrew) concluded that a compressed working week intervention had positive effects on work-life balance. However, reviews collating data on a variety of interventions is warranted. While a more recent systematic review examined interventions such as shift schedule changes, controlled light exposure, behavioural strategies and pharmacological interventions, measurement of mental health outcomes were deliberately excluded (Neil-Sztramko, Pahwa, Demers & Gotay, 2014). Depression was postulated to have different risk factors and aetiologies compared to other chronic disease outcomes.

There is currently no systematic review examining interventions for shift-workers that improve outcomes of low mood and/or depression. Accordingly, the primary objective of this review will be to synthesise the research reporting interventions that have been implemented among shift-workers designed to improve low mood and depression outcomes. A secondary aim is to evaluate the quality of studies in this area. Based on the findings, future directions for intervention and research are suggested.

Methods Search Strategy MEDLINE, PsychINFO, PubMed and Embase were searched from database inception to 18th April 2016. The Medical Subject Headings that were used to capture variations of the key search terms - intervention, depression, and shiftwork - are outlined in Appendix 1. Results were limited to the full text being available in English and for human subjects.

Titles and abstracts were screened for inclusion in a full text evaluation if they met the selection criteria. Full texts were then assessed for eligibility in the systematic review.

Selection Criteria All peer-reviewed, original research articles in English that investigated an intervention on the outcome of depression or low mood in shift-workers were included. Articles were excluded if the intervention was not on shift-workers.

Critical Appraisal The Cochrane Collaboration’s tool for assessing risk of bias (Higgins, Altman & Sterne, 2011) was utilised to assess the quality of selected studies. Quality was assessed on the basis of: i) sequence generation, ii) allocation concealment, iii) blinding of participants, personnel and outcome assessors, iv) completeness of outcome data and v) unbiased outcome reporting. Each selected study was assessed for bias by two independent researchers.

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Data Analysis This review employed the process of narrative synthesis, as described by Popay and colleagues (2006). For each study two reviewers independently extracted data on demographics of participants, study design, intervention methods, outcome measures and study results.

Results Literature Search 325 studies were yielded with the initial search, of which 9 satisfied the criteria for inclusion (Figure 1).

Figure 1. PRISMA flow diagram of literature search

Study

range

and

characteristics

Three of the nine studies investigated pharmacological interventions, including melatonin (James, Tremea, Jones & Krohmer, 1998; Cavallo, Douglas Ris, Succop & Jaskiewicz, 2005), and vitamin C and omega-3 supplementation (Khajehnasiri, Mortazavi, Allameh & Akhondzadeh, 2013). Non-pharmacological interventions assessed included cognitive behavioural therapy (CBT) (Smith-Coggins, Rosekind, Buccino, Dinges & Moser, 1997; Jarnefelt et al., 2012; Lee, Gay & Alsten, 2014), changes to work scheduling (Smith-Coggins et al., 1997; Mitchell & Williamson, 2000), exposure to bright light (Leppamaki, Partonen, Piiroinen, Haukka & Lonnqvist, 2003), and a recovery nap (Wehrens, Hampton, Kerkhofs & Skene, 2012). Six studies measured mood and three measured depression, with a variety of scales used (Table 1). Samples sizes varied considerably between the studies, ranging from 3 to 136 participants with a mean of 42 participants. The age range of participants was 25-67 years.

Narrative Synthesis 1. Pharmacological Synthetic melatonin intervention did not produce significant results in either of the double-blind, randomized, placebo-controlled crossover trials (p > 0.05: James et al., 1998; p = 0.44: Cavallo et al., 2005).

Khajehnasiri et al. (2013) assessed 136 participants who were randomly assigned to four groups (Table 1). While all groups demonstrated significant decreases in depression scores from baseline, there was no significant difference between intervention and non-intervention groups. The results suggest a placebo effect as Group 4 (Placebo Omega-3 + Placebo Vitamin C) also had a markedly reduced depression score (p < 0.05).

2. Non-pharmacological ASIAN MEDICAL STUDENT CONFERENCE 2016 | MANILA, PHILIPPINES

2. Non-pharmacological Interventions that alter circadian rhythm showed mild to moderate improvements. While the change from an 8 to 12 hour shift, with a resultant compressed working week, demonstrated greater improvement in general mood status (p = 0.012) (Mitchell & Williamson, 2000), a recovery nap did not significantly change depression ratings (p = 0.07) (Wehrens et al., 2012).

Interventions aimed at promoting mindfulness displayed positive results. Jarnefelt et al. (2012) conducted CBT on 38 participants, resulting in a significant decrease in depressive symptoms (p = 0.021). Furthermore, the sleep enhancement training system investigated by Lee et al. (involving CBT and muscle relaxation and breathing techniques) resulted in significantly fewer depression-like symptoms compared to baseline (p < 0.001) (2013).

Smith-Coggins et al. (1997) designed a three-component program which comprised of sleep education; work schedule changes that included scheduling 48 hours off-duty to recover from a night shift; and guidance on workplace alertness strategies. There was no alteration in mood ratings (p = 0.05).

Leppamaki et al. (2003) examined the effectiveness of bright light emitting lamps, which were used for four 20minute periods during a night shift over a fortnight.

There was a reduction in symptom scores according to the Scale for Shift-work Complaints, a 17-item questionnaire adopted from the Columbia Jet Lag Scale (p = 0.02).

Critical Appraisal Overall, only two out of nine included studies demonstrated a sound quality of methodology, with low risks of bias in all of the Cochrane Risk of Bias Assessment categories. However, the other seven studies showed high or unclear risk of bias, mainly due to methodological limitations. Only three of the nine studies reported randomisation methods that adequately minimised selection bias. The remainder had either a high or unclear risk of selection bias, as most shift-workers were allocated to control or intervention according to personal preference or clinician judgement. Blinding of participants and key study personnel was sufficient in five studies; while the remaining four were at a high risk of performance bias due to participants being aware of the programme they were undertaking. Seven out of nine papers ensured assessors were properly blinded to allocations and if there was no blinding, outcome measurement was guaranteed to not be influenced by the lack of blinding. Six studies had a low risk of attrition bias with the remainder having high risks mostly due to missing data.

Lastly, there was minimal risk in reporting bias in all studies except for one as the published study protocols were available online.

Discussion Key findings This systematic review identified nine studies that evaluated the impacts of interventions on the depression and/or low mood scores of shift-workers. Five of the nine studies (56%) reported a statistically significant improvement in depression or low mood.

A common trait seen in four of the five interventions that reported a statistically significant improvement in depression/low mood was the targeting of broader mood and/or lifestyle factors, rather than participantsâ&#x20AC;&#x2122; sleep-wake cycles alone. Specifically, Omega 3 and Vitamin-C supplementation has been shown to reduce oxidative stress and depression (Mazza, Pomponi, Janiri, Bria & Mazza, 2007; Block et al., 2009); increased shift duration can increase blocks of free time; bright light intervention is the treatment of choice in seasonal affective disorder (Partonen & Lonnqvist, 1998) and can improve mood even in the absence of depression (Partonen & Lonnqvist, 2000); and the CBT regime included strategies to assist mood and relaxation. The exception to this trend was Lee et al.â&#x20AC;&#x2122;s study (2013), which employed sleep training enhancement.

However, this study was found to have high performance, detection and reporting bias as well as unclear selection bias. The identified trend stands in contrast to the four interventions that failed to significantly improve depression/low mood, which all targeted sleep cycles and attitudes specifically (i.e. melatonin administration, recovery napping and sleeping principles education).

Relation to existing literature The results of this review are analogous to findings from a previous systematic review which concludes that compressed working weeks, by way of increasing night shift durations and days off work, improve work-life balance and health, particularly mental health (Bambra et al., 2008). The review also suggests that whilst improvements in mental or physical health and work-life balance can occur independently, improvements in work-life balance can precipitate positive mental health effects. Although this review did not consider depression specifically, it supports the findings of the present review in suggesting the need for targeting broad lifestyle factors in addressing the mental health of shift-workers.

Limitations of this review Although the papers chosen consistently explored the depressive or mood changes of shift-workers in response to various

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interventions, the main weakness of this systematic review was the small sample size of included studies. This makes it difficult to ascertain the effects of interventions in different population groups, such as age, socioeconomic status and type of shift-work. This weakness, combined with the low variation in intervention types, resulted in a lack of multiple large studies examining the same intervention.

Moreover, many of our studies had small follow-up periods, the longest of which was 2 months (Khajehnasiri et al., 2013), rendering our systematic review unable to assess possible long-term psychological effects. Driesen et al.’s longitudinal study found that the impact of shift-work on the development of depressed mood increases slowly over time, meaning that studies with short follow-up periods may miss this effect (2011).

In addition, our systematic review examined outcomes that were self-reported by the participants through various depression assessment scales. This self-reporting of outcomes results in possible confounding of the data based on the participant’s particular attitudes towards or against certain interventions. Participants’ attitudes may be influenced by their prior experience and/or how the interventions were described and presented to them.

Finally, all included studies, except that of Wehrens et al. (2012), solely examined the depressive and mood outcomes of interventions on a population of shift- workers without establishing an underlying baseline on the effectiveness of these interventions on normal populations. It has been shown in the literature that omega-3 fatty acids (Grosso et al., 2014) and CBT are useful in improving mood in depressed individuals (Thase, 2006). Although inconsistent, there has also been evidence attesting to ameliorative effects of bright lights (Riemersma-van der Lek et al., 2008) and vitamin D (Li et al., 2014; Shaffer et al., 2014; Spedding, 2014).

As such, our systematic review is unable to determine whether or not these mood improvements arose as a result of effective intervention on mood in shift-workers or on mood in any non-specific population.

Implications Innovative and unconventional approaches to improving the workplace environment and scheduling such as bright lights or compressed working weeks with 12 hour shift lengths may be effective in improving the mood of shift-workers.

Additionally, individuals who ensure they are well nourished, both physically, through adequate nutrition, and mentally, through sleeping and wellbeing strategies, may be less likely to experience depressive symptoms.

While the logistical limitations of trialling an intervention on a working population will persist as a major limitation, the mental health of shift-workers remains an area that demands further research and study. Studies with larger power, long-term follow-ups, use of evidence-based measures and comparison to non-shift-worker populations will provide a better understanding on the effectiveness of specific interventions on particular groups of people.

Conclusion Evidence from this systematic review shows that approaches which specifically address the negative effects of shiftwork such as low mood and disturbed lifestyle, as opposed to solely targeting improved sleep, are more effective in improving outcomes of low mood and depression. Nevertheless, research into shift-work’s psychological implications and the interventions that may ameliorate these issues is a relatively novel area. Further interventional trials with larger sample sizes and longer follow-up times will help improve our knowledge on interventions for low mood and depression of shift-workers.

References Australian Bureau of Statistics. (2010). Working Time Arrangements, Australia, November 2009. Retrieved 15 May 2016, from http://www.abs.gov.au/ausstats/abs@.nsf/products/C3AEAD8F78CE3024CA257 B5F0021DC4F Baggild, H. (2000). Shift-work and heart disease: Epidemiological and risk factor aspects. (Unpublished doctoral thesis).

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Grosso, G., Galvano, F., Marventano, S., Malaguarnera, M., Bucolo, C., Drago, F., Caraci, F. (2014). Omega-3 Fatty Acids and Depression: Scientific Evidence and Biological Mechanisms. Oxidative Medicine and Cellular Longevity, 2014, 313570. doi: 10.1155/2014/313570 ASIAN MEDICAL STUDENT CONFERENCE 2016 | MANILA, PHILIPPINES

Jarnefelt, H., Lagerstedt, R., Kajaste, S., Sallinen, M., Savolainen, A., Hublin, C. (2012). Cognitive behavioral therapy for shift-workers with chronic insomnia. Sleep Medicine, 13, 1238-1246. doi: 10.1016/j.brat.2014.02.007 James, M., Tremea, M.O., Jones, J.S., Krohmer, J.R. (1998). Can melatonin improve adaptation to night shift? American Journal of Emergency Medicine, 16(4), 367-370. doi: 10.1016/S0735-6757(98)90129-2 Knuttson, A., Boggild, H. (2010). Gastrointestinal disorders among shift-workers. Scandinavian Journal of Work Environment & Health, 36(2), 85-95. Retrieved from http://www.jstor.org/stable/40967835 Khajehnasiri, F., Mortazavi, S.B., Allameh, A., Akhondzadeh, S. (2013). Effect of omega-3 and ascorbic acid on inflammation markers in depressed shift-workers in Shahid Tondgoyan Oil Refinery, Iran: a randomized double-blind placebo- controlled study. Journal of Clinical Biochemistry and Nutrition, 53(1), 36-40. doi: 10.3164/jcbn.12-98.

Lee, K.A., Gay, C.L., Alsten, C.R. (2014). Home-Based Behavioral Sleep Training for Workers: A Pilot Study. Behavioural Sleep Medicine, 12, 455-468. doi: 10.1080/15402002.2013.825840 Leppämäki, S., Partonen, T., Piiroinen, P., Haukka, J., Lonnqvist, J. (2003). Timed bright-light exposure and complaints related to shift-work among women. Scandinavian Journal of Work Environment & Health, 29(1), 22-26. Retrieved from http://www.jstor.org/stable/40967262 Lexis, M.A., Jansen, N.W., van Amelsvoort, L.G., van den Brandt, P.A., Kant, I. (2009). Depressive complaints as a predictor of sickness absence among the working population. Journal of Occupational and Environmental Medicine, 51, 887-895. doi: 10.1097/JOMB. 0b013e3181aa012a Li, G., Mbuagbaw, L., Samaan, Z., Falavigna, M., Zhang, S., Adachi, J.D., Thabane, L. (2014). Efficacy of vitamin D supplementation in depression in adults: a systematic review. Journal of Clinical Endocriniology and Metabolism, 99(3), 757-767. doi: 10.1210/jc.2013-3450 Mazza, M., Pomponi, M., Janiri, L., Bria, P., Mazza, S. (2007). Omega-3 fatty acids and antioxidants in neurological and psychiatric diseases: an overview. Progress in Neuro-psychopharmacology and Biological Psychiatry, 31, 12-26. doi: 10.1016/j.pnpbp.2006.07.010 Mitchell, R.J., Williamson, A.M. (2000). Evaluation of an 8 hour versus a 12 hour shift roster on employees at a power station. Applied Ergonomics, 31, 83-93.

Retrieved from http://www.sciencedirect.com.wwwproxy0.library.unsw.edu.au/science/article/pii/ S0003687099000253 Moon, H.J., Lee, S.H., Lee, H.S., Lee, K., Kim, J.J. (2015). The association between shift-work and depression in hotel workers. Annals of Occupational and Environmental Medicine, 27, 29. doi: 10.1186/s40557-015-0081-0 Neil-Sztramko, S.E., Pahwa, M., Demers, P.A., Gotay, C.C. (2014). Health- related interventions among night shift-workers: a critical review of the literature. Scandinavian Journal of Work Environment & Health, 40(6), 543-556. doi: 10.5271/ sjweh.3445 Partonen, T., Lonnqvist, J. (1998). Seasonal affective disorder. Lancet 352, 1369-1374. Retrieved from http:// www.sciencedirect.com.wwwproxy0.library.unsw.edu.au/science/article/pii/ S0140673698010150 Partonen, T., Lonnqvist, J. (2000). Bright light improves vitality and alleviates distress in healthy people. Journal of Affective Disorders, 57, 55-61. Retrieved from http://www.sciencedirect.com.wwwproxy0.library.unsw.edu.au/science/article/pii/ S0165032799000634 Riemersma-van der lek, R.F., Swaab, D.F., Twisk, J., Hol, E.M., Hoogendijk, W.J., Van Someren, E.J. (2008). Effect of bright light and melatonin on cognitive and noncognitive function in elderly residents of group care facilities: a randomized controlled trial. Journal of the American Medical Association, 299(22), 2642-2655. doi: 10.1001/jama.

