Abstract Objectives To identify data availability, gaps, and patterns for population level prevalence of loneliness globally, to summarise prevalence estimates within World Health Organization regions when feasible through meta-analysis, and to examine temporal trends of loneliness in countries where data exist. Design Systematic review and meta-analysis. Data sources Embase, Medline, PsycINFO, and Scopus for peer reviewed literature, and Google Scholar and Open Grey for grey literature, supplemented by backward reference searching (to 1 September 2021) Eligibility criteria for selecting studies Observational studies based on nationally representative samples (n≥292), validated instruments, and prevalence data for 2000-19. Two researchers independently extracted data and assessed the risk of bias using the Joanna Briggs Institute checklist. Random effects meta-analysis was conducted in the subset of studies with relatively homogeneous research methods by measurement instrument, age group, and WHO region. Results Prevalence data were available for 113 countries or territories, according to official WHO nomenclature for regions, from 57 studies. Data were available for adolescents (12-17 years) in 77 countries or territories, young adults (18-29 years) in 30 countries, middle aged adults (30-59 years) in 32 countries, and older adults (≥60 years) in 40 countries. Data for all age groups except adolescents were lacking outside of Europe. Overall, 212 estimates for 106 countries from 24 studies were included in meta-analyses. The pooled prevalence of loneliness for adolescents ranged from 9.2% (95% confidence interval 6.8% to 12.4%) in South-East Asia to 14.4% (12.2% to 17.1%) in the Eastern Mediterranean region. For adults, meta-analysis was conducted for the European region only, and a consistent geographical pattern was shown for all adult age groups. The lowest prevalence of loneliness was consistently observed in northern European countries (2.9%, 1.8% to 4.5% for young adults; 2.7%, 2.4% to 3.0% for middle aged adults; and 5.2%, 4.2% to 6.5% for older adults) and the highest in eastern European countries (7.5%, 5.9% to 9.4% for young adults; 9.6%, 7.7% to 12.0% for middle aged adults; and 21.3%, 18.7% to 24.2% for older adults). Conclusion Problematic levels of loneliness are experienced by a substantial proportion of the population in many countries. The substantial difference in data coverage between high income countries (particularly Europe) and low and middle income countries raised an important equity issue. Evidence on the temporal trends of loneliness is insufficient. The findings of this meta-analysis are limited by data scarcity and methodological heterogeneity. Loneliness should be incorporated into general health surveillance with broader geographical and age coverage, using standardised and validated measurement tools. Systematic review registration PROSPERO CRD42019131448.

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The prevalence of loneliness across 113 countries: systematic review and meta-analysis

Suicide attempts are the most important known predictor of death by suicide. The aim of this study is to examine the prevalence, distribution, and associated factors of suicide attempts among young adolescents in 40 low-income and middle-income countries. We used data from the Global School-Based Student Health Survey (2009-2013) and a nationally representative study in China (2010), which are school-based surveys of students primarily aged 12-18 years that assess health behaviors using an anonymous, standardized, self-reported questionnaire. We calculated the prevalence of suicide attempts in young adolescents from 40 low-income and middle-income countries using the surveys. Multilevel logistic models were used to estimate the associations between suicide attempts and potential risk factors, adjusting for gender, age, school and survey year. Results show that the mean 12-month prevalence of suicide attempts was 17.2%, ranging from 6.7% in Malaysia to 61.2% in Samoa. The overall prevalence of suicide attempts was higher for girls than for boys (18.2% vs 16.2%, P<0.05). Among the suicide attempts, the proportion of suicide attempts with a plan was higher for girls than for boys (62.7% vs 53.2%, P<0.05). Both the prevalence of suicide attempts and the proportion of suicide attempts with a plan increased with age. Factors associated with suicide attempts included poor socioeconomic status, history of bullying, loneliness and anxiety, tobacco and alcohol use, and weak family and social relationships. In conclusion, suicide attempts are frequent among young adolescents in low-income and middle-income countries. Girls and older adolescents tend to make suicide attempts with a plan. The data demonstrate the need to strengthen suicide intervention and prevention programs for young adolescents in low-income and middle-income countries.

Prevalence, distribution, and associated factors of suicide attempts in young adolescents: School-based data from 40 low-income and middle-income countries.

Introduction 
In Nepal, a substantial proportion of women still deliver their child at home. Disparities have been observed in utilisation of institutional delivery and skilled birth attendant services. We performed a disaggregated analysis among marginalised and non-marginalised women to identify if different factors are associated with home delivery among these groups.


