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The study was aimed to examine the use of Mobile Assisted Language Learning (MALL) through Cake application in improving speaking skill of grade 6 Bhutanese ESL students and to find out students' learning satisfaction about the use of MALL through Cake. A quasi-experimental research design was incorporated by selecting one section of 30 participants from two sections through a simple random sampling. The quantitative data gathered using pretest, posttest and questionnaire were analyzed and interpreted applying inferential statistics t-test with p < 0.05 level of significance, mean, and standard deviation. Likewise, qualitative data through focus group interview were condensed, coded and analyzed by a theme-based approach. The results based on the pretest and posttest showed that the students' posttest mean score of 13.50 was higher than the pretest mean score of 7.77 with a mean score difference of 5.73. Further, the significant p value was 0.01 which indicated that MALL through Cake was effective in teaching English Speaking. Besides, the findings of questionnaire and focus group interview showed that the students developed much better in speaking skill which was interpreted as a high level of satisfaction; therefore, the use of MALL through Cake application was an effective tool to teach English speaking skill.

Mobile shopping (m-shopping) adoption has been significantly touted in the contemporary era; however, the adoption of m-shopping is still under shadow in many developing countries. The aim of this study is to discover the impact of device system quality on m-shopping adoption among university students with the support of UTAUT and UTAUT2 theories. The study employed PLS-SEM (symmetric) and fsQCA (asymmetric) analysis simultaneously using survey data from 530 respondents who are primarily university students. PLS-SEM results found positive significant relation between device system quality and m-shopping adoption. The study contributes with an extension of earlier studies that combine PLS-SEM (symmetric methods) and fsQCA (asymmetric methods). The study is limited among the university students that may affect the generalizability of the study. The casual recipes in this research aid policymakers to achieve their strategic objectives in implementing positive m-shopping behavior among the university students.

While studies on second language academic discourse socialization are increasing, how less academically prepared undergraduate multilingual students, such as RBSs, negotiate literacy challenges across the curriculum is still under-researched. As part of a larger qualitative study, which explored how three Bhutanese/Nepali youths negotiated the discursive, interactional, material and perceptual challenges they faced across their undergraduate curriculum in a US university, this article focuses on assessment-related textual challenges across the curriculum in a research university. Initiated as a teacher research-based study in an undergraduate ESL writing class, this longitudinal multiple-case study followed three RBSs for five years during their undergraduate study. While all three participants persistently struggled throughout their degree in various academic literacy events, they managed to graduate within five years because of various kinds of support they received. While there was no formal support tailored to RBSs at the university, this article illustrates how some literacy sponsors were able to create informal support mechanisms for these students. It also highlights how the most common literacy support at the university -- that is, teaching of essayist literacies, was inadequate for preparing RBSs well in successfully negotiating academic literacy challenges.

The purpose of this action research was to study the potential of block time lesson planning (BTLP) as a viable alternative to detailed daily lesson planning in managing teachers' workloads. The study delved into primary responsibilities of a teacher such as resourcing lessons, carrying out assessments and daily lesson planning as workloads. A combination of qualitative and quantitative methods was carried out with 40 teachers of Dagapela Middle Secondary School, in Dagana district of Bhutan. Quantitative data was gathered through online survey questionnaires while qualitative data was obtained through semi-structured interviews and participant observations. Results demonstrate that BTLP addressed teachers' workload by creating time to resourcing lessons with teaching learning materials (TLM) and for assessment of student works. We conclude that the BTLP as an alternative to detailed daily lesson planning can help in managing teachers' workload while creating time to concentrate on teaching learning materials (TLM) and assessment routines.

Education in Bhutan aims to provide holistic education focused on developing Head, Hand and Heart aspects of human development. Currently, the school programs are mainly focused on head development with a heavy emphasis on cognitive skills and testing. To help students maximise their individual potential, schools in one area (n=18) implemented an intervention program called, "One Child Seven Skills" to provide each student opportunity to learn at least seven skills. Through written interviews with key stakeholders from a primary school (teachers=5 & students=50), and a high school (teachers=14 & students=217), this study examines perceptions of the effectiveness of the intervention program. The findings revealed that the program helped students develop multiple skills, realize their innate potential, enhance self-confidence, and prepare for an uncertain future. The study suggests that adopting "One Child Seven Skills" program could be a much-needed alternative to the prevailing exam driven education in Bhutan.