299.22.2642 Shaffer, J.A., Edmondson, D., Waason, L.T., Falzon, L., Homma, K., Ezeokoli, N., Davidson, K.W. (2014). Vitamin D supplementation for depressive symptoms: a systematic review and meta-analysis of randomized controlled trials.

Psychosomatic Medicine, 76(3), 190-1896. doi: 10.1097/PSY.0000000000000044 Smith-Coggins, R., Rosekind, M.R., Buccino, K.R., Dinges, D.F., Moser, R.P. (1997). Rotating Shiftwork Schedules: Can We Enhance Physician Adaptation to Night Shifts? Academic Emergency Medicine, 4, 951-961. doi: 10.1111/j.15532712.1997.tb03658.x Spedding, S. (2014). Vitamin D and depression: a systematic review and meta- analysis comparing studies with and without biological flaws. Nutrients, 6(4), 1501-1518. doi: 10.3390/nu6041501 Stevens, R.G., Hansen, J., Costa, G., Haus E., Kauppinen, T., Aronson K.J., Straif, K. (2011). Considerations of circadian impact for defining ‘shift-work’ in cancer studies: IARC Working Group Report. Occupational and Environmental Medicine, 68(2), 154-162. doi: 10.1136/oem.2009.053512 Thase, M.E. (2006). Depression and sleep: pathophysiology and treatment. Dialogues in Clinical Neuroscience, 8(2), 217-226. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16889107 Ustun, T.B., Chatterji, S., Mathers, C., Murray, C.J. (2004). The Global burden of depressive disorders in the year 2000.

British Journal of Psychiatry, 184, 386- 392. doi: 10.1192/bjp.184.5.386 Wang, X.S., Armstrong, M.E., Cairns, B.J., Key, T.J., Travis, R.C. (2011). Shift- work and chronic disease: the epidemiological evidence. Occupational Medicine (London), 61(2), 78-89. doi: :10.1093/occmed/kqr001 Wehrens, S.M.T., Hamptom, S.M., Kerkhofs, M., Skene, D. (2012). Mood, Alertness, and Performance in Response to Sleep Deprivation and Recovery Sleep in Experienced Shiftworkers Versus Non-Shiftworkers. Chronobiology International, 29(5), 537-538. doi: 10.3109/07420528.2012.675258 RESEARCH PAPER COMPETITION

Evaluation of market-based interventions to reduce the prevalence of avian influenza viruses: a systematic review Chenyi XIE, Yihuai HU, Yuxue Nie, Ziyi Jiang, Yue Shiâ&#x20AC;¨

Key words: avian influenza virus, live poultry markets, animal-human interface Background of the Study Avian influenza is an endemic and sometimes pandemic disease in many parts of Asia. Poultry is believed to be the pivotal host of avian influenza viruses (AIVs). Studies of molecular epidemiology indicate that all human influenza viruses root from AIVs either directly or indirectly.(Su et al., 2015) Live poultry markets(LPMs) refer to food markets providing poultry meat as well as live birds either for sale or for slaughter, which are common in Asia, such as China, Thailand, Laos etc., primarily in urban areas. LPMs not only act as an essential part of food supply, but also play an important role in the spread and evolution of AIVs because they facilitate the maintenance, amplification, and dissemination of AIVs. (N. Y. Kung et al., 2007) This Systematic Review summarized the market-based interventions that have been reported all over the world and focused on the evaluation of these interventions according to their effectiveness, which could be instructive for policymakers to set out preventative strategies and subsequently relieve the burden of clinical problems from political aspects.

Methods This study conducted a comprehensive search in MEDLINE, MEDLINE in process (based of Pubmed database), Web of Science, Google Scholar, OIE/FAO Network of Expertise on Animal Influenza website, WHO (World Health Organization Web and CDC (Centre for Disease Prevention and Control) database to systemically review the studies on interventions taken in poultry markets in the purpose of reducing the prevalence of AIVs. Due to the heterogeneity of the included studies, no statistical pooling was possible. Results will be presented in narrative synthesis, including tables and figures to aid in data presentation.

Results 13 published studies(Bulaga et al., 2003; Indriani et al., 2010; Kang et al., 2015; N Y Kung et al., 2003; Lau et al., 2007; Leung et al., 2012; Liu et al., 2014; Martin et al., 2011; Trock, Gaeta, Gonzalez, Pederson, & Senne, 2008; Xie et al., 2016; Yu et al., 2014; Jun Yuan et al., 2015; Yuan, Tang, Yang, Wang, & Zheng, 2014) evaluating effect of market-based intervention on control of AIVs conducted in 5 regions (Mainland China, Hong Kong SAR, China, the United State, Indonesia) were included in this systematic review. Based on the methodology and principal objective, the 13 studies were identified to be before and after surveillance studies and analytical cross sectional studies. Studies were appraised by reviewers for methodological quality using the standardized critical appraisal instrument for Experimental Studies from the Joanna Briggs Institute. (Table1) These findings show that market-based interventions are effective in reducing the prevalence of AIVs. These findings were grouped into five categories, which were then meta-aggregated into 5 synthesized findings. The 5 synthesized findings provide an evidence-base that improves our understanding of interventions aimed at reducing prevalence of AVIs and therefore should be considered for future prevention strategies.

Conclusion Our findings show that market-based interventions refer to a range of comprehensive measures to reduce the prevalence of AIVs. Actions should be taken in each procedure of the supply chain of poultry products. During influenza seasons, prompt closure of LPMs is effective in controlling influenza outbreaks, although immediately after reintroducing live poultry, markets were detected to be re-contaminated by AIVs. Therefore, temporary closure of LPMs could only be an intervention in times of stress because it is not an intentional strategy with estimated economic loss. Permanent LPMs closure and promotion of new meat type products (fresh chilled chickens) could significantly reduce the prevalence of AIVs in markets in the long term. But there is scarcity of support of permanent LPMs closure due to the conventional preference for live poultry and food safety consideration in some Asian countries. Consequently, rest day and ban on overnight poultry combined with biosecurity measures may be better alternatives with a comprehensive deliberation of effectiveness, acceptance of citizens and economic sustainability currently.

Reference Achenbach, J. E., & Bowen, R. A. (2013). Effect of oseltamivir carboxylate consumption on emergence of drug-resistant H5N2 avian influenza virus in Mallard ducks. Antimicrob Agents Chemother, 57(5), 2171-2181. doi: 10.1128/AAC. 02126-12 ASIAN MEDICAL STUDENT CONFERENCE 2016 | MANILA, PHILIPPINES

Antia, R., Regoes, R. R., Koella, J. C., & Bergstrom, C. T. (2003). The role of evolution in the emergence of infectious diseases. Nature, 426(6967), 658-661. doi: 10.1038/nature02104 Bulaga, L. L., Garber, L., Senne, D. A., Myers, T. J., Good, R., Wainwright, S., . . . Suarez, D. L. (2003). Epidemiologic and surveillance studies on avian influenza in live-bird markets in New York and New Jersey, 2001. Avian Dis, 47(3 Suppl), 996-1001. doi: 10.1637/0005-2086-47.s3.996 Indriani, R., Samaan, G., Gultom, A., Loth, L., Irianti, S., Adjid, R., . . . Darminto. (2010). Environmental sampling for avian influenza virus A (H5N1) in live-bird markets, Indonesia. Emerg Infect Dis, 16(12), 1889-1895. doi: 10.3201/ eid1612.100402 Jang, Y. H., & Seong, B. L. (2014). Options and obstacles for designing a universal influenza vaccine. Viruses, 6(8), 3159-3180. doi: 10.3390/v6083159 Kang, M., He, J., Song, T., Rutherford, S., Wu, J., Lin, J., . . . Zhong, H. (2015). Environmental Sampling for Avian Influenza A(H7N9) in Live-Poultry Markets in Guangdong, China. PLoS One, 10(5), e0126335. doi: 10.1371/journal.pone.

0126335 Kung, N. Y., Guan, Y., Perkins, N. R., Bissett, L., Ellis, T., Sims, L., . . . Peiris, J. S. M. (2003). The impact of a monthly rest day on avian influenza virus isolation rates in retail live poultry markets in Hong Kong. Avian Dis, 47(3 Suppl), 1037-1041. doi: 10.1637/0005-2086-47.s3.1037 Kung, N. Y., Morris, R. S., Perkins, N. R., Sims, L. D., Ellis, T. M., Bissett, L., . . . Peiris, M. J. (2007). Risk for infection with highly pathogenic influenza A virus (H5N1) in chickens, Hong Kong, 2002. Emerg Infect Dis, 13(3), 412-418. doi: 10.3201/eid1303.060365 Lam, T. T., Wang, J., Shen, Y., Zhou, B., Duan, L., Cheung, C. L., . . . Guan, Y. (2013). The genesis and source of the H7N9 influenza viruses causing human infections in China. Nature, 502(7470), 241-244. doi: 10.1038/nature12515 Lau, E. H. Y., Leung, Y. H. C., Zhang, L. J., Cowling, B. J., Mak, S. P., Guan, Y., . . . Peiris, J. S. M. (2007). Effect of interventions on influenza A (H9N2) isolation in Hong Kong's live poultry markets, 1999-2005. Emerg Infect Dis, 13(9), 1340-1347. doi: 10.3201/eid1309.061549 Leung, Y. H. C., Lau, E. H. Y., Zhang, L. J., Guan, Y., Cowling, B. J., & Peiris, J. S. M. (2012). Avian influenza and ban on overnight poultry storage in live poultry markets, Hong Kong. Emerg Infect Dis, 18(8), 1339-1341. doi: 10.3201/ eid1808.111879 Liu, H., Chen, Z., Xiao, X., Lu, J., Di, B., Li, K., . . . Yang, Z. (2014). [Effects of resting days on live poultry markets in controlling the avian influenza pollution]. Zhonghua Liu Xing Bing Xue Za Zhi, 35(7), 832-836.

Martin, V., Zhou, X., Marshall, E., Jia, B., Fusheng, G., FrancoDixon, M. A., . . . Gilbert, M. (2011). Risk-based surveillance for avian influenza control along poultry market chains in South China: The value of social network analysis. Prev Vet Med, 102(3), 196-205. doi: 10.1016/j.prevetmed.2011.07.007 Santhia, K., Ramy, A., Jayaningsih, P., Samaan, G., Putra, A. A., Dibia, N., . . . Kandun, N. (2009). Avian influenza A H5N1 infections in Bali Province, Indonesia: a behavioral, virological and seroepidemiological study. Influenza Other Respir Viruses, 3(3), 81-89.

Su, S., Bi, Y., Wong, G., Gray, G. C., Gao, G. F., & Li, S. (2015). Epidemiology, Evolution, and Recent Outbreaks of Avian Influenza Virus in China. J Virol, 89(17), 8671-8676. doi: 10.1128/JVI.01034-15 Ta, Y. T., Nguyen, T. T., To, P. B., Pham da, X., Le, H. T., Alali, W. Q., . . . Doyle, M. P. (2012). Prevalence of Salmonella on c h i c k e n c a r c a s s e s f r o m r e t a i l m a r k e t s i n Vi e t n a m . J F o o d P r o t , 7 5 ( 1 0 ) , 1 8 5 1 - 1 8 5 4 . d o i : 10.4315/0362-028X.JFP-12-130 Trock, S. C., Gaeta, M., Gonzalez, A., Pederson, J. C., & Senne, D. A. (2008). Evaluation of routine depopulation, cleaning, and disinfection procedures in the live bird markets, New York. Avian Dis, 52(1), 160-162. doi: 10.1637/7980-040607Reg Xie, C. J., Su, W. Z., Li, K. B., Chen, J. D., Liu, J. P., Feng, J., . . . Wang, M. (2016). [Effect of supply of fresh poultry products on reducing environment contamination of avian influenza virus in markets]. Zhonghua Liu Xing Bing Xue Za Zhi, 37(3), 353-357. doi: 10.3760/cma.j.issn.0254-6450.2016.03.012 Yu, H., Wu, J. T., Cowling, B. J., Liao, Q., Fang, V. J., Zhou, S., . . . Leung, G. M. (2014). Effect of closure of live poultry markets on poultry-to-person transmission of avian influenza A H7N9 virus: an ecological study. Lancet, 383(9916), 541-548. doi: 10.1016/S0140-6736(13)61904-2 Yuan, J., Lau, E. H. Y., Li, K., Leung, Y. H. C., Yang, Z., Xie, C., . . . Peiris, M. (2015). Effect of Live Poultry Market Closure on Avian Influenza A(H7N9) Virus Activity in Guangzhou, China, 2014. Emerg Infect Dis, 21(10), 1784-1793. doi: 10.3201/eid2110.150623 Yuan, J., Liao, Q., Xie, C. J., Ma, X. W., Cai, W. F., Liu, Y. H., . . . Lau, E. H. (2014). Attitudinal changes toward control measures in live poultry markets among the general public and live poultry traders, Guangzhou, China, JanuaryFebruary, 2014. Am J Infect Control, 42(12), 1322-1324. doi: 10.1016/j.ajic.2014.08.010 Yuan, J., Tang, X., Yang, Z., Wang, M., & Zheng, B. (2014). Enhanced disinfection and regular closure of wet markets reduced the risk of avian influenza A virus transmission. Clin Infect Dis, 58(7), 1037-1038. doi: 10.1093/cid/cit951 Yuan, J., Xie, C., Liu, Y., Ma, X., Cai, W., Liu, Y., . . . Wang, M. (2015). [Acceptance and influence factor of central slaughtering of live poultry in residents of Guangzhou]. Zhonghua Yu Fang Yi Xue Za Zhi, 49(3), 237-242.

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Social Determinants Affecting Menstrual Hygiene Snimarjot Kaur

Key words: Menstrual hygiene, Menstruation, Adolescent health, Reproductive health, RTI, Reproductive tract infections Background In India, where menstruation has been considered as a taboo4,2 since historical times, with incidences of menstruating women not being allowed inside certain shrines and temples5; menstrual hygiene is not discussed openly in the society and is not a part of the educational curriculum.9 This often leads to multiple reproductive health problems in women like reproductive tract infections and other gynaecological problems.1,12,13 A plethora of factors and possible reasons can be ascribed to this neglect of hygiene among menstruating women.

Some of them may be education10, culture3, governance, finance, human resources and access to technology.

After reviewing the existing literature relevant to the topic, it was found that most of the studies1,2,3,4,5,10,11,12,13 were related to the status of menstrual hygiene practices, beliefs and conceptions related to menstruation or the knowledge and source of knowledge about menstrual hygiene. But, no prior study focused on the social determinants affecting menstrual practices like education, culture, finances and technology, among others.

Most menstruation related studies have been conducted in South India2,5,10,11,12. No such study has been conducted in North India to establish the facts about how these social determinants affect menstrual hygiene. It is this gap in the knowledge of our society that this study tries to fill.

Aim and Objectives The aim of the study is to know how social determinants like education, culture, governance, finance, human resources, technology affect menstrual hygiene, to highlight their interdependence and also to know if these social determinants have regional variations.

Methods Type of study: A community based, cross sectional study.

Place of study: The present study was undertaken among adolescent girls in North India (a) Urban-rural population of Aliganj, Delhi; (b) Safdarjung Hospital Delhi Out Patient Department (OPD); (c) Village Kala Sanghian of district Kapurthala (in Punjab) and; (d) Civil Hospital OPD, Jalandhar, Punjab.

Duration of study: One month; May 2016 Study population: 120 girls were randomly selected from four above mentioned clusters of 30 girls each so as to study a wider population and analyse for the presence of regional variations among the cities.

Study tool: A pre-designed, structured questionnaire8 was used in the study.

The data collection technique was a personal interview of the study subjects. Written informed consent was taken for participation in the study.

