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Southeast Asia is a region of enormous social, economic, and political diversity, both across and within countries, shaped by its history, geography, and position as a major crossroad of trade and the movement of goods and services. These factors have not only contributed to the disparate health status of the region's diverse populations, but also to the diverse nature of its health systems, which are at varying stages of evolution. Rapid but inequitable socioeconomic development, coupled with differing rates of demographic and epidemiological transitions, have accentuated health disparities and posed great public health challenges for national health systems, particularly the control of emerging infectious diseases and the rise of non-communicable diseases within ageing populations. While novel forms of health care are evolving in the region, such as corporatised public health-care systems (government owned, but operating according to corporate principles and with private-sector participation) and financing mechanisms to achieve universal coverage, there are key lessons for health reforms and decentralisation. New challenges have emerged with rising trade in health services, migration of the health workforce, and medical tourism. Juxtaposed between the emerging giant economies of China and India, countries of the region are attempting to forge a common regional identity, despite their diversity, to seek mutually acceptable and effective solutions to key regional health challenges. In this first paper in the Lancet Series on health in southeast Asia, we present an overview of key demographic and epidemiological changes in the region, explore challenges facing health systems, and draw attention to the potential for regional collaboration in health.

BackgroundGlobally, ageing impacts all countries, with a majority of older persons residing in lower- and middle-income countries now and into the future. An understanding of the health and well-being of these ageing populations is important for policy and planning; however, research on ageing and adult health that informs policy predominantly comes from higher-income countries. A collaboration between the WHO Study on global AGEing and adult health (SAGE) and International Network for the Demographic Evaluation of Populations and Their Health in developing countries (INDEPTH), with support from the US National Institute on Aging (NIA) and the Swedish Council for Working Life and Social Research (FAS), has resulted in valuable health, disability and well-being information through a first wave of data collection in 2006–2007 from field sites in South Africa, Tanzania, Kenya, Ghana, Viet Nam, Bangladesh, Indonesia and India.ObjectiveTo provide an overview of the demographic and health characteristics of participating countries, describe the research collaboration and introduce the first dataset and outputs.MethodsData from two SAGE survey modules implemented in eight Health and Demographic Surveillance Systems (HDSS) were merged with core HDSS data to produce a summary dataset for the site-specific and cross-site analyses described in this supplement. Each participating HDSS site used standardised training materials and survey instruments. Face-to-face interviews were conducted. Ethical clearance was obtained from WHO and the local ethical authority for each participating HDSS site.ResultsPeople aged 50 years and over in the eight participating countries represent over 15% of the current global older population, and is projected to reach 23% by 2030. The Asian HDSS sites have a larger proportion of burden of disease from non-communicable diseases and injuries relative to their African counterparts. A pooled sample of over 46,000 persons aged 50 and over from these eight HDSS sites was produced. The SAGE modules resulted in self-reported health, health status, functioning (from the WHO Disability Assessment Scale (WHODAS-II)) and well-being (from the WHO Quality of Life instrument (WHOQoL) variables). The HDSS databases contributed age, sex, marital status, education, socio-economic status and household size variables.ConclusionThe INDEPTH WHO–SAGE collaboration demonstrates the value and future possibilities for this type of research in informing policy and planning for a number of countries. This INDEPTH WHO–SAGE dataset will be placed in the public domain together with this open-access supplement and will be available through the GHA website (www.globalhealthaction.net) and other repositories. An improved dataset is being developed containing supplementary HDSS variables and vignette-adjusted health variables. This living collaboration is now preparing for a next wave of data collection.

Rotavirus remains the most common cause of severe, dehydrating diarrhea among children worldwide. Several rotavirus vaccines are under development. Decisions about new vaccine introduction will require reliable data on disease impact. The Asian Rotavirus Surveillance Network, begun in 2000 to facilitate collection of these data, is a regional collaboration of 36 hospitals in nine countries or areas that conduct surveillance for rotavirus hospitalizations using a uniform World Health Organization protocol. We summarize the Network's organization and experience from August 2001 through July 2002. During this period, 45% of acute diarrheal hospitalizations among children 0–5 years were attributable to rotavirus, higher than previous estimates. Rotavirus was detected in all sites year-round. This network is a novel, regional approach to surveillance for vaccine-preventable diseases. Such a network should provide increased visibility and advocacy, enable more efficient data collection, facilitate training, and serve as the paradigm for rotavirus surveillance activities in other regions.

Background:Cervical cancer (CC) is a leading cause of cancer deaths among Indonesian women. Pilot prevention programs, including human papillomavirus (HPV) vaccination for young adolescent girls, and cervical screening for women, have been implemented. However, many communities are yet to receive these interventions, nor targeted education regarding CC prevention. This study explored community readiness and acceptance of HPV vaccination and CC screening, as well as knowledge and perceptions of HPV and CC, to determine facilitators and barriers to upscaling CC prevention in rural Central Java. Methods:Qualitative data collection in October 2015 consisted of four focus group discussions with married women and men, and 22 semi-structured interviews with married women. All 57 participants, 39 women and 15 men, lived in Purworejo Regency in rural Central Java. Results:Most participants had no knowledge of HPV or the causal link between HPV and CC. However, most participants were supportive of vaccinating their children against HPV. Most participants had heard of cervical cancer, although understandings of symptoms and causes were very poor. Less than half of the women interviewed had undergone CC screening. Multiple barriers to screening were reported, including: a dislike of pelvic exams; embarrassment at being screened by a male doctor; anxiety over the cost; fearing a positive result; and being asymptomatic and thus not perceiving the need for screening.Conclusions:Extensive community education about HPV and CC, targeting women and men, adolescents, health workers and teachers, is crucial to support the introduction of the HPV Demonstration Program and the upscaling of CC screening. Low incomes among rural families underline the need for the HPV vaccine to be provided free within the National Immunization Program, and for CC screening to be free at primary health clinics.