Primary education plays a critical role in any country's education system, and it is essential to review its effectiveness periodically. To draw accurate conclusions from the review, it is crucial to develop a framework that will effectually and efficiently guide educators and others in comprehending the complexities of primary education and aid in devising practical strategies to improve its quality. This article describes the process of designing a comprehensive framework for reviewing primary education in Bhutan. The authors aim to help other teacher educators and their partners devise frameworks to improve education programs in their areas.

Despite the increasing number of students on the autism spectrum attending regular schools worldwide, research on the knowledge and use of teaching strategies to support the inclusion of students on the autism spectrum in the South Asian region remains scarce. The current study was informed by Florian and Spratt's Inclusive Pedagogy Framework and utilised an exploratory sequential mixed-method design to investigate Bhutanese teachers' knowledge and use of pedagogical strategies for the inclusion of students on the autism spectrum. Data was collected via semi-structured interviews (n = 16), classroom observations (n = 7) and online surveys (n = 106). The analysis revealed that although teachers reported their knowledge of effective inclusive strategies, they made limited use of them in their practice, which resulted in the micro-exclusion of students on the autism spectrum despite their physical placement in regular classrooms/schools. Recommendations for enhancing Bhutanese teachers' skills and capacity to implement effective strategies for including students on the autism spectrum are provided.

Action research has gained widespread recognition as a tool to improve teaching practices in many countries, and action research based on Kemmis and McTaggart's model was recently introduced in Bhutan to raise teaching quality. This study explored how Bhutanese secondary science teachers carried out the process of action research and the factors which supported or constrained them. Focusing on one case study school in Bhutan, data were collected progressively, using interviews, teachers' diaries, and classroom observations, as three science teachers carried out their first action research project over a period of seven weeks. Data were analysed using the coding procedures of grounded theory. The findings showed that the teachers used a messy process of action research which was not consistent with the linear process depicted in Kemmis and McTaggart's model. The constraints they faced included concerns about science curriculum coverage, lack of time, inadequate knowledge, the hierarchical education system, and the Buddhist value of "Driglam Namzha." However, teachers' collaboration, motivation, and Buddhist values of "Tha Dam Tshig" and "Zhenphen" facilitated their progress. In response to the influence of cultural factors on action research in Bhutan, the study proposes a new context-sensitive model called the "Sherig" Action Research (SAR) model for Bhutanese teachers.

An online questionnaire investigating the attitudes of Bhutanese school leaders towards inclusive education was conducted in 2016. The respondents were 20 school leaders, 16 males and 4 females, with an average age of 41 years, and teaching experience ranging from 8 to 32 years. Responses revealed that this group of school leaders had generally positive attitudes towards inclusive education; however, they were uncertain about including children with high support needs resulting from socio-emotional, cognitive and behavioural difficulties. Results confirmed that the school leaders' religious beliefs did not negatively influence their perceptions of disability and inclusive education. The findings from this exploratory study highlight the need for a legal and educational framework to underpin inclusive education in Bhutan. Such a framework will guide the provision of adequate professional learning for school leaders, appropriate resourcing, and the implementation of further systemic support.

This qualitative study explored the potential sources of enjoyment and boredom in geography classes among Bhutanese secondary school students. Utilizing open-ended surveys and semi-structured interviews, 206 participants aged 17 to 22, predominantly from classes 11 and 12, shared their perspectives. The thematic analysis of the data revealed four sources that contributed to students' enjoyment and boredom in geography classes. The findings on sources of enjoyment included sources like enthusiasm, encouragement, friendliness and support which emerged as crucial contributors to enjoyment. Moreover, video-integrated lessons, field trips, and challenging and hands-on activities, actively contributed to positive emotional experiences. Additionally, individual interest in geography, aspirations to become geographers, the relevance of materials and topics to learners' interests, were found to enhance geography class enjoyment. Conversely, the findings on sources of boredom included monotonous teaching methods, poorly prepared lessons, difficult content, dissatisfaction with presentation tasks, textbook-based activities, lack of interest in the subject or negative moods linked to boredom. Altogether, this study contributes to the growing research trend, focusing on the dimensions of students' emotions in the learning process. Based on the findings of the study, recommendations are made and directions for future research are presented.