Materials and methods 
This study used data from the 2016 Nepal Demographic and Health Survey. It involves the analysis of 3,837 women who had experienced at least one live birth in the five years preceding the survey. Women were categorised as marginalised and non-marginalised based on ethnic group. Bivariate and multivariable logistic regression analysis were performed to identify factors associated with home delivery.


Results 
A higher proportion of marginalised women delivered at home (47%) than non-marginalised women (26%). Compared to non-marginalised women (35%), a larger proportion of marginalised women (64%) felt that it was not necessary to give birth at health facility. The multivariable analysis indicated an independent association of having no or basic education, belonging to middle, poorer and the poorest wealth quintile, residing in Province 2 and not having completed of four antenatal care visits per protocol with home delivery among both marginalised and non-marginalised women. Whereas residing in a rural area, residing in Province 7, and at a distance of >30 minutes to a health facility were factors independently associated with home delivery only among marginalised women.


Conclusion 
We conclude that poor education, poor economic status, non-completion of four ANC visits and belonging to Province 2 particularly determined either group of women to deliver at home, whereas residing in rural areas, living far from health facility, and belonging to Province 7 determined marginalised women to deliver at home. Preventing mothers from delivering at home would thus require focusing on specific geographical areas besides considering wider socio-economic determinants.

Determinants of home delivery in Nepal - A disaggregated analysis of marginalised and non-marginalised women from the 2016 Nepal Demographic and Health Survey.

Background. Reducing maternal mortality remains a significant challenge in Indonesia, especially for achieving the country’s Sustainable Development Goals (SDGs) by 2030. One of the challenges is increasing delivery at healthcare facilities to ensure safe and healthy births. In Indonesia, research on factors affecting women’s use of facility-based childbirth services is scarce. Objective. This study was conducted to identify the determinants of facility-based deliveries in Indonesia. Methods. This study used data from the Indonesia Demographic and Health Survey of 2012, with a cross-sectional design. An odds ratio with 95% confidence intervals (CI) was employed to outline the independent variables for the determinants, including maternal age and education, place of residence, involvement in decision-making, employment status, economic status, and number of antenatal care visits. The dependent variable in this study was the place of delivery: whether it took place in healthcare or nonhealthcare facilities. The statistical significance was set at p<0.05 using bivariate analysis and binary logistic regression. Results. This study showed that a high level of education (OR: 3.035, 95% CI: 2.310–3.987), high economic status (OR: 6.691, 95% CI: 5.768–7.761), urban residence (OR: 2.947, 95% CI: 2.730–3.181), working status (OR: 0.853, 95% CI: 0.793–0.918), involvement in decision-making (OR: 0.887, 95% CI: 0.804–0.910), and having more than four visits to antenatal care centers (OR: 1.917, 95% CI: 1.783–2.061) were significant determinants of delivery at healthcare facilities. Conclusion. Efforts to improve facility-based childbirth in Indonesia must strengthen initiatives that promote women’s education, women’s autonomy, opportunities for wealth creation, and increased uptake of antenatal care, among others. Any barriers related to maternal healthcare services and cultural factors on the use of health facilities for childbirth in Indonesia require further monitoring and evaluation.

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Determinants of Facility-Based Childbirth in Indonesia.

Background: Suicide is the third leading cause of death in adolescents worldwide, self-esteem is a strong protective factor, and parents may be able to provide interventions This cross-sectional study aimed to determine how parents can help enhance their adolescent’s self-esteem and prevent suicidal behavior among adolescents in Nepal Methods: Self-administered questionnaires were distributed to adolescents aged 13–19 years and their parents at eight high schools in three provinces in Nepal (n = 575 pairs) The data were analyzed using descriptive and inferential statistics (bivariate and multivariate regression analyses) Results: The mean self-esteem score of adolescents according to the Rosenberg Self-Esteem Scale was 1659, and the prevalence of suicidal behavior was 113% Parent’s knowledge about the development of self-esteem in adolescents was significantly positively related to parenting practice (communication, support, positive reinforcement, etc) (B = 10, 95% confidence interval, CI 089–111) and authoritative parenting style (B = 02, 95% CI 015–025) Parental authoritativeness was positively associated with the self-esteem of their adolescents (B = 01, 95% CI 001–018), while adolescents with authoritarian parents were prone to suicidal risk behavior (adjusted odds ratio, AOR = 11, 95% CI 10–119) Conclusion: Counseling to parents based on our findings would be helpful to enhance the self-esteem and prevent suicidal risk behavior in their adolescent children

https://www.mdpi.com/1660-4601/17/17/6039/pdf

Impact of Parents’ Knowledge about the Development of Self-Esteem in Adolescents and Their Parenting Practice on the Self-Esteem and Suicidal Behavior of Urban High School Students in Nepal