Sample size calculation: According to Menstrual Hygiene Management National Guidelines December 20156, 100% adolescent girls had had no discussion on the process of menstruation and 6% of the girls had never heard of sanitary napkins. The level of awareness and practices related to menstrual hygiene varied in between this range. Taking the lowest figure of 6% for girls who have never heard of sanitary napkins, the sample size came out to be 22 subjects each, for cluster sampling. 4 clusters were taken at 5% confidence limit and 95% confidence level according to Epi Info 7 Software of CDC Atlanta and WHO7.

Statistical Analysis: It was carried out using Microsoft Office Excel and the data was considered significant for the fields for which the p-value came out to be less than 0.05 (by using the Chi square test).

Results After the analysis of the data obtained, the following results could be deciphered: • The mean age of adolescent girls in the sample population is 15.6 years with a standard deviation of ± 1.66 years. 47.1% of the sample population is rural and 53.3% urban.

• 60% respondents didn't know about menstruation before menarche.

• For those who knew, the knowledge mostly came from mothers (43.6%) and teachers (34.5%) followed by friends (30.9%), relatives (10.9%), textbooks (5.5%) and media (1.8%). [Fig. 1] ASIAN MEDICAL STUDENT CONFERENCE 2016 | MANILA, PHILIPPINES

• 75% didn't know about the organ from which menstruation occurs. [Fig. 2]

• 38.2% girls did not know the cause of menstruation and 22% thought that it was a ‘God-given’ phenomenon.

• 87.5% girls used sanitary pads during menstruation. Other absorbents used included new cloth (3.4%), old washed cloth (2.5%), sanitary pad + old or new washed cloth (9.2%).

• Out of those who used cloth, 75% washed cloth every day, 25% used new cloth every day.[Fig. 4]

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• 55.1% changed sanitary pads 3-4 times a day, 36.4% changed it twice a day, 5.9% changed it more than 5 times a day and 2.5% did not change at all. [Fig. 5]

• 98.3% girls took a bath daily and 97.5% cleaned their external genitalia regularly out of which 17.2% used only water whereas 82.8% used soap and water.

• 86.7% were exposed to advertisements of sanitary pads in media but only 23.3% thought that these advertisements were not helpful and effective.

• Of the various restrictions imposed on girls during menstruation 46.6% girls were restricted from going to religious places which was more prevalent in Delhi (68.3%) than Punjab (25%). p-value comes out to be 0.000002 which is less than 0.05.

Hence, the result is significant.

• 41% were restricted from having certain food products like curd, sour food products etc. 23.5% girls were not allowed to play games,13.3% not allowed to attend marriages and 9.8% not allowed to go to school.

• According to the respondents restrictions were imposed 54% by parents, 30% by oneself, 22% by elderly and 12.2% due to customs prevailing in the area. [Fig 6]

• 21.8% reported that they were considered impure during menstrual days.

• 62.5% said that the men in the family did not know about menstruation and did not offer any emotional support during the periods.

• It was seen that 36.2% respondents were ready to pay as much as required on sanitary napkins whereas 9.6% could merely afford to spend ₹2-₹4. 54.3% could spend anywhere from ₹5 to ₹10. [Fig. 7]

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• Of the subjects who used cloth 45.5% dried it inside the house, 36.4% dried it outside the house with sunlight and 18% dried it outside the house without sunlight.

• 98.3% disposed of the pads by wrapping them. 86.7% threw them in a dustbin collected by garbage collector, 5.8% in an open area nearby, 5% burnt the pads, 1.7% flushed and 1.7% threw in a pond or river nearby.

• When it comes to access to infrastructure for proper menstrual hygiene 60% report that separate toilets for men and women were available, 74.8% say that there was no problem of privacy and 68.7% say that water taps are not an issue.

61.7% did not know about any policy regarding distribution of free or low cost pads by the government which varied considerably between Punjab (85%) and Delhi (38.3%). p-value comes out to be 0 which is less than 0.05. Hence, the result is significant.

Conclusion As discovered during the course of the study, most adolescent girls didn't know about menstruation before menarche and main source of knowledge was their mother. Due to lack of knowledge about menstruation most girls didn't know about source or cause of menstruation. A majority also said that the men in the family do not know about menstruation and do not provide any emotional support, which shows a lack of empathy towards gender problems.

More number of respondents used sanitary pads then cloth and were aware about the need to frequently change the pad.

Major cultural and religious restrictions are also prevalent. A significant regional variation was seen. Lesser religious restrictions in Punjab than New Delhi possibly because of majority of the Sikh population which does not practise such cultures. Majority of the Participants do not know about government initiatives, particularly in Punjab.

A major difference has also been observed about awareness of government policies. As New Delhi is the national capital legislature is well imposed and implemented whereas in cities of Punjab adolescent girls are hardly aware of any initiatives of the government.

Neither NGO’s are active enough to spread awareness about menstrual hygiene. Technology is not being exploited to its full potential. Most girls are unaware of low cost sanitary pads vending machines. When given a chance they are very enthusiastic about getting them installed. Also, internet as a medium for gaining knowledge on the subject is rarely used.

Therefore, it is recommended that more awareness programmes should be instituted among adolescent girls particularly in rural part of India. Government should take more initiatives to make and implement newer policies.

Technological advancement should be encouraged by installing vending machines and making them available to everyone.

References [1] A Dasgupta, M Sarkar Department of Preventive and Social Medicine, All India Institute of Hygiene & Public Health, Kolkata, West Bengal, India Menstrual hygiene: How hygienic is the adolescent girl? Retrieved from http:// www.ijcm.org.in/article.asp issn=0970-0218;year=2008;volume=33;issue=2;spage=77;epage=80;aulast=Dasg [2] Kamath R1, Ghosh D2, Lena A2, Chandrasekaran V2 A study on knowledge and practices regarding menstrual hygiene among rural and urban adolescent girls in Udupi Taluk, Manipal, India GLOBAL JOURNAL OF MEDICINE AND PUBLIC HEALTH [3] Dr. Neelima Sharma, Dr. Pooja Sharma, Dr. Neha Sharma, Dr. R.R. Wavare, Dr.Bishal Gautam, Dr. Madan Sharma A cross sectional study of knowledge, attitude and practices of menstrual hygiene among medical students in north India A JOURNAL OF PHYTOPHARMACOLOGY 2013 [4] AJ Singh Department of Community Medicine, PGIMER, Chandigarh - 160012, India Place of menstruation in the reproductive lives of women of rural North India Retrieved from http://www.ijcm.org.in/article.asp? issn=0970-0218;year=2006;volume=31;issue=1;spage=10;epage=14;aulast=Singh [5] Aru Bhartiya Menstruation, Religion and Society International Journal of Social Science and Humanity, Vol. 3, No. 6, November 2013 [6] unicef.in/Uploads/Publications/Resources/pub_doc107.pdf [ 7 ] h t t p s : / / w w w. c d c . g o v / e p i i n f o / i n d e x . h t m l [ 8 ] h t t p s : / / d o c s . g o o g l e . c o m / f o r m s / d / 1S2v4a6EO6IToAn_I1t32eszBqvsAs38Oo2IqqJXH8Ko/viewform? c=0&w=1&usp=mail_form_link [9] Mona Gupta, K. V. Ramani, Werner Soors. Adolescent Health in India: Still at Crossroads Advances in Applied Sociology 2012. Vol.2, No.4, 320-324 Retrieved from http://file.scirp.org/pdf/AASoci20120400014_32321960.pdf [10] Prateek Bobhate, Saurabh Shrivastava. A Cross Sectional Study of Knowledge and Practices about Reproductive Health among Female Adolescents in an Urban Slum of Mumbai. Journal of Family and Reproductive Health 2011.

5(4) 117-124. Retrieved from http://jfrh.tums.ac.ir/index.php/jfrh/article/view/131 [11] Subhash B. Thakre, Sushama S. Thakre, Monica Reddy, Nidhi Rathi, Ketaki Pathak, Suresh Ughade. Menstrual Hygiene: Knowledge and Practice among Adolescent School Girls of Saoner, Nagpur District Journal of Clinical and Diagnostic Research, India 2011

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[12] Mudey AB, Keshwani N, Mudey GA, Goyal RC (2010). A cross-sectional study on the awareness regarding safe and hygienic practices amongst school going adolescent girls in the rural areas of Wardha District. Global Journal of Health Science. 2(2):225-231.

[13] Bhatia JC, Cleland J. Self- reported symptoms of gynaecological morbidity and their treatment in south India (1995).

Studies in Family Planning.26/4:491-495.

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Relation between Usage of Indonesiaâ&#x20AC;&#x2122;s National Health Insurance (Badan Penyelenggara Jaminan Nasional for Health) and Patient-Reported Treatment Outcome in Breast Cancer Patients who Undergo Mastectomy Gilda Athalia Sudarto, Mila Astrilia, Alicia Sandjaja, Felix Lee Keywords: BPJS for Health, Breast Cancer, Mastectomy Background of the Study Breast cancer is the cancer with the highest rate of incidence and mortality in women. In the world, in 2008 there were 1:38 million new breast cancer cases and mortality reached 458.400 (Jemal, 2011). In Indonesia, 2012, the incidences of breast cancer are 40.3 / 100,000, or nearly 100,000 new cases. While the mortality rate from breast cancer in the same year was 16.6 / 100,000, or equivalent with 41,000 deaths (Youlden, 2014).

A study in 2012 that looked at the relationship between economic burden related to the treatment of breast cancer with the quality of life of patients who had recovered from the disease indicate that the events the economy such as increased health insurance premiums, a decrease in the level of income, unemployment, and the depletion of savings, is closely linked to poorer quality of life after treatment (Meneses, 2012). Both studies indicate that breast cancer is a huge economic burden on the welfare of patients, therefore government assistance in the form of national health insurance is indispensable.

Badan Penyelenggara Jaminan Nasional (BPJS) for Health developed in Indonesia is part of the national social insurance system is administered through mechanisms of social health insurance which is compulsory (mandatory) with the aim to meet the basic health needs of society in a comprehensive manner (health promotion, preventive, curative and rehabilitative). Through the mechanism of social insurance is expected that the health financing can be controlled so that assuredness health financing became uncertain and continuously available which, in turn, social justice for all Indonesian people can be realized (Kemenkes, 2013). Therefore, the use of BPJS for Health itself might influence the outcome of therapy in patients with breast cancer. However, no studies have investigated the relationship. Therefore, necessary to study the relationship between the benefits of BPJS for Health membership with treatment outcomes, as measured using a patient-reported outcome questionnaire, in patients with breast cancer who undergo mastectomy.

Methods A population-based survey was performed in the hospitals type A in Indonesia. This research use cross-sectional analysis design and primary data was collected by using Functional Assessment of Cancer Therapy-Breast (FACT-B) Questionnaire in women (45-65 years old) who undergo mastectomy in past a year. Samples consist of 2 groups: BPJS for Health members and non-BPJS for Health members. Each group has 73 samples.

Result It was found that breast cancer patients who are members of BPJS for Health reported treatment outcomes that are not significantly different from those who are non-members. Independent T-test for assessing the total scores of FACT-B in both patient groups showed p = 0.763 (equal variance assumed), with an average score of 92.3/148 in BPJS for Health group and 91.6/148 in non-BPJS for Health group. We also conducted statistical examination on each domain of FACT-B and revealed that domains with normally distributed data (domain 2, domain 4, and domain 5) had p-value of 0.597, 0.975, and 0.668 respectively, indicating an absence of significant differences in outcomes from social wellness (domain 2), functional wellness (domain 4), and other complaints (domain 5) among BPJS for Health users and non- BPJS for Health ones. Meanwhile, domain 1 (physical wellness) and domain 3 (emotional wellness) were analyzed with Mann-Whitney U test and yielded similar results (p = 0.836 and p = 0.295 respectively).

Conclusion There is no significant difference between treatment outcome in patients who are under BPJS for Health scheme and that in patients under other schemes (p > 0.05). Considering that the FACT-B scores were slightly higher in patients using BPJS for Health than those not, this research provides evidence that BPJS for Health insurance scheme has benefited breast-cancer patients in terms of patient-reported treatment outcome. However, further studies are required to evaluate the effectiveness of BPJS for Health using other parameters so as to build a strong evidence for its performance.

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References: Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. (2011). Global cancer statistics. CA Cancer J Clin;61:69-90.â&#x20AC;¨ Kemenkes RI. (2013). Bahan paparan jaminan kesehatan nasional (JKN) dalam sistem jaminan sosial nasional.

Jakarta, Indonesia: JKN Press.

Meneses K, Azuero A, Hassey L, McNees P, Pisu M. (2012). Does economic burden influence quality of life in breast cancer survivors?.Gynecol Oncol;124:437-43.

Youlden DR, Cramb SM, Yip CH, Baade PD. (2014). Incidence and mortality of female breast cancer in the Asia-Pacific region. Cancer Biol Med.;11(2):101-15.

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Community initiatives in preventive medicine - Saku, Japan

Aya Namba, Eriko Kamijo, Keiichi Matsui, Kotaku Nakasone, Kyohei Sano, Satoru Ueda, Shiichi Ihara, Syungo Takeuchi, Tomoki Matsuoka

Background of the Study Saku city located in the East part of Nagano Prefecture, which situated in the center of Honshu the main island of Japan has been developed by agriculture. Looking into the specific data, the National Medical Care Expenditure for the elderly in the latter stage was $8,370 in Japan, on the other hand $6,732 in Saku from the survey held in 20081. Inquiring into self-perceived health, the rate of people who chose 1 or 2 on the scale of 1-5, 5 referring to the best condition and 1 to the worst, was only 7% in Saku2, while the average was 23.2% in Japan3. It indicates that most residents have confidence in their own health. These results are highly estimated by WHO, and Saku Central Hospital, a base hospital in this region, was registered as “Health Promoting Hospitals”. It represents that this hospital is evaluated as the one aiming at improving the health outcomes of people living in the community and at enhancing its health impact on the hospital’s environment4.

About 70 years ago, however, the residents couldn’t receive enough medical treatments because of the condition of poor transportation and its culture. Moreover, the infrastructure was not well-improved and the residents had little knowledge on health. For these reasons, health conditions of the residents faced a severe situation.

The purpose of this research was to reveal the key factors of the success that Saku has become one of the healthiest cities in Japan by improving health conditions. We casted a spotlight on health services provided by Saku Central Hospital and the strong connectedness among the residents to extract the factors. This paper mainly focused on Health Services and Social Support Networks as social determinants of health5. We would like to suggest that this success is caused by the relationship between these determinants.

Methods and Results

In this part, we would like to evaluate the usefulness of following three actions from the viewpoint of preventative medicine: Visiting Examination, Health Volunteers, and Health Management System. This study was conducted by using analyzed secondary data and information obtained by interviewing staffs at 70th Saku Central Hospital Festival in 21st and 22nd May, 2016.

Visiting Examination In the 1945, Saku Central Hospital started Visiting Examination in rural area after encountered many critically ill cases at the hospital. Only 2% of population in Saku could afford medical costs6. Thus, medical care wasn’t accessible to them. To resolve the situation, the Hospital organized “home visit volunteer group” among agricultural cooperative and doctors found out common diseases through this activity in the community, as well as potential patients, and disease background.

The incidence rate of tuberculosis was 618 people in Saku7, while 490 people in Japan8 (per 100,000 population). In addition, the rate of death from cerebrovascular disease was 177 people in Saku; however, it is only 127 people in Japan (per 100,000 population)9.

During Visiting Examination in the community, hospital staffs offered a play on the theme of health. The purpose of Play was health promotion, dedicated better understanding and actual health action10. To attract the residents, they made a play suitable to the needs of local people. Later on, these activities changed into “Health Festival” in the community.

Visiting Examination developed to medical checkup because the doctors’ thought that regular check-up had to be introduced so as to promote prevention. Even simple vital checkup helped villagers to aware their health status.

Prior to visiting examination, village officials, hospital staffs and health volunteer had meetings for the schedule, upon medical checkup, local women’s association prepared for staff meals. After the health checkup, villagers and hospital staffs had social gathering which helped closer distance between doctors, nurses and villagers and maintained interpersonal relationship.