This study explored attitudes toward English as a lingua franca (ELF) among in-service English teachers in Bhutan. Employing a mixed-method design, we collected data from 191 participants through surveys and interviews. The findings revealed that the majority of teachers held positive attitudes toward ELF. They identified English as a communicative lingua franca in Bhutan and suggested a shift in English teaching priorities toward enhancing learners' communicative skills, increasing exposure to English varieties, and moving away from the native speaker-centric model. Additionally, the participants were inclined to believe that imitating native-like accents and pronunciation is not essential for Bhutanese English speakers/learners. However, concerns were raised about potential adverse effects on Bhutanese English learners' English proficiency test scores, such as IELTS and TOEFL, which play a crucial role in determining the educational and career opportunities for most of them both within and outside the country, if ELF was to be prioritised in the context. The study concludes with suggestions on the potential integration of ELF-informed materials in the Bhutanese context and beyond.

This interpretivist study employed a qualitative multiple-embedded case study to examine the infusion of Gross National Happiness (GNH) values in teaching Mathematics. The study aimed to gain insights into Mathematics teachers' perceptions, understandings and practices of GNH values in Bhutanese classrooms. The study involved 10 teachers teaching Mathematics in grades XI and XII (age 16 to 18 years) students from five schools in eastern Bhutan using purposive sampling. The data collected through semi-structured interviews, classroom observations and field notes were analysed thematically. The study found that teachers have limited knowledge, skills and strategies required to explicitly infuse GNH values into Mathematics. First, the majority of teacher participants have not participated in any professional development programme related to GNH. Second, some teacher participants who participated in the GNH professional development programme did not receive clear guidance on how to plan and conduct lessons with GNH values in Mathematics. Third, the majority of the teachers face difficulty relating the concept of Mathematics to GNH. The knowledge generated from the study can contribute to the empirical baseline for future researchers related to GNH and Mathematics education. The study recommends research on factors affecting the infusion of GNH values in teaching Mathematics

Adopting the social constructionist approach, this study reports on Bhutanese teachers' views about the inclusion of students on the autism spectrum in regular schools. Following an exploratory sequential mixed-methods approach, 16 teachers from seven inclusive schools in Bhutan were interviewed and the analysis of their responses guided the development of an online survey instrument completed by 106 Bhutanese educators in 18 schools. Teachers' views about the inclusion of students on the autism spectrum seemed to be influenced by the social, educational, and religious context of Bhutan. Although teachers generally supported inclusion, they also expressed confusion and uncertainty about the best placement in schools for students on the autism spectrum. The implications of findings for the importance of increasing support for teacher training and allocation of adequate resources to schools are discussed.

Background: Star anise fruit has been used in spice in Asian cuisine, ingredient for traditional medicines, component for antiviral drugs and as parts of tea and beverage across the globe. Toxicity from these plants has been reported due to adulteration with similar toxic species and from consumption with high toxic dose. Most physician and public are unaware of these adverse effects. Cases: We present two cases of star anise toxicity. Both of the patients presented with gastrointestinal and neurological symptoms after consumption of the said fruit. All of the labs and imaging test was negative for other causes and star anise toxicity diagnosis was made after detailed history, events and related symptoms. They were managed supportively and discharged after 24 h of observation. Conclusion: Emergency department doctors should be vigilant about possible star anise toxicity in patient presenting with suggestive symptoms, negative investigation for other possible cause and in area where these plant species is available. A detailed drug and ingestion history is essential. [ABSTRACT FROM AUTHOR]