Suicide is one of the leading causes of death and Disability Adjusted Life Years (DALYs) worldwide. The economic, emotional and human cost of suicidal behaviour to individuals, families, communities and society makes it a serious public health issue. We aim to determine the prevalence and factors associated with self-reported suicidal behaviour (suicidal ideation and attempt) among school going adolescents (13–17 years). This is a secondary analysis of a nationally representative data for Bhutan namely Global School Based Student Health Survey in 2016 which reports on various dimensions of adolescent health including suicidal behaviour. The survey employed a multistage sampling method to recruit participants aged 13–17 years (n = 5809) from 50 schools (25 each in rural and urban area). The survey used an anonymous self-administered pre-tested 84-item questionnaire. Weighted analysis was done. Adjusted prevalence ratios (aPRs) and adjusted Odds Ratios (aORs) have been presented with 95% confidence intervals (95% CI). A total of 667 (11.6%) adolescents reported considering a suicide attempt whereas 656 (11.3%) reported attempting suicide in the past 12 months. Among those reporting suicidal ideation, 388 (58.6%) reported attempting a suicide and 274 (41.4%) had ideation alone, whereas, 247 (38.9%) reported attempting a suicide without previous ideation. Female sex, food insecurity, physical attack, sexual violence, bullying, feeling of loneliness, low parental engagement, reported worry about lack of sleep, urge to use drugs/alcohol, smokeless tobacco use, drug abuse and parental smoking were the factors associated with suicidal attempt. All these factors except smokeless tobacco use and parental smoking were associated with suicidal ideation. Having helpful/close friends was found to be protective against suicide ideation. Suicidal behaviour among school going adolescents in Bhutan is high and alarming, especially among girls. Bullying, sexual violence, feeling of loneliness and drug abuse were some of the key risk factors identified. It is important to identify these risk factors early and effectively tackle them in order to prevent suicides. It requires a multi-faceted intervention with the support of the children, community, teachers and parents.

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Suicidal ideation and attempt among school going adolescents in Bhutan - a secondary analysis of a global school-based student health survey in Bhutan 2016

Background Despite Bhutan's remarkable progress in the area of maternal and child health during the era of the Millennium Development Goals, a large proportion of pregnant women are still delivering at home with no skilled attendant. Limited empirical studies have been carried out to understand the factors associated with delivery at home in Bhutan. Methods This cross-sectional analytical study used secondary data collected in the nationally representative National Health Survey 2012. The survey included a total of 2213 women aged 15–49 years who had a live birth in the 2 years preceding the survey and were selected using multistage stratified cluster sampling. Weighted analysis was done to evaluate determinants for the place of delivery. Unadjusted and adjusted prevalence ratios with 95% confidence intervals (CIs) were calculated to assess the possible association of factors with home delivery. Results Out of 2213 women aged 15–49 years who had a live birth in the 2 years preceding the survey, 73.7% had an institutional delivery. Coverage of institutional delivery ranged from 49.4% in Zhemgang district to 96.1% in Paro district. Women in the poorest wealth quintile were 7.35 times more likely to have a birth at home compared to women in the richest quintile (adjusted prevalence ratio [aPR]: 7.35, 95% CI: 2.59–20.9). The older mothers aged 30–49 years were 0.79 times (aPR: 0.79, 95% CI: 0.70–0.88) less likely to have a home delivery than mothers aged 15–19 years. Women who had fewer than four antenatal care visits were 1.50 times (aPR: 1.50, 95% CI: 1.35–1.66) more likely to give birth at home compared to those who had four or more visits. The mothers giving birth for a third or more time were 1.88 times (aPR: 1.88, 95% CI: 1.60–2.22) more likely to give birth at home compared to those giving birth for the first time. Women living in rural areas were 2.87 times (aPR: 2.87, 95% CI: 1.42–5.77) more likely to deliver at home compared to those living in urban areas and women living in the eastern region of the country were 1.35 times (aPR: 1.35, 95% CI: 1.17–1.55) more likely to have a home delivery compared to those living in the western region. Conclusion Lower socioeconomic status, rural location, eastern location, non- first birth, and having fewer than four antenatal visits were significant factors associated with home delivery. These findings should inform further research and policy to build on Bhutan's progress in promoting institutional delivery as the key strategy towards improving maternal and child health and achieving the relevant targets of Sustainable Development Goal 3.