The Activities of Health Volunteers In Saku, health management activities have been conducted mainly by the community. Health volunteers work as intermediators between the residents and health care providers, and they mostly take part in those activities to provide medical knowledge to the residents and also to enlighten them. In addition, health volunteers are chosen by the recommendation of residents and appointed by the mayor. This health service had taken into consideration because of the amoebic dysentery epidemicin 195311. Lack of knowledge about sanitation led to the epidemic. In order to solve the situation, health care providers introduced the residents with medical knowledge and, finally, the epidemic came to an end in 1954 due to these activities and improvement in infrastructure11. Subsequently, Nagano prefectural office newly established the health instructor position to prevent amoebic dysentery from spreading (Fig. b) and the results show that the number of patients who were diagnosed as amoebic dysentery stopped increasing significantly after 195511. Moreover, health RESEARCH PAPER COMPETITION

instructors provided direction not only to prevent amoebic dysentery but to eradicate tick and round warm. (Fig. c)12 The results reveal that the rate of parasitic infection decreased from 43.4% to 4% only in 9 years12. A women’s association is also another example of health promoting activities. Owing to their activities, more and more women undergo uterine and breast cancer screening gradually (Fig. d, Fig. e)13. Furthermore, looking into the survey conducted from 1997 to 1998, 48.5% of the young (the 20s), and 82.6% of the elderly (the 70s and over) evaluated the knowledge of health volunteers as useful14.

Furthermore, the survey was held in the 1968 to examine how accurately the residents had knowledge about health. The calculation of chi-square test showed that accuracy about tetanus and farmer’s syndrome were statistically significant at the p= 0.05 and p= 0.01 level (Fig. f)15.

In 1984, health volunteers came up with an idea of Health Festival to realize their opinion that the residents should concern about their health more subjectively and spread the knowledge over the region16.

The main project of Health Festival was residents’ presentations of their own experience and research, and health volunteers also made presentations about health and medicine. In the festival, the residents selected the theme voluntarily every year, studied it throughout the year and gave a presentation about the results of their investigation16.

In fact, residents’ both participant and evaluation on Health Festival were remarkably high. The rate of the residents who attend Health Festival more than several time were 42.7% (the 50s and 60s) and 64.2% (the 70s and over) (14). In addition, the rate of the residents who thought Health Festival as useful was below: 60.6% (the 20s), 51.4% (the 30s and 40s), 73.7% (the 50s and 60s) and 82.2% (the 70s and over) (14).

Health Management System In 1959, Yachiho village, Saku region started medical check-up for entire residents. The purpose of this project was to detect diseases in the early stage, to prevent diseases and to know the problem of their health. Moreover, Saku region not only did the medical check-up but also did some projects as described below, under the slogan of ‘Health education through medical check-up’. Residents were directly explained how to view the medical check-up list and the details of the results.

Residents made opportunities to discuss the health condition of the community and how to cope with that condition by the result17.

Medical check-up for entire residents cost a lot and it took time to have an effect. At first there was a protest movement but Saku continued this project, and the medical examination rate reached to about 80% which is a very high rate (Fig. g)18. Gradually there was an effect on residents’ health. For example, the number of ‘Patients whose diseases are too late to be cured’ and ‘Patients who died because the diseases were too late to be cured’ have decreased (Fig. h)19.

In addition, ‘Healthcare Notebook’ and ‘Medical Record Register’ were introduced to Saku. People bring ‘Healthcare Notebook’ when they go to a doctor or to the medical check-up, and they write the medical histories and the results of medical check-up. In the ‘Healthcare Notebook’, there are not only spaces for the doctors to write but also sections for residents to fill in by themselves to take care of their health. Moreover, it provides useful health information. By regularly checking ‘Healthcare Notebook’, people can always know their own health conditions and doctors can recognize patients’ medical histories at once even if it is the first visit.

Financial conditions of households, family structures, and sanitary conditions of Saku is written in ‘Medical Record Register’. The village office and the health management department of the hospital utilize this so that people can understand their community health. Saku was the earliest region to start these projects which was rooted in the community. These unique projects attracted great attention, and in 1981, senior government officers, Department of Health, Labor, and Welfare visited Saku Central Hospital to inspect these health management systems. This how inspection helped to legislate "Law of Health and Medical Services for the Elderly", implementation in 1983, and the law adopted "Healthcare Notebook" for distribution all over Japan20. it was determined to distribute ‘Healthcare Notebook’ all over Japan. By referring to this instance, you can realize that the success in Saku has been widely spread throughout Japan.

Saku made a big success in detecting diseases in the early stage and preventing diseases because of the high medical examination rate. In addition, Saku established the original way for residents to manage their own health by themselves and the health management system of the community by introducing ‘Healthcare Notebook’ and ‘Medical Record Register’.

Conclusion

The purpose of this research is to analyze health services held in Saku so as to reveal the key factors of the success. We would like to suggest that three factors proposed in Methods and Results play an important role in the community.

Visiting examination began in order to reduce the number of fatal patients, and the doctors were able to come to realize the situation and the problems of the region. We’ve confirmed that this health service contributed to building strong relationship between the health professionals and the local residents and this has made it easier to introduce various health services.

The system of health volunteers was introduced to prevent amoebic dysentery from spreading in that area again.

Health volunteers provided knowledge about health to the residents through health outreach program, and it encouraged the residents to participate in the activities voluntarily. We presume that these activities have helped the residents join the health ASIAN MEDICAL STUDENT CONFERENCE 2016 | MANILA, PHILIPPINES

promoting activities without hesitation.

Health management system was established to extend preventive medicine. For example, it made the residents have Medical check-up and fill in their Healthcare notebook by themselves, aiming at improvement in health education as well as detect diseases in the early stage. We assume that the system led to the improvement of the people’s attitudes toward their health because they could manage their own health conditions by using the system.

It is a remarkable fact that the residents lecture health knowledge to each other as practice of preventive medicine.

In Saku, social services had been provided by health professionals as they were done in other regions, however social services have become social support network in which local residents participate in on their own initiative.

Now, we will discuss the key points of this success. This study suggests two factors; one is that these Health Services met the local residents’ demands, and the other is that their attitude toward health became better because of the social services which let local residents know their own state of health and urge them to take control of their own healthcare.

In Saku, visiting care revealed what people required and it helped the society to establish a new social service.

Health Management System changed residents’ attitude toward their health and made people interested in the health outreach program. Health volunteers provided health outreach services which people can participate in with enjoyment, such as the Health Festival. In this way these three social services stated above was connected and changed into social support network led by the local residents themselves.

References 1. Saku-shi ga motu sekaisaikoukenkoutoshi ni muketa sozi (The regional uniqueness in Saku leads to the healthiest city in the world). The scheme of realizing the healthiest city in the world. Saku office (2008). p11. Retrieved from https:// www.city.saku.nagano.jp/kenko/kenkozoshin/sonota/koso.files/file1 230.pdf 2. Natsukawa S. Nouson koureisya no kenkou sien suisinn zigyou houkokusho (The report paper about health supporting and promoting business) (2010). The Japanese Research Association of Rural Medicine, The Japanese institute of Rural medicine. p123 3. Koureisya no seikatsuzittai ni kansuru tyousakekka (The results about actual life situation of the elderly). Cabinet Office of Japan (2010). p7 Retrieved from http://www8.cao.go.jp/kourei/ishiki/h20/kenkyu/zentai/pdf/p7-28.pdf 4. Christina Dietscher, Jürgen Pelikan, Hermann Schmied. Health Promoting Hospitals Retrieved from http:// www.oxfordbibliographies.com/view/document/obo- 9780199756797/obo-9780199756797-0131.xml 5. Health Impact Assessment –Social determinants of health. WHO. Retrieved from http://www.euro.who.int/__data/assets/ pdf_file/0005/98438/e81384.pdf (6) Wakatsuki, T. Kenko na mura healthy village. Iwanami Shoten. p.133- 134 6. Wakatsuki, T. Kenko na mura (a healthy village). Iwanami Shoten. p.126 (8) Shimao, T. Ohmori, M. Notification Rate of TB in Japan (1949-2001) p.23. the Research Institute of Tuberculosis, Japan Anti-tuberculosis Association 7. Wakatsuki, T. Kenko na mura (a healthy village). Iwanami Shoten. p.145 (10) Wakatsuki, T. Mura de Byouki to Tatakau.

Iwanami Shoten. p.28-34 8. Maezima, F (2011). Senngo no kennkou・seikatuzyoukyou (people`s health and the situation of their life after WWII).

Kenkou na chiiki dukuri ni mukete (to make the local residents healthy). Saku central hospital, p.33 9. Saguchi, M. Ipponyari, N. Uchida, N. Ide, J.Mizusawa, M. Yoshida, T. Takamizawa, Y. Asanuma, S(2011). Kenkoukadai to sono taisaku (the health problem and the measures against it). Kenkou na chiiki dukuri ni mukete (to make the local residents healthy). Saku central hospital, p.81 10. Iijima, I. Ichikawa, S. Sugita, R. Nakayama, D. Maejima, H. Yui, S. Takase, M. Mizusawa. M. Kobayasi, S. Ikeda, T. Nakazawa, A. (2011). Chiki katudou no zicchi to hyouka (local activity and evaluation of it). Kenkou na chiiki dukuri ni mukete (to make the local residents healthy). Saku central hospital, p.193 11. Matusima, M (2011). Zenson kenkou kanri no kouka to hyoukaII (the effect and the evaluation of Medical management system II). Kenkou na chiiki dukuri ni mukete (to make the local residents healthy). Saku central hospital, p.245 12. Matusima, M (2011). Zenson kenkou kanri no kouka to hyouka (the effect and the evaluation of Medical management system). Kenkou na chiiki dukuri ni mukete (to make the local residents healthy). Saku central hospital, p.107 13. Iijima, I. Ichikawa, S. Sugita, R. Nakayama, D. Maejima, H. Yui, S. Takase, M. Mizusawa. M. Kobayasi, S. Ikeda, T. Nakazawa, A. (2011). Chiki katudou no zicchi to hyouka (local activity and evaluation of it). Kenkou na chiiki dukuri ni mukete (to make the local residents healthy). Saku central hospital, 175-176 14. Omoto, K (2008). The development of health prevention system in Japan.

15. Tokyo Keizai daigaku kaisi (magazine of Tokyo Keizai University) (261). Tokyo Keizai University,183-189 16. Matusima, M (2011). Zenson kenkou kanri no kouka to hyouka (the effect and the evaluation of Medical management system). Kenkou na chiiki dukuri ni mukete (to make the local residents healthy). Saku central hospital, p.101 17. Matusima, M (2011). Zenson kenkou kanri no kouka to hyouka (the effect and the evaluation of Medical management system). Kenkou na chiiki dukuri ni mukete (to make the local residents healthy). Saku central hospital, p.103

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18. Wakatuki, S (1993). Kenkou kanri no gennten yachiho mura (health management started from Yachiho village). Kenkou na chiiki dukuri ni mukete (to make the local residents healthy). Saku central hospital, p.15 19. Maezima, F (2011). Zyuumin no group katsudo (residentsâ&#x20AC;&#x2122; group activities) Kenkou na chiiki dukuri ni mukete (to make the local residents healthy). Saku central hospital, 35-38

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Do Universiti Sains Malaysia Medical Students Burn Out? Chin Ri Wei Andrew, Chua Yun Yuan, Chu Min Ning, Nur Farhanie Binti Mahadi, Muhammad Saiful Bahri Yusoff, Wong Mung Seong, Lee Yeong Yeh arjot Kaur

Key words: Burnout, Malaysia, Medical Students, Student Wellbeing, Higher Education Background of the Study The academic life of medical students can be considered psychologically toxic. A recent meta-analysis revealed a high prevalence of depression among medical students across the globe – the estimated prevalence was 28.0% (95% confidence interval [CI] 24.2–32.1%) (Puthran, Zhang, Tam, & Ho, 2016). In contrast, prior to entry into medical school, the prevalence of depression was only between 1.4% and 1.8% (Smith, Peterson, Degenhardt, & Johnson, 2007; Yusoff et al., 2013). Since burnout can be considered as the stage before depression, therefore we hypothesized the prevalence of burnout would be higher than depression amongst medical students.

Burnout is characterized by three features that include emotional exhaustion, depersonalization and reduced professional efficacy (Lee, Medford, & Halim, 2015) . Emotional exhaustion is manifested by emotional depletion from being overworked, depersonalization is a sense of being unfeeling towards patients or peers (often negative, callous and detached responses), and reduced professional efficacy, a domain specific to human services industry, is a reduced sense of competence or achievement in one’s work. Based on recent data, more than half of students in United States medical schools reported burnout. (Liselotte N Dyrbye et al., 2008; Santen, Holt, Kemp, & Hemphill, 2010) but none were reported from Malaysia.

For that reason, this study was designed to address two questions; 1) What is the prevalence of burnout among medical students in a Malaysian medical school? 2) Are gender, ethnicity and year of study the associated factors of burnout?

Methods We performed a cross sectional study of medical students from year one to five of Universiti Sains Malaysia (USM) from August to November 2015. Eligible participants were consented prior to study entry. Ethical approval was obtained from the Human Research Ethics Committee of USM. Participants were approached via Facebook Messenger and the data were collected through an online questionnaire using the Google Forms platform. Each respondent submitted only one Google Form as no resubmission link was provided once the respondent submitted the completed form. The Copenhagen Burnout Inventory (CBI) questionnaire was distributed to USM medical students from year 1 to year 5.

The 19-item CBI questionnaire has three domains that include personal, work-related and client-related burnout with responses in 5-point Likert scale ranging from 0 to 4. All items except item 2(g) has reverse scoring in view of its positive wording. Higher scores indicate a higher level of burnout. Any mean scores of more than 2 was considered as burnout.

The statistical analysis was performed by SPSS. The prevalence of burnout and its associated factors were presented in frequency and percentage. Chi- Square test was performed to examine the association between factor variables and burnout in view of the expected count less than 5 is less than 20%.

Results The response rate was 55.8% in 810 of students surveyed. The highest response rate was 79.3% from first year students and the lowest was 45.8% from third year students. Of 452 participants, 307 (67.9%) reported burnout. Personal burnout was the highest at 81.6%, followed by work-related burnout at 73.7% and client-related burnout at 68.6% (Figure 1).

The prevalence of burnout was highest in year 4 especially personal and work-related burnout (Figure 2). However, the rate of burnout and its domain according to year of study is not statistically significant as shown in Figure 2. Year 4 is the transition period from pre-clinical years to clinical years and it requires them to adapt quickly in a patient-centered learning environment. This might have caused the personal burnout in year 4 students in our study. In addition, they need to familiarize with additional ward works and on-calls which can be stressful for first-timers, and this then led to work-related burnout in our participants.

On the other hand, the prevalence of client-related burnout was highest in year 1 students followed closely by year 5 students (Figure 2). In this context, clients were referred to as the person to which the respondents spent most of their time with during the academic session, for examples lecturers, patients and friends. The client-related burnout among Year 1 students could be the result of having difficulties in adapting to the lecturer’s teaching style which is different from that of their pre-university institution and the inadequate academic assistance from their seniors in view of the newly-implemented ASIAN MEDICAL STUDENT CONFERENCE 2016 | MANILA, PHILIPPINES

curriculum.

With respect to gender, female medical students reported a higher level of burnout (81.8%) compared to male students but this was not statistically significant (p < 0.05) (Figure 3). According to ethnicity, overall burnout was higher with the Malays (68.7%) compared to the non-Malays (67.3%) but again this was not statistically significant (Figure 4). Among three domains of burnout, personal burnout was the most prevalent across all ethnicities (Figure 4).

These results indicated that regardless of gender, ethnicity and year of study, medical students were vulnerable to burnout. This finding is supported by previous studies (Cecil, McHale, Hart, & Laidlaw, 2014) (de Oliva Costa EĂŠ, Santos, de Abreu Santos, de Melo, & de Andrade TĂ­, 2012).