IntroductionIncreasing life expectancy and longevity for people in many highly populated low- and middle-income countries has led to an increase in the number of older people. The population aged 60 years and over in Indonesia is projected to increase from 8.4% in 2005 to 25% in 2050. Understanding the determinants of healthy ageing is essential in targeting health-promotion programmes for older people in Indonesia.ObjectiveTo describe patterns of socio-economic and demographic factors associated with health status, and to identify any spatial clustering of poor health among older people in Indonesia.MethodsIn 2007, the WHO Study on global AGEing and adult health (SAGE) was conducted among 14,958 people aged 50 years and over in Purworejo District, Central Java, Indonesia. Three outcome measures were used in this analysis: self-reported quality of life (QoL), self-reported functioning and disability, and overall health score calculated from self-reported health over eight health domains. The factors associated with each health outcome were identified using multivariable logistic regression. Purely spatial analysis using Poisson regression was conducted to identify clusters of households with poor health outcomes.Results Women, older age groups, people not in any marital relationship and low educational and socio-economic levels were associated with poor health outcomes, regardless of the health indices used. Older people with low educational and socio-economic status (SES) had 3.4 times higher odds of being in the worst QoL quintile (OR = 3.35; 95% CI = 2.73–4.11) as compared to people with high education and high SES. This disadvantaged group also had higher odds of being in the worst functioning and most disabled quintile (OR = 1.67; 95% CI = 1.35–2.06) and the lowest overall health score quintile (OR = 1.66; 95% CI = 1.36–2.03). Poor health and QoL are not randomly distributed among the population over 50 years old in Purworejo District, Indonesia. Spatial analysis showed that clusters of households with at least one member being in the worst quintiles of QoL, functioning and health score intersected in the central part of Purworejo District, which is a semi-urban area with more developed economic activities compared with other areas in the district.ConclusionBeing female, old, unmarried and having low educational and socio-economic levels were significantly associated with poor self-reported QoL, health status and disability among older people in Purworejo District. This study showed the existence of geographical pockets of vulnerable older people in Purworejo District, and emphasized the need to take immediate action to address issues of older people's health and QoL.

The aim of the study was to identify determinants of exclusive breastfeeding (EBF) at the individual, family, community, and organizational level. This study was a secondary analysis of data from a multilevel promotion of EBF program in two rural public health centers (PHCs) in the Demak district, Central Java, Indonesia. The program was a quasi-experimental study with a pretest-posttest control group. A total of 599 participants were enrolled, consisting of 163 mother infant pairs, 163 fathers, 163 grandmothers, 82 community leaders, and 28 midwives. EBF duration and its determinants were measured and analyzed using Cox proportional-hazard model. Mothers with a high level of breastfeeding knowledge had the greatest EBF duration. Mothers who had a knowledge score >80 had a 73 % (HR 0.27, 95 % CI 0.15, 0.48) greater chance of EBF compared to mothers who had a knowledge score of <60. Factors which shortened EBF duration were grandmother's lack of support for EBF (HR 2.04, 95 % CI 1.33, 3.14), received formula samples at discharge (HR 1.99, 95 % CI 1.25, 3.16), and maternal experience of breast engorgement (HR 1.97, 95 % CI 1.32, 2.94). High maternal breastfeeding knowledge was the only factor associated with longer duration of EBF. Barriers to EBF were breast engorgement, receiving formula samples at discharge, and a grandmother's lack of support for EBF.

BackgroundBecause most deaths in Africa and Asia are not well documented, estimates of mortality are often made using scanty data. The INDEPTH Network works to alleviate this problem by collating detailed individual data from defined Health and Demographic Surveillance sites. By registering all deaths over time and carrying out verbal autopsies to determine cause of death across many such sites, using standardised methods, the Network seeks to generate population-based mortality statistics that are not otherwise available.ObjectiveTo build a large standardised mortality database from African and Asian sites, detailing the relevant methods, and use it to describe cause-specific mortality patterns.DesignIndividual demographic and verbal autopsy (VA) data from 22 INDEPTH sites were collated into a standardised database. The INDEPTH 2013 population was used for standardisation. The WHO 2012 VA standard and the InterVA-4 model were used for assigning cause of death.ResultsA total of 111,910 deaths occurring over 12,204,043 person-years (accumulated between 1992 and 2012) were registered across the 22 sites, and for 98,429 of these deaths (88.0%) verbal autopsies were successfully completed. There was considerable variation in all-cause mortality between sites, with most of the differences being accounted for by variations in infectious causes as a proportion of all deaths.ConclusionsThis dataset documents individual deaths across Africa and Asia in a standardised way, and on an unprecedented scale. While INDEPTH sites are not constructed to constitute a representative sample, and VA may not be the ideal method of determining cause of death, nevertheless these findings represent detailed mortality patterns for parts of the world that are severely under-served in terms of measuring mortality. Further papers explore details of mortality patterns among children and specifically for NCDs, external causes, pregnancy-related mortality, malaria, and HIV/AIDS. Comparisons will also be made where possible with other findings on mortality in the same regions. Findings presented here and in accompanying papers support the need for continued work towards much wider implementation of universal civil registration of deaths by cause on a worldwide basis.