Factors associated with delivery at home in Bhutan: findings from the National Health Survey 2012.

Introduction: The estimated global maternal deaths in 2013 was 289000. In Bhutan, Maternal Mortality Ratio hasremarkably declined from 770 deaths per 100,000 live births in 1984 to 86 in 2012. However, the maternal mortalityratio still remains high and a high proportion of delivery still take place at homes (26%) despite of adopting 100%institutional delivery policy ever since 2005. This study was carried out to determine the important factors that preventwomen from coming to the health facilities for safe delivery.
Methods: A cross-sectional study among the women who delivered in Chukha District in 2013 was carried out after seeking ethical approval from Research Ethics Boardof Health and World Health Organization. Chukha is a district with the second highest number of population in Bhutanwhere 55.7% of the people live in rural villages.
Results: Out of 899 eligible listed women, 78.1% participated in thestudy and among the participants 11.5% had delivered at home. The number of home deliveries was higher in ruralareas, 17.3%, as compared to urban places, 6.4%. Women who were delivering for third or more times are 2.42 timesmore likely to give birth at home compared to women who were delivering for the first time. Women residing at placesmore than three hours away from the health facility were 2.58 times more likely to give birth at home compared towomen residing less than three hours away. During their last pregnancy, 99.4% of the participants have sought at leastone ANC.
Conclusions: This study suggests that the two most important factors associated with home delivery are thedistance to health facility from their residences and the parity.
Keywords: Bhutan; Facility delivery; Home delivery; Place of delivery.

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Preference of place of delivery and its determinants: a cross-sectional study in Chukha district, Bhutan

The COVID-19 pandemic is continuing to ravage countries across the world. It has displaced families and impacted economies around the world. Our fight against the pandemic is never ending, but COVID-19 vaccines offer unique promises and opportunities to win this war. As more and more vaccines are approved for use, many countries including Bhutan have started vaccinating their population against the SARS-CoV2 disease. Bhutan has fully vaccinated 61.5% of its people and 11.2% partially including children aged between 12 and 17 years. The country used many strategies to increase vaccine accessibility and availability such as government's exhaustive efforts to secure enough vaccine doses, careful preparations, use of international partners, and integration of its tradition and culture for wider vaccine acceptance. The protection from vaccines coupled with other public health measures has helped keep the number of COVID-19 cases to a manageable number without straining its health system too much. The success story is a "beacon of hope for the region" as the world looks to rebuild itself from this long exhausting fight against the COVID-19 pandemic.

Bhutan's COVID-19 Vaccination Efforts and the Evolution of COVID-19 Cases in the Aftermath.

Introduction: Research Ethics Board of Health (REBH), established in 2009, is the only ethics review board in Bhutan. The REBH was certified by the Strategic Initiative for Developing Capacity in Ethical Review (SIDCER), Forum for Ethical Review Committees in the Asian and Western Pacific Regions (FERCAP) in 2010 and recertified in 2013, and it received the FederalWideAssurance (FWA) from the Office for Human Research Protections (OHRP), USA, in 2010 and in 2013.All researchers conducting health related research in Bhutan have to seek prior ethical clearance from REBH under the requirements of the National Health Policy 2011.
 Objective: The article aims to describe the performance of REBH, its standard and review procedure. Methods: A descriptive study of records and database of REBH from 2009 to 2015.
 Results: As of December 2015, the REBH has received 227 protocols with an average of 32 protocols per year. The median number of days for the initial review was 21 days (Min 0 days; Max 85 days). The median duration for approval of protocols from the date of receiving the application was 48 days. The average number of times the protocols were reviewed before issuing the approval letter was 2.
 Conclusions: There has been a progressive increase in the number of protocols submitted to REBH. This indicated an increasing research culture in Bhutan. It takes about one and half months to get an approval from REBH; therefore, researchers have to consider the time required for ethical clearance process while planning research projects.

Tashi Dema

Papers

Suicidal ideation and attempt among school going adolescents in Bhutan - a secondary analysis of a global school-based student health survey in Bhutan 2016

Factors associated with delivery at home in Bhutan: findings from the National Health Survey 2012.

Preference of place of delivery and its determinants: a cross-sectional study in Chukha district, Bhutan

Bhutan's COVID-19 Vaccination Efforts and the Evolution of COVID-19 Cases in the Aftermath.

Research Ethics Board of Health: a seven year review of the only ethics review board in Bhutan