The conceptual model of coping reservoir might explain burnout among medical students (Dunn, Iglewicz, & Moutier, 2008). This model describes coping capabilities and subsequent well-being of students. Through negative input by depleting factors like stress, internal conflict, and time and energy demands, coupled with limited replenishing factors like lacking of psychosocial support from peers and medical school administration, less involvement in social activities due to limited leisure time and insufficient intellectual stimulation; these will diminish the studentsâ&#x20AC;&#x2122; coping reservoir for handling medical school challenges, and may eventually lead to burnout.

According to a multi-institutional study done in the United States on burnout and suicidal ideation among medical students (L. N. Dyrbye et al., 2008), burnout demonstrated a strong dose-response relationship with suicidal ideation. This association also satisfied both the temporality requirement (burnout preceded suicidal ideation) and the criteria for reversibility (risk for suicidal ideation returned to baseline with recovery from burnout). Hence establishes an association between burnout and suicidal ideation among medical students.

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Conclusion Based on CBI, the prevalence of burnout among medical students from USM is 67.9%, but the most prevalent type across all years of study is personal burnout. Regardless of gender, ethnicity and year of study, medical students are vulnerable to burnout.

We believe a significant proportion of these burned out students may be at risk for getting depression or even suicidal ideation later but this needs further studies. For both mental and social well-being of future doctors, the problem of burnout should be a concern for the school administration.

References Cecil, J., McHale, C., Hart, J., & Laidlaw, A. (2014). Behaviour and burnout in medical students. 2014. doi:10.3402/ meo.v19.25209 deOlivaCostaEé,F.,Santos,S.A.,deAbreuSantos,A.T.R.,deMelo,E.V.,& de Andrade Tí, M. (2012). Burnout Syndrome and associated factors among medical students: a cross-sectional study. Clinics (Sao Paulo), 67(6), 573-579. doi: 10.6061/clinics/2012(06)05 Dunn, L. B., Iglewicz, A., & Moutier, C. (2008). A conceptual model of medical student well-being: promoting resilience and preventing burnout. Acad Psychiatry, 32(1), 44-53. doi:10.1176/appi.ap.32.1.44 Dyrbye,L.N.,Thomas,M.R.,Massie,F.S.,Power,D.V.,Eacker,A.,Harper,W., . . . Novotny, P. J. (2008). Burnout and suicidal ideation among US medical students. Annals of internal medicine, 149(5), 334-341.

Lee,Y.,Medford,A.,&Halim,A.(2015).Burnoutinphysicians.The journal of the Royal College of Physicians of Edinburgh, 45(2), 104-107.

Puthran, R., Zhang, M. W., Tam, W. W., & Ho, R. C. (2016). Prevalence of depression amongst medical students: a metaâ €•analysis. Medical education, 50(4), 456-468.

Santen,S.A.,Holt,D.B.,Kemp,J.D.,&Hemphill,R.R.(2010).Burnoutinmedical students: examining the prevalence and associated factors. Southern Medical Journal, 103(8), 758-763.

Smith, C. K., Peterson, D. F., Degenhardt, B. F., & Johnson, J. C. (2007). Depression, anxiety, and perceived hassles among entering medical students. Psychology, health & medicine, 12(1), 31-39.

Yusoff, M. S. B., Abdul Rahim, A. F., Baba, A. A., Ismail, S. B., Mat Pa, M. N., & Esa, A. R. (2013). The impact of medical education on psychological health of students: A cohort study. Psychology, health & medicine, 18(4), 420-430.

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The Impact of Housing on the Health and Wellbeing of Older Chinese Migrants in New Zealand Chew, Nicholas, and Shie, Caroline

Key words: Housing, Older Chinese, Health Background of the Study

Health inequities arising from the social gradient is prevalent in New Zealand. There is a growing Chinese population in New Zealand, with almost a three-fold increase of older Chinese people (aged 65 and above) who were born overseas from 2001 to 2013 (Statistics New Zealand, 2001; Statistics New Zealand, 2013). Chinese makes up the majority of New Zealand’s Asian population. Older Chinese migrating to New Zealand in their old age face many challenges like language barriers and culture shock. Most Ageing in Place policies in New Zealand have focused on established residents (those who were born in New Zealand or have lived in New Zealand for more than 10 years after immigration), but missed out on older immigrants who recently arrived in New Zealand (for less than 10 years). The latter group does not receive publicly funded superannuation and they are most likely to be susceptible to social determinants of health.

Earlier reports have shown that the Chinese population are less likely to be homeowners, and are also least likely to report housing hazards. Together with cultural differences, immigrant status and reduced social connectedness, the older Chinese population tends to be more vulnerable to the consequences of poor housing. To this date, little research has been done on the impact of housing on the health and wellbeing of older Chinese people living in New Zealand. This paper aims to portray the importance of housing, household safety, social connectedness and culture on the health and wellbeing of older Chinese people. In order to address these issues, we propose the initiative of stronger collaborations between local community organisations and primary healthcare providers to promote community involvement, security and a sense of belonging. Our main goal is to enable older Chinese people who have migrated in their old age to experience successful ageing in place.

Methods

A literature review was carried out using the database PubMed, Medline and Google Scholar. The search terms were "Older Chinese Housing New Zealand", "Ageing in Place", "Older Chinese Housing", "Older People Housing New Zealand", and "Older People Social Determinants of Health". There were 102 hits of which 34 were relevant. 16 of these were review articles and the rest were original reports. The author could not access 8 of these articles. Hence a total of 26 articles were reviewed.

This study incorporated a qualitative component involving semi-structured interviews with informants regarding the proposed intervention of a collaborative approach to promote health and wellbeing of the older Chinese immigrants, through facilitated partnerships between local housing organisations, community associations and networks, and primary healthcare providers such as general practitioners. The interviews were conducted in 2016. The authors highlighted the important findings of the literature review to the various key informants and services, emphasizing that cultural differences, immigrant status and social isolation may result in certain housing situations that are different from 'mainstream' New Zealanders, and that these health-related issues are often overlooked. We obtained feedback from the key informants regarding the possibility of stronger collaboration between primary healthcare and community services in order to develop services to help bridge this gap. The paper outlined the general structure of this initiative – 1) Mapping out areas where majority of older Chinese communities reside; 2) Identifying the available community/housing organisations, health services within the region; 3) Initiating discussions between the services.

The informants involved were senior researchers in the field of migrant health, community leaders, property managers, senior medical consultants and allied health professionals. The informants provided their assessment and feedback through semi-structured interviews. The interviews were done via phone calls, email correspondence or face-toface, which lasted between 30 - 45 minutes.

Results The paper has identified five major components of housing that have impacted the health and wellbeing of the older Chinese community.

1) Housing tenure, home modification, repair and maintenance: Home ownership was found to be significantly lower in the older Chinese community; home repairs and maintenance were not common practices amongst the older Chinese people (Ho, Lewin, & Muntz, 2010). Established papers have demonstrated that housing tenure is closely linked to cardiovascular and all-cause mortality (Costa-Font, 2007; Macintryre et al, 2003; Evans et al, 2003). Elderly people renting homes have higher mortality rates than those in self-owned houses (Howden-Chapman, Signal, & Crane, 2009). Older people with twice the housing equity had 3.4% higher self-reported health RESEARCH PAPER COMPETITION

2) Living arrangements: The most common living arrangement type within the Chinese population was living as a ‘couple with children and family members’. However, we noted that the older Chinese people are experiencing a gradual cultural change in which the younger counterparts are choosing to live independently from their parents (Ho et al., 2010; Selvarajah, 2004). Studies have shown that large household types can act as a double-edged sword. Large household types can be beneficial for older people’s health and wellbeing, particularly for those in ‘transitional’ life stages (dependent elderly) as family members are able to offers physical, psychological and emotional support. However, increased housing density can also lead to overcrowding, resulting in increased risk of communicable illnesses, as well as increased stress and tension amongst family members (Garner, 2006).

3) Housing safety: Most of the older Chinese people have reported concerns regarding housing hazards, such as dampness and cold. A poorly insulated house is more susceptible to being damp, which creates an ideal environment for mould and microorganisms to grow. There is a positive correlation between damp housing, presence of mould and increased rates in respiratory conditions and asthma. A study in Auckland found that cold stress increases the risk of cardiovascular mortality (Howden-Chapman et al., 2009). Nevertheless, the majority of older people, especially those living in larger household types, were satisfied with the levels of safety within their homes and neighbourhood (King, 2009).

4) Social connectedness: With the rising proportion of frail Chinese people, there is increased risk of potential neglect and isolation. Close family relationships and the traditional norms of support in the Chinese culture remain the key protective factors. There is a gradual cultural change as it is increasingly common for older Chinese people to live independently from their families (Blakemore, 1999). The surveys demonstrated that a large proportion of older Chinese people have made attempts to develop social connectedness within the community and that they are often reliant on the co-ethnic interactions with the local community for their daily activities. Moreover, they still valued companionship with children and spouse more highly than social support from others (Ho et al., 2010). Studies have shown that older adults with stronger support levels have better health and wellbeing outcomes (Bowling, 1991; Ashida & Heaney, 2008). Older people with perceived social connectedness and the sense of belonging and security are likely to have a positive psychological state, impacting on the neuroendocrine and immune function (Cohen, Gottlieb, & Underwood, 2000). Moreover, it has been shown that loneliness was associated with chronic illnesses like pulmonary disease and arthritis among older people (Penninx et al., 1999; Ashida & Heaney, 2008).

5) Immigration and culture: Migration often result in unfamiliarity, disruption of social networks, cultural values and daily practices that are essential to one’s life (Li, Hodgetts, & Ho, 2010). The current literature highlights the importance of culture and place-based identity, which offers a sense of belonging and security, through home-ownership and housing design (Li et al., 2010; Wilmoth & Chen, 2003). Moreover, establishing safety nets within the community through local healthcare providers and local community organisations can improve health-seeking behaviours and appropriate use of healthcare resources. Research has shown that immigrants in less- established areas tend to rely on emergency departments for their healthcare due to language barriers, poor health literacy and inadequate understanding of the healthcare system (Derose Escarce, & Lurie, 2007).

Overall, due to language and cultural differences, older Chinese people who have migrated to New Zealand in old age are more vulnerable to the consequences of poor housing. Studies have agreed that poor housing can affect health and wellbeing both physically and psychologically. In order to tackle these housing-related issues, the paper recommended stronger collaboration between local community organisations, housing services and primary healthcare organisations. This can be done through policies and services that are culturally appropriate for these older Chinese immigrants in order to bridge the gap between housing and health. From the semi- structured interviews with the key informants, our findings reinforced that a stronger collaboration between primary healthcare services and local community organisations can promote community involvement, place-based identity, accessible primary healthcare services, housing safety, patient education, and general housing information.

However, some of the barriers to this initiative were identified: 1) lack of interest in housing amongst general practitioners; 2) patient data confidentiality; 3) lack of financial resources; 4) lack of interactions with housing organisations; 5) limitations of current governmental policies; 6) lack of a centralized system to coordinate partnerships; 7) unclear of mechanism of collaboration.

Conclusion Housing is an important social determinant of health for older Chinese people, especially those who have recently migrated, as it is a proxy of socioeconomic status, family unity, social connectedness, and feelings of safety. The study proposes a stronger collaboration between the local community organisations and the primary healthcare providers to develop safety nets, promote community involvement and encourage successful ageing in place within the older migrant Chinese population. This paper also offers insight into the views of housing professionals, community services, migrant health experts and healthcare providers (particularly, general practitioners) on the initiative of bridging the gap between housing and health.

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1440-1614.1999.00519.x Aroian, K. J., Wu, B., & Tran, T. V. (2005). Health care and social service use among Chinese immigrant elders. Research in Nursing & Health, 28(2), 95–105. http://doi.org/10.1002/nur.20069 Ashida, S., & Heaney, C. A. (2008). Differential associations of social support and social connectedness with structural features of social networks and the health status of older adults. Journal of Aging and Health, 20(7), 872–893. http:// doi.org/10.1177/0898264308324626 Blakemore, K. (2000). Health and social care needs in minority communities: an over- problematized issue? Health & Social Care in the Community, 8(1), 22–30. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/11560671 Bowling, A. (1991). Social support and social networks: Their relationship to the successful and unsuccessful survival of elderly people in the community. An analysis of concepts and a review of the evidence. Family Practice, 8(1), 68-83.

Chung, H. F. L., & Tung, R. L. (2013). Immigrant social networks and foreign entry: Australia and New Zealand firms in the European Union and Greater China. International Business Review, 22(1), 18–31. http://doi.org/10.1016/j.ibusrev.

2012.01.005 Cohen, S., Gotlieb, B. H., & Underwood, L. G. (2000). Social Relationships and Health. Social Support Measurement and Intervention: A Guide for Health and Social Scientists. http://doi.org/10.1016/0277-9536(92)90365-W Costa-Font, J. (2008). Housing assets and the socio-economic determinants of health and disability in old age. Health and Place, 14(3), 478–491. http://doi.org/10.1016/j.healthplace.2007.09.005 Costigan, C. L., & Koryzma, C. M. (2011). Acculturation and adjustment among immigrant Chinese parents: mediating role of parenting efficacy. Journal of Counseling Psychology, 58(2), 183– 196. http://doi.org/10.1037/a0021696 Derose, K. P., Escarce, J. J., & Lurie, N. (2007). Immigrants and health care: Sources of vulnerability. Health Affairs. http:// doi.org/10.1377/hlthaff.26.5.1258 Dunn, J. R., & Dyck, I. (2000). Social determinants of health in Canada’s immigrant population: results from the National Population Health Survey. Social Science & Medicine, 51(11), 1573– 1593. http://doi.org/10.1016/ S0277-9536(00)00053-8 Evandrou, M. (2000). Social inequalities in later life: the socio-economic position of older people from ethnic minority groups in Britain. Popul Trends, (101), 11–18.

Evans, G. W., Wells, N. M., & Moch, A. (2003). Housing and mental health: a review of the evidence and a methodological and conceptual critique. Journal of Social Issues, 59(3), 475– 500. http://doi.org/10.1111/1540-4560.00074 Garner, G. (2006). The ecology and inter-relationship between housing and health outcomes. Retrieved from http:// eprints.qut.edu.au/7216/1/7216.pdf Ho, E., Lewin J., & Muntz M. (2009). Ageing well in a new country: preliminary findings of a survey of older chinese in new Zealand. The University of Waikato, 1 – 23.

Howden-Chapman, P., Viggers, H., Chapman, R., O’Dea, D., Free, S., & O’Sullivan, K. (2009). Warm homes: Drivers of the demand for heating in the residential sector in New Zealand. Energy Policy, 37(9), 3387–3399. http://doi.org/10.1016/ j.enpol.2008.12.023 Jatrana, S., & Blakely, T. (2008). Ethnic inequalities in mortality among the elderly in New Zealand. Australian and New Zealand Journal of Public Health, 32(5), 437–443. http://doi.org/10.1111/j.1753-6405.2008.00276.x Johnston, R. J., Trlin, a. D., Henderson, a. M., North, N. H., & Skinner, M. J. (2005). Housing Experience and Settlement Satisfaction: Recent Chinese, Indian and South African Skilled Immigrants to New Zealand. Housing Studies, 20(3), 401–421. http://doi.org/10.1080/02673030500062418 Krieger, J., & Higgins, D. L. (2002). Housing and health: Time again for public health action. American Journal of Public Health. http://doi.org/10.2105/AJPH.92.5.758 Koopman-Boyden P., & Waldegrave C. (2009). Enhancing wellbeing in an ageing society: 65 – 84 year old New Zealanders in 2007. Population Studies Centre and Family Centre Social Policy Research Unity, 1, 1 – 200.

Li, W. W., Hodgetts, D., & Sonn, C. (2014). Multiple senses of community among older Chinese migrants to New Zealand.

