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The following study is a synopsis of health and welfare in the Qinghai area based on a report by a team from UCLA led by Kunchok Gyaltsen MPH, MIIM, Tibetan Medical Doctor.

VI. CONCLUSION AND DISCUSSION :
The goal of this study is to provide an overview of the lives and health of Tibetan women, children and families living in rural villages of Qinghai Province. Here we summarize our main findings.

Education, Literacy and Income:

In the study population, half of the adult and almost all of the children have attended school at some point. Adults who did attend school completed an average of five years and children completed an average of four years.  The national government requirement of nine years of compulsory education appears to have increased the proportion of children who attend school compared to their elders.

However, while many attend schools, they generally do not complete the full nine years of school. We also found that one third of reproductive age women had attended school (not shown) and that 20% report that they are able to read and write Tibetan, a finding which contradicts the conventional wisdom that almost all Tibetan women are illiterate. Given the high rates of school attendance among children, it is likely that the proportion of reproductive age women who are literate will increase in the next several decades.

Nonetheless, the effects of attending school on women’s and children’s health will depend not only on attending school, but also on completing school, since relatively few rural Tibetans are able to complete even the six-year primary education, let alone the full nine-year compulsory education. Therefore, an emphasis on school completion is still crucial to improve the educational level of the Tibetan population and especially that of the female population. The quality and content of schooling is also an important issue to address, but this study did not collect data on these issues.  

Our results show that annual income is very low for these rural Tibetan families. However, the value of animal assets relative to annual income is high. Holding wealth in animals is traditional in rural Tibetan households. Animals are generally not raised to be sold or slaughtered for household consumption, but rather as a longer term investment. For most families, cash income comes primarily from raising crops and working outside the home, such as collecting medicinal plants. Collection of medicinal plants has become a particularly important means of  supplementing income because of substantial price increases for a particular herb, known in English as Chinese caterpillar fungus (Cordyceps sinensis).  

Water, Sanitation and Hygiene

Most participants in this study had access to clean drinking water and most had access to piped water (although often at some distance from their house at a communal tap). More than half of respondents said that they had adequate water supply throughout the year. All respondents reported they heated water to the boiling point before drinking it. However, we suspect that these responses were due in part to women’s knowledge that they were supposed to boil drinking water rather than to actual practice.

The availability of water is likely to be due to government infrastructure projects in the area. For similar reasons, a high proportion of households use latrines in this area.  However, other types of waste management are poor since virtually all households report that they dump trash and refuse near their house.

All households use human waste as night soil or agricultural fertilizer. Use of human waste as fertilizer can be an environmentally sound means of waste disposal and a low cost form of fertilizer. However, without composting or proper treatment, night soil can easily transmit many types of infectious diseases among people. The fact that night soil is so commonly used suggests that it is important for Tibetan and other rural  farmers to have access to information about its proper treatment prior to its use as fertilizer for crops used for human consumption.  

Health Care Facilities

Almost every village has a village doctor or village health workers and almost all of them are male. These health providers practice both Tibetan and western medicine and commonly use injections (often of antibiotics, often given inappropriately and/or in extremely high doses). Adults and children needing health care are most likely to seek help from a village doctor or health care worker because they are often the only health care providers available within a reasonable distance.

Township health centers and county hospitals are located at considerable distance from the villages and on average it takes two hours to reach them. Many families (70%) did not seek health care at all when an adult family member was sick. Not surprisingly, families appear to seek health care for adults only when the illness is serious.

Families were more likely to seek health care when their children became sick, although in one third of the cases of child illness, they did not seek care from a health provider.   Village health workers and village doctors are often the only health care providers available to village residents. Thus, it is essential to improve the quality of services that they provide by training them in disease prevention and management and regularly updating their skills and knowledge. Township health centers, country hospitals and higher level health facilities are often too far from the villages to be of use. 

Transportation is a huge issue for villagers who need health care, because generally the only way to reach these health facilities is to walk for several hours. For urgent health situations, such as deliveries and health emergencies, it is clearly impossible to reach these facilities in time to get help.

Common child health problems in this population were diarrhea and respiratory/chest ailments, cough, and ear disorders. Diarrhea and respiratory disease is common in undernourished children, particularly in conditions of poor hygiene and sanitation.

Even though drinking water supplies in these villages appear to be relatively good compared to other areas, some families continue to get their water from contaminated springs. Even those with piped water have to carry it some distance and store it in  containers in the house. As many studies have shown, the cleanliness of the storage container, the implement used to dip the water, and cups, plates and utensils can affect the likelihood of disease transmission.

Although all respondents say that they boil their water before drinking, it seems unlikely that this practice is really universal given the scarcity of firewood. Poor hand washing can also be a source of disease transmission and less than half of participants in this study reported washing their hands after using the latrine.

Moreover, one third of women report that their families do not have adequate water supply which makes practices such as hand washing and careful washing of dishes and utensils more difficult.

Respiratory and cough problems may be related to the weather and climate. During the cold season, homes are not well heated and illnesses among children are most common in the winter and spring.   Respiratory disease may also be more common during winter because families spend more time indoors in close contact with each other and because smoky cooking and heating fires can cause respiratory problems, especially for young children.  

Another major cause of child morbidity and mortality in these villages is the lack of immunization coverage. Despite provincial and national immunization programs which are consistent with WHO recommendations, none of the children in the study areas appear to have received all of the immunizations that they should have. Among those who received at least one vaccine dose, very few received more than one or two doses.

Adults were even less likely to be immunized. In these villages, children often die in infancy. Eighteen percent of respondents reported that one or more of their children died within the first five years of life. Since many of the deaths occurred within one month of birth, it is likely that the quality of maternal care and delivery care is part of the cause.

Almost all deliveries occur at home and are attended by untrained family members, including mothers and sisters. No trained health care providers are available at all to assist in delivery in these villages – putting both mothers and infants at serious risk.

Furthermore, most women do not visit health workers or receive any prenatal care during their pregnancies. Clearly, there is an urgent need for better health care and health facilities for women and children in these areas.   Women's Health Aside from pregnancy and delivery, other aspects of women’s health examined in this study included contraceptive use and knowledge of major diseases. The results show that most women used contraceptive methods, particularly the Copper IUD. Side effects of the IUD appear to be very common in this population: almost half of the sample reported having abdominal pain or uterine infections associated with IUD use. These results suggest that women need more contraceptive method choices and also better information on the use of contraception. It may also be important to train health care providers in better methods to insert IUDs without causing infection

We also found that study participants knew very little about common infectious diseases such as tuberculosis, sexually-transmitted diseases, HIV, and AIDS. This is a serious problem for this population because many people leave their villages for work and may return home with TB or STDs. These results suggest that programs to educate women and their family members about infectious disease and its prevention are crucial for these villages.  

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