Journal of Community and Applied Social Psychology, 24(1), 26– 36. http://doi.org/10.1002/casp.2174 Macintyre, S., Ellaway, A., Hiscock, R., Kearns, A., Der, G., & McKay, L. (2003). What features of the home and the area might help to explain observed relationships between housing tenure and health? Evidence from the west of Scotland.

Health and Place, 9(3), 207–218. http://doi.org/10.1016/S1353-8292(02)00040-0 Marmot, M., Friel, S., Bell, R., Houweling, T. A., & Taylor, S. (2008). Closing the gap in a generation: health equity through action on the social determinants of health. The Lancet, 372(9650), 1661–1669. http://doi.org/10.1016/ S0140-6736(08)61690-6 Park, H. J., & Kim, C. G. (2013). Ageing in an inconvenient paradise: The immigrant experiences of older Korean people in New Zealand. Australasian Journal on Ageing, 32(3), 158–162. http://doi.org/10.1111/j.1741-6612.2012.00642.x

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Penninx, B. W. J. H., van Tilburg, T., Kriegsman, D. M. W., Boeke, a. J. P., Deeg, D. J. H., & van Eijk, J. T. M. (1999). Social Network, Social Support, and Loneliness in Older Persons with Different Chronic Diseases. Journal of Aging and Health, 11(2), 151–168. http://doi.org/10.1177/089826439901100202 Rutter, J., & Latorre, M. (2009). Social housing allocation and immigrant communities. Institute for Public Policy Research.

Selvarajah C. (2004). Expatriation experiences of Chinese immigrants in New Zealand: factors contributing to adjustment of older immigrants. Management Research News, 27, 26 – 45.

Stafford, M., & McCarthy, M. (2009). Neighbourhoods, housing, and health. In Social Determinants of Health. http://doi.org/ 10.1093/acprof:oso/9780198565895.003.14 Tsang, E. Y. L., Liamputtong, P., & Pierson, J. (2004). The views of older Chinese people in Melbourne about their quality of life. Ageing and Society, 24, 51–74. http://doi.org/Doi 10.1017/S0144686x03001375 Wen Li, W., Hodgetts, D., & Ho, E. (2010). Gardens, transitions and identity reconstruction among older Chinese immigrants to New Zealand. Journal of Health Psychology, 15(5), 786–796. http://doi.org/10.1177/1359105310368179 Wiles, J. L., Allen, R. E. S., Palmer, A. J., Hayman, K. J., Keeling, S., & Kerse, N. (2009). Older people and their social spaces: A study of well-being and attachment to place in Aotearoa New Zealand. Social Science and Medicine, 68(4), 664–671. http://doi.org/10.1016/j.socscimed.2008.11.030 Wilmoth, J. M., & Chen, P. C. (2003). Immigrant status, living arrangements, and depressive symptoms among middle-aged and older adults. Journals of Gerontology Series B- Psychological Sciences and Social Sciences, 58(5), S305–S313. http://doi.org/10.1093/geronb/58.5.S305

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Factors Affecting the Acquisition of Health Insurance Acquirement among Migrant Factory Workers: Pilot study

Premcharoen, Jongsarit, Kittipute, Jinna, Koem, Chanthorn, Som, Sintan, Chuthong, Watcharakorn, Jaroenwareekul, Surachat, Wongsuttilert, Alisara Key words: health insurance; worker; factory Background of the Study

In accordance with the Rio Political Declaration, the WHO Social Determinants of Health (SDH) Unit has addressed areas including better governance for health and development, health in all policies training, health sector re-orientation towards the SDH and reducing health inequities, guidance on pro-equity linkages between environmental and social health determinants, and monitoring progress on the SDH and health equity[1-2]. One of the main objectives of the SDHs adopted by Thailand’s Ministry of Health is enhancing healthcare coverage for Thai people and migrant workers. The Thai government provides health insurance for all Thais and documented migrant workers. Illegal migrants with temporary registration status are able to opt into the Compulsory Migrant Health Insurance scheme. Thai and Non-Thai factory workers with health insurance are able to access medical services and additionally may receive the benefits of health promotion and disease prevention projects initiated under the Social Security Scheme.

Chonburi province’s manufacturing and tourism sectors draw migrant workers because of its industrial complexes and its tourist attractions. Thailand’s Ministry of Labor reported that Chonburi had 140,120 legal migrant workers, the highest number of migrant workers in any Thai province [4]. Patient data (2014-2015) from the Burapha University Hospital in Chonburi’s Saensuk Municipality reveals that non-Thai nationals represent 6.3% of total patient registration. The top three nationalities amongst foreign nationals are Cambodian (29.9%), Myanmar (25.8%) and Laos (20.6%) [5]. In Chonburi 67.3% of migrant workers do not have health insurance [4]. These uninsured workers may not enjoy the noted benefits of access to the healthcare system. A recent study found that Thai government spent 259.6 million baht providing health care for uninsured migrant workers [6].

The objective of this research paper is to gather and evaluate baseline demographic information concerning Thai & immigrant workers and analyze factors affecting the acquisition of health insurance.

Research Method Retrospective cross-sectional study Study Participants and Procedure In April 2016 the Saensuk Municipality, implemented a research project Strengthening Network, Healthy Labor. A total of 114 Thai and migrant laborers employed at two factories were invited to participate by completing a questionnaire. All invited participants returned questionnaire forms. Fifty-nine (51.8%) questionnaires were included in this study. Fifty-five (48.2%) incomplete questionnaires were excluded.

All questionnaires were number coded to protect participants’ identities. In co-operation with Saensuk Municipality questionnaires from this survey were used in this research project. We chose the parameters relating to health insurance coverage from those included in the questionnaires completed during the Municipality’s project and transferred to our data collection form for analysis. All study procedures were approved by the Institutional Review Board of the Faculty of Medicine, Burapha University.

Data Analysis Homogeneity of baseline data and health-related parameters between Thai workers and immigrant workers were analyzed. Categorical data, including gender, religion, marital status, educational level, income, Thai language skills, underlying disease, health insurance status, feeling about health status, incidence of sickness or accident during prior 6 months, difficulty travelling for care, channel for receiving health information, and factory environment impact worker health were analyzed with chi-square test. Continuous data, such as age, was analyzed with independent t-test. Simple logistic regression analysis with a 95% confidence interval by odds ratio established which parameters influence health insurance coverage. Statistical analyses were conducted using STATA 10 and the traditional alpha of 0.05 for statistical significance.

Results This study included 59 questionnaires. Twenty-six participants (44.1%) were Thai workers and 33 (56.0%) participants were immigrant workers. Table 1 provides information about baseline characteristics of workers. Table 2 provides a comparison of health-related parameters for Thai and immigrant workers. Table 3 provides a comparison of parameters for insured and non-insured workers.

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Discussion This study aimed to examine factors associated with acquisition of health insurance among Thai and immigrant workers in SaenSuk municipality. Table 1 suggests there are statistically significant differences between Thai and migrant workers concerning marital status, educational level, average income, skills in reading and writing Thai, and health insurance status. We found that almost of migrants (63.6%) were married with child, but almost of Thai workers (73.1%) were single. All Thai workers had health insurance, but some migrants did not. Migrant workers who are married with children should be a target of health campaign that promoting health insurance. Migrants had also lower average income than Thai workers. Moreover, most of them had poorer reading (30.3%) and writing (24.2%) skills of Thai language. Future policy should ensure that language barriers do not negatively affect migrant workers health status.

In bivariate analyses (Table 2), the incidence of sickness or accident during prior 6 months, difficulty travelling for care, and channel for receiving health information were statistically different between Thai and migrant workers. Most of Thai and migrant workers have no underlying disease and feel themselves to be healthy, but, Thai workers had a greater incidence of sickness or accident in the prior 6 months than did immigrants (p<0.05).

This may suggest that migrant workers are healthier and better adapt to a new workplace than Thai. Migrant workers had significantly greater difficulty with transportation (p<0.05). Future policy should ensure that migrant workers have access to transportation to access medical services.

There are statistically significant differences between the communication channels that Thai and migrant workers received health communications from. Television was the most effective media in both groups, but Thai workers used ASIAN MEDICAL STUDENT CONFERENCE 2016 | MANILA, PHILIPPINES

an internet media more. The differences in preferred channels may be related to significant differences of skill in reading and writing Thai. Future policy should ensure the health promotion materials targeting both Thai and migrant workers use appropriate channels and appropriate media.

Regarding the factory environment, both groups had similar notions about workplace hazards and their impact on their health. The three most common problems were dust, noise pollution and heat. The employer should ensure that workers are made aware of workplace hazards and comply with existing occupational health and safety legislation. Future policy should enhance existing legislation and its control and monitoring.

The prevalence of uninsured Thai and migrant worker is low (8.5%), suggesting good health insurance coverage in the Saensuk district [see Table 3]. However, fewer migrant workers acquired health insurance than Thai workers (p <0.05).

This inequity is significantly correlated with the average income after expenses less than 85.7 US dollars (OD=7.31; 1.00-54.91) and poor reading skill of Thai language (OD=7.37; 1.00-54.91) [see Table 3]. A similar study found that poor communicating skills of local language and lower income effected to the health insurance of migrants [7]. Baker and colleagues show that poor reading ability influences access to healthcare services [8]. Migrant workers in SaenSuk Municipality showed inability to read Thai well. Our study revealed that migrant workers are unable to read Thai well and also have low income. The income disparity must be addressed by appropriate social means such as discussions between the Thai government and employer organizations.

This study has several limitations. First, this study is a retrospective design which lacks some data. Additionally, the survey undertaken by SaenSuk Municipality that our research is based on only considered legal migrant workers. Future research must address the issue of health insurance in the illegal migrant worker population.

Conclusion In conclusion, low average income and poor reading skill of Thai language are highly correlated with health insurance achievement in factory workers. This result may help Thai government and employer organizations planning the policy to improve health quality of migrant workers.

References 1. WHO. (2016). Social determinants of health. Retrieved March 1, 2016, http://www.who.int/social_determinants/en/ 2. WHO. (2015). What are social determinants of health? Retrieved March 1, 2016, http://www.who.int/social_determinants/ sdh_definition/en/ 3. Curran, U. Z., Suphanchaimat, R., & Ramon Lorenzo Luis R. Guinto. (2015). Universal health coverage in “One ASEAN”: Are migrants included? Global health action.8.

4. Department of Employment of Thailand. (2014). Statistics of Legal Foreign Workers in the Kingdom of Thailand.

5. Burapha University Hospital. (2014-2015). The Patient’s Database Between 19 – 60 Years Old in Burapha University Hospital.

6. Sutad Sriwilai. (2013). The impact of labor migration on health systems and expense in Thailand.

7. Migrant working group.(2015). Migrant situation in Thailand 2015. Bangkok: Migrant working group, 2015.

8. Baker, D., Parker, R., Williams, M., & Imara, M. (1996). The health care experience of patients with low literacy. Archives of family medicine., 5(6), 329–34.

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RESEARCH POSTER COMPETITION A Single Centre Audit of Acute Reperfusion Therapy Performance Time and Outcome in Patients with Acute Ischaemic Stroke Social determinants hepatitis B virus infection among children aged 4-6 years in Mongolia Pilot Study of Prevalence and Associated Factors in Health Insurance Inaccessibility among Migrant Workers in Bangkok Metropolitan Region Barriers to Sexual Healthcare in the Australian Refugee Population Alcohol and Drug Addiction in Medical Students: Self-awareness and Comparison with National Data Pre-eclampsia: Outcome of Screening Methods as Intervention on Intermediate Determinants of Health in Lowering Maternal Mortality Rate (MMR) in Surabaya Association Between the Level of Knowledge on Tagalog Translation of Medical Terminologies of the OMMC-OPD OB-GYN Residents and the Motherâ&#x20AC;&#x2122;s Understanding of Prenatal Care A Systematic Review: How Food Affects the Symptoms of ADHD in Children The relationship between heart disease mortality rate and the arrival time to ER

A Single Centre Audit of Acute Reperfusion Therapy Performance Time and Outcome in Patients with Acute Ischaemic Stroke SK Wong, SA Aljeffry, NF Manan, HC Tiong, ZK Law, WY Nafisah Background of the Study Stroke is the third leading cause of death in Malaysia. Acute reperfusion therapy including intravenous recombinant tissue plasminogen activator and endovascular treatment are both recommended treatment in acute ischaemic strole. Acute stroke units have been shown to improve mortality rates, increase functional independence, and reduce rates of discharge to long term care facilities. To date, there is little published data on performance and outcome of acute reperfusion therapies in UKMMC. There is a need to assess the outcome of the patients who received acute reperfusion therapies so as to identify weakness in our service.

Methods This is a retrospective study. The data was retrieved from UKMMC stroke registry and hospital records. Patientsâ&#x20AC;&#x2122; detail including name, registration number, or identity card number were anonymised upon completion of data collection.

The case report form was used for data collection. The case report forms and data collected could be accessed by members of the research team only.

Results

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Conclusion For this audit, time performance such as onset-to-needle time and door-to-needle time were significantly improved with the establishment of the stroke unit. There was significant association between the establishment of stroke unit and their effect on patientâ&#x20AC;&#x2122;s developed complication. Unfortunately, there was no significant association between the length of stay before and after establishment of stroke unit, but there was a reduction for mean length of stay after the stroke unit has been established. Also, there was no significant difference in terms of outcome (mRS after 3 months). In conclusion, this audit suggests that forming UKMMC Stroke Unit is better in terms of time performance and less complications developed among the acute stroke ischaemic patients.

References Ronning, O. M., & Guldvog, B. (1998). Stroke Unit Versus General Medical Wards, II: Neurological Deficits and Activities of Daily Living : A Quasi-Randomized Controlled Trial. Stroke, 29(3), 586-590. doi:10.1161/01.str.29.3.586 Collaboration, S. U. (1997). How Do Stroke Units Improve Patient Outcomes? : A Collaborative Systematic Review of the Randomized Trials. Stroke, 28(11), 2139-2144. doi:10.1161/01.str.28.11.2139 The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): A randomised controlled trial. (2012). The Lancet, 379(9834), 2352-2363. doi:10.1016/s0140-6736(12)60768-5 Al-Wafai, A., Humphries, W., & Elijovich, L. (2014). Intravenous Thrombolytic and Endovascular Treatment of Acute Ischemic Stroke. PanVascular Medicine, 1-26. doi:10.1007/978-3-642-37393-0_96-1 â&#x20AC;¨

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Social determinants hepatitis B virus infection among children aged 4-6 years in Mongolia Nasanjargal E, Enkhgerel Ts, Yesu-Ujin E, Suvd-Erdene S, Oyundari T, Anudari S, Mandukhai G, Davaalkham D Background of the Study Worldwide, two billion people have been infected with hepatitis B virus (HBV), 360 million have chronic infection, and 600,000 die each year from HBV-related liver disease or hepatocellular carcinoma1. Liver cancer is the single most common cause of mortality – one of the highest rates in the world and six times the global average2. One in ten deaths in Mongolia was reported to be caused by liver cancer. Mongolia’s National Strategy on Viral Hepatitis Control covered the period from 2010 to 2015 and proposed five objectives, with the overarching aim of reducing the incidence of viral hepatitis to 10 cases per 10,000 by 2015. This goal has now been achieved. The prevalence of hepatitis B surface antigen (HBsAg) among 4–6 year olds has now met the regional goal of <1.0%3.

According to the Centers for Disease Control (CDC) 2012, prevalence of Hepatitis B in Mongolia is high intermediate at 5-7% compared to the world average4. Systematic review conducted by Ted Alcorn (world report) from 1965 to 2013 in 161 countries identified Central Asia and the Western Pacific region as areas of high endemic HBV infection.

Mongolia has one of the highest rates of HBV carriage5 (Fig. 2) and thus HBV infection and related complications are the most crucial public health problems. Children are susceptible to HBV infection because their immune systems are not fully developed. Also, for Mongolia, the maternal and child health care service delivery system is not adequate. Recent studies show that common risk factors of HBV among children are undergoing surgical procedures, mother to child transmission, and abrasion during hair cut in barber shops6. Additionally, from the Canadian Laboratory Centre for Disease Control’s review of the risk of transmission of blood-borne infections, particularly HBV, it is clear that procedures involving the piercing of skin (skin piercing) and tattooing, must be considered means of infection7. According to a study in North Jordan, logisticregression analysis showed that significant risk factors for acquisition of HBV infection were sharing toothbrushes8.

Therefore, our study purposes were: (1) to risk factors of HBV of children 4-6 years-old in Mongolia and (2) to find out possible intervention strategies which medical students might organize for prevention and education for children and their parents.

Methodology The study participants were randomly selected from lists of the population aged 4-6 years. A questionnaire covered the information including demographic variables, socio-economic variables, information regarding parents, exposure to potential HBV risk factors (e.g. injections, blood transfusion, sharing of toothbrush, ear piercing, dental procedures), personal and family histories of past diseases (including questions on hepatitis, liver cancer and etc.), and history of immunization. The Enzyme-Linked Immunosorbent Assays (ELISA and also simple rapid test (Abbott Determine test strip)) lab test was used to determine the HBsAg among children.

The survey was conducted in accordance with the national policies on ethics for surveys involving human subjects.

The principal investigator obtained ethical clearance from the Ethical Review Committees (ERC) of the Mongolian Ministry of Health, the Health Sciences University of Mongolia and the World Health Organization Western Pacific Region. The informed consent form was presented to the parent/guardian of each participant and a signed formed received back from the patient/guardian prior to participant enrolment.

Researchers and statisticians were involved in training before the beginning of the data entry process. In order to ensure quality control, all questionnaires were double checked for internal consistency. Completed, edited and approved questionnaires and other forms were double-entered and differences between the two databases reconciled. During the data entry, the checking and processing working group had a close cooperation with the field staffs. Data were analyzed by SPSS software. Descriptive and detailed statistical analyses were conducted. Prevalence of HBsAg carriage was described as the proportion and 95% confidence interval (CI) according to the cluster survey method. In order to determine the risk factors for HBV transmission, univariate and multivariate logistic regression analyses were performed between the dependent and independent variables and the results were described as Odds Ratio (OR) and their 95% confidence intervals. The content analyses method was used in analyzing the qualitative data from qualitative.

Results majority of the children (63.2%) were living in families with 4-5 members and family size was higher in rural areas compared to urban areas. In addition, the proportion of children living in apartments was higher in cities than in province centers and rural soums. The average duration living at the current home address was 11.0±9.1 years (9.66±8.0 in cities, 10.73±8.96 in province centers and 12.35±9.79 in soums). Nearly 98% of the children were living with both parents; a small ASIAN MEDICAL STUDENT CONFERENCE 2016 | MANILA, PHILIPPINES

fraction of the children (2.3%) had divorced/parted or decreased parents and were not living with both parents.

Among a total of 5894 children aged 4-6 years, 31 children were positive for HBsAg giving a national prevalence of HBsAg carriage of 0.535% (95% CI: 0.36- 0.73%). Prevalence of HBsAg carriage among children aged 4, 5, and 6 years old was 0.34% (n=7), 0.66% (n=14) and 0.56% (n=10), respectively. Eighteen boys (0.59%) and 13 girls (0.45%) were positive for HbsAg. No significant differences were found in the prevalence of HBsAg carriage by age (p=0.359) or gender (p=0.486).

Potential risk factors for HBV infection among children were studied based on the information obtained from parents/ guardians using a standardized questionnaire. HBsAg carriage was higher in children with a history of surgical manipulations, blood test, or ear piercing (for girls) compared to those with no history of the procedure. Hepatitis and liver cancer history of family members were also non-significantly associated with HBsAg seropositivity.

Potential risk factors for HBV infection among children were identified using univariate and multivariate logistic regression analyses (Table 3). Univariate analysis revealed no significant association between HbsAg carriage and children’s age and sex. This could be related to the limited age range of children participating in the study (ages 4-6 only).

Residential area, particularly living in rural areas, was an important predictive factor for HBV infection. For instance, the risk of being an HbsAg carrier was 2.4 times higher (2.35, 95% CI: 1.03-5.35, p=0.042) in children who live in rural soums compared to those living in cities. There was not a significant difference between provincial centers and cities.

Conclusion 1. Surgical manipulations, blood tests, and ear piercing (girls only) are significant predictors of HBsAg carriage among children in Mongolia.

2. Family histories of hepatitis or liver cancer were associated with increased risk of HBsAg carriage among children although it was not significant in the multivariate model.

References 1. Shepard CW, Simard EP, Finelli L, Fiore AE, Bell BP (2006, Jun 5).. Hepatitis B virus infection: epidemiology and vaccination. Epidemiol Rev. 2006;28:112-25.

2. World Report (2011, Apr 2). Retrieved from http://www.thelancet.com Vol337 3. WHO Regional Office for the Western Pacific Situation and Response 4. Ott JJ, Stevens GA, Groeger J, Wiersma ST. (2012) Global epidemiology of hepatitis B virus infection: new estimates of age-specific HBsAg seroprevalence and endemicity. Vaccine,30(12): 2212-2219.

5. Aparna Schweitzer, Johannes Horn, Rafael T Mikolajczyk, Gérard Krause, Jördis J Ott (2015, Oct 17), Estimations of worldwide prevalence of chronic hepatitis B virus infection: a systematic review of data published between 1965 and 2013, The Lancet, Supplementary 6. Rukunuzzaman M, Afroza A (2001, Oct) Risk factors of hepatitis B virus infection in children. Mymensingh Med J. 20(4): 700-8 7. Gayle H. Shomokura, BS, and Paul R. Gully, MB CHB FRCPC FFCM, (1995, Sep-Oct). Risk of hepatitis C virus infection from tattooing and other skin piercing services, Can J Infect Dis. 6(5): 232-238 8. Hayajneh WA, Masaadeh HA, Hayajneh YA (2010, Feb) A case-control study of risk factors for hepatitis B virus infection in North Jordan. J Med Virol. ;82(2):220-3

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Pilot Study of Prevalence and Associated Factors in Health Insurance Inaccessibility among Migrant Workers in Bangkok Metropolitan Region Varistha Metem, Aphisara Kositwongsakul, Boonsub Sakboonyarat, Phunlerd Piyaraj, Ploypun Narindrarangkura Keywords: migrant workers, health insurance, health insurance inaccessibility Background of the Study Nowadays, there are more than 1.5 million registered migrant workers in Thailand. They are the key factors in running a business, thus making major contribution to the development in Thailand’s economy. However, some migrant workers are found to have not received proper medical care. This condition may make migrants vulnerable to poor long-term health. Healthcare accessibility should not be nationality-based. Therefore, this study focuses on examining prevalence and associated factors of health insurance inaccessibility among migrant workers.

Methodology This study aims to determine prevalence and associated factors in health insurance inaccessibility among migrant workers in Bangkok Metropolitan Region. This study used questionnaires and interviews of 165 migrant workers who worked in this region during April – May 2016.

Results The analysis was performed on 165 respondents, 84 males and 81 females. Participants mainly constituted of Burmese 72.1 % (n=119). Migrant workers who had no health insurance were 71.5% (n=118). We evaluated participants for Thai language communication skill that found migrant workers had no Thai language reading skill 84.2% (n=139), no writing skill 81.2% (n=134), no speaking skill 32.1% (n=53) and no listening skill 18.8% (n=31). According to the univariate and multivariate analysis, the associated factors which consider significant are having problems in insurance inaccessibility process (OR=36.40, 95% CI: 2.12-625.94, p=0.013), communication problem (OR=18.34, 95% CI: 2.97-124.76, p=0.003) and awareness in health insurance’s benefits (OR=10.85, 95% CI: 2.34-50.26, p=0.002). While gender, age and nationality are not shown remarkable effect to health insurance inaccessibility.

Conclusion The major factors that associated with health insurance inaccessibility are communication barrier, problems in process in accessing to health insurance and recognition of health insurance’s benefits. Advocating health insurant information through various ways with their native language, especially through employers, which help them realized the benefit of having health insurance, is highly recommended.

ASIAN MEDICAL STUDENT CONFERENCE 2016 | MANILA, PHILIPPINES

Barriers to Sexual Healthcare in the Australian Refugee Population

Introduction Refugees are people who fear being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion. A refugee is outside the country of his or her nationality, and is unable to, or unwilling to be protected by that country – WHO. By the end of 2014, 59.5 million individuals were forcibly dis- placed as a result of persecution (UNHCR Mid-Year Trends 2015, 2015). In the 2013-2014 period, Australia received 35,156 refugee visas applications, with 6,501 visas being grant- ed (Australia's Offshore Humanitarian Programme: 2013-14, 2014).

Refugees face many health challenges, including those related to reproductive wellbeing. Sexual health, or the state of physical, mental and social well-being in relation to sexuality (WHO, 2016), remains an area that has been inadequately addressed in refugee populations. Barriers to access include lack of easy accessibility to information and health services, specific gender and cultural norms, pre-migration and migration experiences, mental health status, lower socio-economic status and language barriers (Hach, 2012). In additional, female refugees face issues relating to violence, pregnancy and delivery-related complications (WHO, 2015).

Current strategies to alleviate gaps in sexual and reproductive health do not sufficiently address the complexity and diverse social determinants of health amongst refugees and immigrant women where it is widely known that current health outcomes are strongly attributed to social determinants (Hach, 2012). Barriers to sexual healthcare in Australian refugee populations have not yet been systematically reviewed, and this study therefore aims to appraise and synthesise available data on this topic this topic represents a clear gap in the literature.

Methodology Data sources and searches PubMed and The University of Melbourne Discovery databases were searched for available research studies using the relevant terms: refugee AND health AND Australia AND (contraception OR sexual OR reproductive). Articles were selected according to Figure 1.

Selection criteria Inclusion: The studies focused on key outcomes of sexual or reproductive health including: • Contraception Health screening Sexually transmitted infections (STIs) • Study participants were people with a refugee background currently residing in Australia • The research was performed in Australia Articles were published in English and in an academic journal Exclusion: Studies which focussed exclusively on maternal health Critical appraisal Each article was appraised independently by three authors for extraction of demographic data and methodological quality, which was based on The Cochrane Collaboration’s ‘Risk of bi- as’ assessment tool (Higgins et al., 2011). Any discrepancies in assessment were discussed between the three authors.

Data analysis Narrative synthesis was applied in this review. Studies were categorised by methodology, and both statistical and qualitative results were included in the synthesis.

Results A total of nine studies of mixed methodology were identified for review. All studies identified a limited access to sexual education within refugee populations as a major factor influencing poor participation in sexual healthcare.

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Key Findings The topics of contraception, health screening and STIs were most frequently identified by participants. Barriers to the implementation and uptake of these topics were similar, with cultural, religious and social barriers being most frequently reported.

Among refugee youth, conflict between what was taught and considered acceptable in the home versus was taught in schools was an identified issue. Ngum Chi Watts (2015) found that many refugee parents were unwilling to talk about contraception and STIs, for fear that it may provoke promiscuous behaviour. With religious, social and cultural values surrounding abstinence, many refugee young people stated that seeking ad- vice or participating in health screening would bring shame and stigma, often being unwilling to engage in health services for fear that disclosure of sexual activity would be made to parents.

Discussion Overall, our review demonstrates that within Australia's refugee population, there remain contextual and structural barriers that limit sexual healthcare. Very few refugee adults had participated in any formal sexual education and many possessed little knowledge about sexual and reproductive health issues, be- sides HIV/AIDS. These results affirm the findings of a qualitative study in Nepal, which found that engagement in sexual health services within adults was closely tied to their ability to trust healthcare staff for confidentiality, poor knowledge on sex- ual and reproductive health and embarrassment.

Limitations The main limitation of this review is the heterogeneous nature of the studies included. The populations studied varied in age, country of origin and cohort size, and methods of data collec- tion varied in structure, planning and execution.

Implications for further research Majority of the studies we reviewed used a qualitative approach. This is valuable in per- forming initial exploration of a topic, but it is important that fu- ture research includes more quantitative data.

Conclusion Australian refugees experience challenges in regard to their utilisation and uptake of sexual healthcare and prevention. A lack of opportunity for sexual education has resulted in many refugees being misinformed regarding the use, benefits, and long term implications of engaging in sexual healthcare. Measures need to be taken to address these barriers in a cul- turally sensitive and relevant way. While progress has been made, there still remains much cultural taboo within popula- tions, and opportunities exist for improved sexual education strategies to address these barriers.

ASIAN MEDICAL STUDENT CONFERENCE 2016 | MANILA, PHILIPPINES

Alcohol and Drug Addiction in Medical Students: Selfawareness and Comparison with National Data Anish Anand

Background This study was done to find out the number and cause of substance abuse in medical schools and also about its effect on society, health, and education. The doctors are vulnerable to substance abuse/addiction due to their ready accessibility to the substances of abuse. According to various studies done earlier, there is higher percentage use of alcohol, tranquillizers, and psychedelic among medical students. this study was done to verify this hypothesis that there is higher rate of substance abuse in medical schools Substance use among medical students could have a very serious impact on the conduct, safety, and efficiency of future doctors. even with so many articles and debates and medico-legal and ethical ramifications, very little research has been done in this context. this study has implications in planning preventive and interventional strategies for this professional group.

In this study, we also tried to find out about the nature of self awareness. We found out that only a few of the students consider it as a problem. Only 25.8% of students considered it as a problem and seek help. We also performed CAGE test to know about the percentage of addicts in the demographic and majority of the drinkers answered more than three yes and were considered alcohol addicts.

Family play a pivotal role in health of individual. In majority of the cases, the family is the first institution which supports in time of crisis, but as they are unaware, recovery of individual is difficult. According to an individual survey[1], â&#x20AC;&#x153;The alcohol abuser in India is 21.4% way lower than the medical professionals who abuse it. Also the cannabis users in India are only 3%, whereas in medical profession, it is around 18.5%, which is way higher.â&#x20AC;?

Methodology A methodical, cross-sectional survey of medical students from four different medical schools in different places in India was conducted. A brief self-reported questionnaire was used to identify current and lifetime use of tobacco, alcohol, cannabis, heroin and non-prescription drugs. Multivariable logistic regression analysis was used to identify factors associated with illicit substance use.

The sample size was taken to be 200, which was divided among four different group of students belonging to different colleges to also take consideration of cultural disparities. This study was done over a period of two months and the data was collected manually and by also modern means of communication like internet.

Results After conducting the study, it was found out that of the total 77 females included in this study, 25.6% were currently abusing any substance; whereas in males, this ratio was way higher. Out of the 123 males, 54.3% were abusing it. The major reason for this disparity was strong adherence to their tradition, as it does not allow women to indulge in these activities.

Alcohol topped the chart with a total of 87 people (43.5%), where as 58 (29%) abused tobacco. Cannabis was used by 37 (18.5%) people. Out of the total sample population, 0.5% also abused some other substances like heroine for recreational purposes.

This study also aimed at finding the root cause of the substance abuse. It was found that 79.7% of students started using this after entering medical school, while 20.3% of them were already using these before. It was found that peer pressure was the biggest factor in making people addicted to them with 48% of people admitting that they started using it under the effect of peer pressure. While it is also surprising to know that almost 27% of people wanted to do it and had already planned on doing it after joining college. 13% of them were pressured by seniors, while 8% used them to cope up with the hectic schedules; whereas, only a mer 4% used it for depression, contrary to traditional beliefs.

In this study, the frequency of substance abuse was also taken in to consideration. It was found out that 60.3% of people were chronic smokers, while 22.4% of them smoked irregularly, and 20.9% of them were occasional smokers.

In the alcoholics, it was found out that 24.1% were chronic alcoholic, whereas 31% of them were occasional drinkers. The most important phenomena here is that among the occasional drinkers, almost two-third of them indulged in heavy drinking. Binge drinking is more harmful than regular drinking as the sudden rise in alcohol in the blood is dangerous to the vital organs. For cannabis, only 10% of users were addicted to it.

The majority of the users used it occasionally for recreational purposes. Another important thing that came out of this survey was that some people used cannabis for religious purposes during festivals. A whopping 56.7% of people used it for RESEARCH POSTER COMPETITION

such occasions.

In this study, people also admitted that the substance abuse was also reducing their efficiency as students and also they were spending a lot of time either using or trying to procure it, instead of enhancing their skills.

Conclusion It is apparent from the survey that the menace of alcoholism and drug addiction afflict the medical students, particularly after entering medical schools, the main causes being peer pressure and will. It can also be inferred that the use had caused destruction of a positive self-image in some students. Some of them also faced social rejection and financial troubles because of it. Majority of the students admitted to have shared about their habits with their families, but not many of them shed light upon the actual frequency and amount of alcohol and drugs that they were using.

The study results are parallel to those of similar studies that have been done across the globe.

This study indicates that most of the students use alcohol and substances, and tend to ignore the consequences despite being aware of them, thereby making them more probe to addictions. Positive reinforcements are suggested for those whose social and personal lives have been affected. These can be in the form of help groups, encouragement for good recreational activities, and in serious cases, even psychosocio therapy. More awareness should be spread regarding the problems faced by such people and the social stigma should be removed. College authorities can also help such students cope with the losses faced on the academic front.

References Pratima Murthy, N. Manjunatha, B.N. Subodh, Prabhat Kumar Chand, and Vivek Benegal,. (2010), Substance use and addiction research in India. Indian J Psychiatry Kumar P, Basu D., (200). Substance abuse by medical students and doctors. J Indian Med Assoc.

Rai D, Gaete J, Girotra S, Pal HR, Araya R,. (2008). Substance use among medical students: time to reignite the debate?

Nat Med J India

ASIAN MEDICAL STUDENT CONFERENCE 2016 | MANILA, PHILIPPINES

Pre-eclampsia: Outcome of Screening Methods as Intervention on Intermediate Determinants of Health in Lowering Maternal Mortality Rate (MRR) in Surabaya Alvin Satpura, Amy Rosalie Saukamto, Rizqy Rahmatyah, Syarihaf D. Auliani, Agus Sulstyono Background Maternal Mortality Rate (MMR) is one among many benchmarks that shows our progress towards Sustainable Development Goals (SDGs). MMR is a multifactorial problem that requires involvement of multiple factorial departments of Indonesia’s Ministry and is influenced by many determinant factors. Among these diverse factors, one that is changeable, is the health service provided. In 2013, Indonesia still has 359 maternal deaths per 100,000 live births, whereas SDGs targeted 70 deaths per 100,000 live births. One of the many reasons of the high MMR in Indonesia is the uneven distribution of health care providers. Until today, there are still plenty of remote areas that only have access to primary health center without proper access to better healthcare facilities. These are the two most common causes of maternal death in Indonesia: post-partum hemorrhage and pre-eclampsia. However, statistics showed that in East Java—the 3rd most contributing province to maternal death—pre-eclapmsia is the most common cause (29.4%). Lowering the incidence of preeclampsia in East Java would also lower the national MMR significantly. Thus, since 2013, there have been a simple method of screening for pre-eclampsia in Surabaya (the capital city of East JavA). This method is easy, simple, and does not cost much that every primary health center—even in the remote areas—should be able to do it. Moreover, the screening in Surabaya has shown successful result in lowering local MMR. Therefore, we aim to show the result of this simple screening method in lower MMR caused by pre-eclampsia that every region in Indonesia could also implement this method, which would lead to national declining of our MMR. Methods This is a cross-sectional study using secondary data from Surabaya’s public health office. This secondary data cover data from 62 public health centers in Surabaya. The research was conducted using purposive sampling method on pregnant women that came to Surabaya’s public health centers during 2012-2015. These women were screened for pre-eclapmsia, which consists of: (1) risk factors (maternal history, age, history of pre-eclapmsia, and degenerative disease); (2) obesity (BMI>29.0); (3) MAP>90mmHg; and (4) ROT>15mmHg. These screening methods were done during 12-28 weeks of gestational age. Individuals with > 2 matching results are considered positive and were given low-dose aspirin (LDA) 125mg (80-150mg/day). They were later referred to secondary healthcare facility for further screening method using Doppler Velocimetry Ultrasonography.

Results

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Discussion Based on the data from Surabayaâ&#x20AC;&#x2122;s public health office, the number of preeclampsia cases found from 2012 to 2015 increased 33%. Still, maternal deaths in the same years that are caused by pre-eclampsia decreased from 18, 14, 11, to 7 deaths. Data for 2012 compared to 2015 is equal to 61.1% decrease of maternal death caused by pre-eclampsia. The same data also shows that, overall, the number of maternal deaths in Surabaya (regardless of the cause) decreased from 60, 49, 39, to 38 deaths (36.67%). These three results are the outcome of pre-eclampsia screening implementation during 2013 to 2015. During these years, screening in Surabaya was highly encouraged. As the result, more pregnant women are screened and more pre-eclampsia cases are successfully found. Furthermore, more pregnant women with pre-eclampsia are given treatment. Thus, the number of maternal deaths in Surabaya from 2013 to 2015 are successfully lowered.

Conclusion MMR is indeed affected by many factors. Although this research does not cover all the causes, based on these results, screening for pre-eclampsia can be considered as a successful method in lowering MMR significantly, specifically in Surabaya. Moreover, there is already a known successful therapy that is simple enough to be done by primary health centers in even the most remote areas, which is LDA therapy. This screening and therapy method should be introduced and executed in every health centers so that maternal deaths as one of the problem on social determinants of health could be further reduced and better health serviced could be achieved.

References 1. Emergent therapy for acute-onset, severe hypertension with preeclampsia or eclampsia. (2011), ACOG, Committee Opinion no. 514: Obstet Gynecol; 118:1465-1468 2. Data Preeklampsia Kota Surabaya tahun 2012-2015. (2016). Dinas Kesehatan (Dinkes) Kota Surabaya 3. Infodatin: Pusat Data dan Informasi Kementrian Kesehatan RI. (2014) [ebook] Kementrian Kesehatan Republik Indonesia. Available at: http://www.depkes.go.id/download.php?file=download/pusdatin/infodatin/infodatin-ibo.pdf [Accessed 20 Jan. 2016] 4. Buku Saku Pelayanan Kesehatan Ibu di Fasilitas Kesehatan dasar dan Rujukan 1st edition. (2013). Kementrian Kesehatan Republik Indonesia 5. [ebook] Kementrian Kesehatan Republik Indonesia. (2013). Survei Demografi dan Kesehatan Indonesia 2012. Available at http://chnrl.org/pelatihan-demograpfi/SDKI-2012.pdf [Accessed 20 Jan. 2016].

6. WHO recommendations for Prevention and Treatment of pre-ecplampsia and eclampsia. (2011) World Health Organization.

ASIAN MEDICAL STUDENT CONFERENCE 2016 | MANILA, PHILIPPINES

A Systematic Review: How Food Affects the Symptoms of ADHD in Children Chiu Li-Cheng, Kao Yu-Chien, Lee Da-Wei

Introduction ADHD(Attention deficit/hyperacavity disorder) is a common brain disorder in Taiwan, some will recover when getting older. However, many of them have little changes. The estimated ADHD situation in Taiwan, according to the National Statistics (2014).

Food might be a substitute for drugs. A change in diet might be used as a mild treatment for ADHD. Materials and Methods The main focus: 5 major factors that may alleviate or exacerbate the symptoms of ADHD.

The article screening process (databse: PubMed, Medline)

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Results

Conclusion Summary The study is to prove the hypothesis that food can indeed affect the symptoms of ADHD in children. The metaanalysis result shows that the four main factors, including PUFAs, Minerals, Elimination diets, additives have a positive effect on ADHD. In contrast, binge drinking during pregnancy has a negative effect.

This study utilizes many papers in PubMed and Medline, so we believe it is sufficient to suppose the hypothesis is correct. However, the detailed pathology mechanism between the aforementioned social determinants and ADHD require more investigation.

Limitations 1. Various assessment scales 2. The alcohol content of the beverages were different 3. Food therapies are not common in ADHD treatment 4. Rating scores from parents and teachers are not objective enough References Lepping P, Huber M.(2010) Role of zinc in the pathogenesis of attention deficit hyperactivity disorder: implication for research and treatment. CNS Drugs, 24 (9), 721-8. doi 10.2165/11537610-000000000-00000 Kanarek RB(2011) Artificial food dyes and attention deficit hyper. Nutrition Reviews,69 (7),385-39. doi:10.1111/j.

1753-4887.2011.00385.x Heilskov Rytter MJ, Andersen LB, Houmann T, Bilenberg N, Hvolby A. (2014) Diet in the treatment of ADHD in children—a systematic review of the literature. Nordic Journal of Psychiatry, 69 (1), 1-18. doi: 10.3109/08039488.2014.921933 ASIAN MEDICAL STUDENT CONFERENCE 2016 | MANILA, PHILIPPINES

The relationship between heart disease mortality rate and the arrival time to ER

Background of the Study In Korea, there are three major causes of death. These are cancer, cerebropathy, and heart disease. The number of people who die of heart disease has been increasing from 2010 to 2012. Thus, itâ&#x20AC;&#x2122;s important to analyze what social determinants have impact on heart diseases. Myocardial infarction, commonly known as a heart attack, occurs when blood flow stops to a part of the heart causing damage to the heart muscle. When myocardial infarction occurs, emergency medicine within golden time matters. And golden time varies in different locations.

Materials and Methods Test of significance is one in this research. Death rates caused by myocardial infarction in Seoul, Gangwon, Jeju are used. The results source is governanceâ&#x20AC;&#x2122;s research in 2013.

Results

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Discussion Social determinants - accessibility of hospital, health manpower, number of medical care institutions, geographical conditions (mountainous area of Gangwondo).

Gangwon and Jeju have smaller number of health manpower and medical care institution. But Jejuâ&#x20AC;&#x2122;s mortality rate is similar with Seouls's and time taken to arrive ER has no significant difference. Therefore, emergency disease like AMI is affected more by time to arrive Er than number of health manpower and medical care institution.

Conclusion From this study, we know that time is most important element to emergency patient. Thus, there are solutions of reduce time: Government: From this study, we should find a solution to reduce access time to hospital rather than equalization of manpower and hospital number. When we see result of Rearranging Emergency Medical Service Region (Rearranging Emergency Medical Service Region Using GIS Network Analysis - Daejon Metropolitan City Case 2015), there is a signiificant result. Refer to paper, rearranging institutions can be one of solutions.

Public: When people study CPR, people can take emergency measures fast before ambulance and it can help patients a lot.

ASIAN MEDICAL STUDENT CONFERENCE 2016 | MANILA, PHILIPPINES

PHOTOGRAPHY COMPETITION A Kid on The Street When will we change OURSELVES Cradle in Dark Alley Raising the flag on cultural disparities For whom the bell tolls A Hidden Accomplice of Oxy Tragedy Water, please The Faรงade of Depression

A Kid on The Street Ahmad Aulia Rizaly Do you know the feeling of sleeping in your room, on comfy bed, right under warm blanket? For some of us, this is daily routine, but for those living on street such as child on my photograph, such feeling is luxury they do not have. There are 4.1 million children living on street. These children tend to have no access to education. Lacking of education means that in the future, they will be lacking of employment opportunity.

This population will later be living on poverty, so will generations after them. When poverty exists among population, so does poor health.

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When will we change OURSELVES Lkham-Erdene Byambadoo Education is one of the important issue for the social determinant of health. Life chances of teenage mothers and their children threatened by barriers to education.

Teenage mothers are being thrown on the career scrap heap because they face so many barriers in getting back into school. The barriers usually caused by our guilty attitude. When will we destroy the our guilty attitude?

ASIAN MEDICAL STUDENT CONFERENCE 2016 | MANILA, PHILIPPINES

Cradle in Dark Alley AMSA Philippines

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Raising the flag on cultural disparities Emily Tay Indigenous Australians expect to live 10-17 years less than other Australians. Cultural factors such as lack of access to healthcare, low socio-economic status, and poor health literacy contribute to these health disparities. Closing the gap is everyoneâ&#x20AC;&#x2122;s business, as is highlighted in the multicultural presence at this Indigenous Rights rally held in Melbourne, Australia. The Aboriginal flag is waved against a background of the iconic Flinders Street Station, framing the crowd of passionate Australians and a banner that reads â&#x20AC;&#x2DC;stop racism now.

For whom the bell tolls Dongchu Xu, Xin He, Jinxin Qi Doctor Chen died, for the revenge of the discolored teeth twenty-five years ago, which is as ludicrous as the folly that a patient held waitin for debridement killed doctor Wong merely for waiting.The chained hospitals of quaks prosper still, the media hype perpetuates, but the decent doctor fall victim for social resentment. Nobody wins when it backfires to doctor-patient bond. Terrified doctrs set a priority of their safety rather than try every possible way to cure patients. Silenced, thousands of candles strive to ignite the night.

ASIAN MEDICAL STUDENT CONFERENCE 2016 | MANILA, PHILIPPINES

A Hidden Accomplice of Oxy Tragedy Soomin Chung The Humidifier Sanitizer(HS) of Oxy Corporation has caused more than 200 victims in Korea, including 95 deaths. The Disease Control Centre found out correlation between the HS and lung injury; toxicant PHMG caused serious respiratory damages. Shockingly, these products were certified by the government. There are many loopholes in issuing safety certification and negligence of the government contributed to innocent deaths. In this photo, HS product with KC(Korea Certification) mark is added to humidifier and people suffer from the steam. To ensure the safety of products and eventually, public health, the government should tighten up its regulations.

Water, please Hsu, Ming-Wei In Chinese culture, we deeply believe that the environment makes who we are. In the photo, a shell is staking on a plastic cup, like a eye looking at those who pollute the water. Plastic products may poison the water; moreover, the shell warns that the environment is deteriorating, and the diversity losing. If we can live in a clean world, I believe that lots of diseases would decrease and even vanish. That is, letâ&#x20AC;&#x2122;s work hand in hand to preserve our environment, and leave the next generation a cup of drinkable water!

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The Façade of Depression Ying Jin, Woojin Chae, Richard Wu, Dean Owyang, Sam Kim 1 in 4 people are affected by mental health problems every year, of which 75% do not receive any help from the NHS. This issue affects people from all over the world with different backgrounds. However due to cultural influences, the Asian population are less likely to seek medical treatment compared to individuals of other ethnicities.

Our photo depicts the individual desperately fantasising about his social status. However he is conflicted by the uncertainty of other peopleâ&#x20AC;&#x2122;s opinions and judgements. The darkness that engulfs the depressed individual clashes with the light that represents the potential benefits of supportive friends.

ASIAN MEDICAL STUDENT CONFERENCE 2016 | MANILA, PHILIPPINES

Health Beyond Our Clinics 28 JUNE - 05 JULY 5, 2016 MANILA, PHILIPPINES

The Asian Medical Studentsâ&#x20AC;&#x2122; Conference is the largest event of medical students in Asia and is an annual conference of the Asian Medical Studentsâ&#x20AC;&#x2122; Association International (AMSA-I).

It involves the participation of hundreds of medical students from as many as 24 local chapters around the Asia-Pacific region.

The theme for this year's Asian Medical Students' Conference is "Health Beyond Our Clinics". It will start with a case of how a family battled against a disease that struck one of its members. The case will highlight the difficulties this family faced amid the following nonmedical factors, which despite not being clinically relevant, are nevertheless integral to the healthcare system: Governance / Education / Technology / Environment / Human Resources.

ISSN: 2226-3403 Vol. 6, AMSC 2016 Issue September 2017

Published by Asian Medical Students’ Association International Journal of Asian Medical Students’ Association National Yang Ming University No. 155, Sec. 2, Linong Street, Taipei, 112 Taiwan (ROC) j-amsa@amsa-international.org