We describe the bias adjustment and downscaling to a resolution of 1 × 1 km of daily temperature, precipitation and solar radiation of a multimodel ensemble of Coupled Model Intercomparison Project Phase 6 (CMIP6) GCMs with the local observational data set BhutanClim for Bhutan and an analysis of the results for 1996–2100. The GCMs were selected based on their ability to reproduce local temporal and spatial precipitation patterns, resulting in a total of 14 models for each shared socioeconomic pathway (SSP). The results are shown for five global warming levels (GWLs) 1.5, 2, 3, 4 and 5°C, providing insight into the projected impacts of climate change at different warming levels. The daily temperature and precipitation data are publicly available, which is of great benefit for climate impact studies, such as ecological, hydrological or infrastructure‐related studies. In this paper, we discuss showcase climate indicators. Peak‐over‐threshold climate indicators such as hot days above 30°C are relevant for human health. In the capital city of Thimphu, these are currently rare, at 4 days per year, but might increase to more than 80 for GWL5.0. Precipitation increases in the summer months, but slightly decreases in the drier winter months. Accordingly, the 3‐month SPEI drought index is projected to increase in summer, but strongly decreases in the winter months, mostly pronounced in February. The increasing severity of late‐winter and spring droughts might have a negative impact on vegetation, wildfires and water supply. [ABSTRACT FROM AUTHOR]

In 2020, Bhutan pioneered a school-based gender-neutral human papillomavirus (HPV) vaccination program, achieving an impressive 96% vaccination coverage rate by 2021. This study, conducted through 49 in-depth interviews with community leaders, policymakers, parents, teachers, and health workers, and 12 focus group discussions with boys who received HPV vaccination. We used conventional content analysis to analyze the data. Enablers of the extension of gender-neutral HPV vaccination included social mobilization and advocacy efforts, which encompassed community engagement and leadership and collaborations with schools. Equally crucial were proficient program management and the strategic use of digital interventions. Challenges included tracking and reaching eligible adolescents. Vaccinated boys perceived school-based vaccination to be a key enabler of vaccine update. The study concludes that extending a girls-only HPV vaccination program to gender-neutral is feasible and acceptable in Bhutan. Findings related to challenges and ways for overcoming them can support other countries interested in gender-neutral HPV vaccination program. [ABSTRACT FROM AUTHOR]

The authors conducted a comprehensive review of Hesperiidae species in Bhutan, scrutinizing three existing checklists and 25 new records presented by Van der Poel et al. (2023). A thorough examination of all available documents and evidence confirmed 145 Hesperiidae species in Bhutan, with four additional species listed as tentative and one as "cf." (requiring further research). The updated checklist excludes 14 species that were listed in one or more of the three existing checklists and provides justifications for not including these species. Additionally, 11 unverifiable or wrongly identified species presented by non-peer-reviewed sources were not included in the checklist. Sixteen species with no verifiable records in the last 70 years were also identified. This review provides a comprehensive and authoritative checklist of Hesperiidae species in Bhutan. [ABSTRACT FROM AUTHOR]

Background: The need for palliative care is ever-increasing globally. However, it is least developed or not available in most low-and-middle-income-countries including Bhutan. Objective: This study was aimed at exploring the perspectives of Bhutanese healthcare professionals on the need for palliative care in the country. Design: This is a cross-sectional, mixed-method study. Setting/subjects: The study sites included all levels of healthcare in Bhutan and involved doctors, nurses, physiotherapists, pharmacists, health assistants and Drungtshos (traditional physicians). Data were collected through surveys, focus group discussions and in-depth interviews. Results: While the majority of the participants were directly involved in taking care of terminally ill and dying patients, only 14% had received some form of palliative care training for a duration ranging from 1 day to 6 weeks. Ninety-five percent of the participants reported that they faced challenges related to lack of palliative care knowledge and skills; limited resources including analgesics; shortage of doctors and nurses and lack of a palliative care team; issues with low illiteracy and financial challenges among patients; and policies and other systemic issues. The qualitative data generated four major themes: past adverse experiences; unique and complex needs for palliative care; challenges faced while caring for terminally ill and dying patients; and the urgent need for palliative care in Bhutan. Conclusion: Bhutanese healthcare professionals had very limited exposure to palliative care. This study identified a crucial need for palliative care and informs the development of an appropriate palliative care model for Bhutan. Plain language summary: 'There is no such word as palliative care for us at the moment': A study exploring the perceptions of healthcare professionals on the need for palliative care in Bhutan Palliative care is least developed in most low-and-middle-income-countries. This study was aimed at exploring the perspectives of healthcare professionals on the need for palliative care in Bhutan. Utilising both quantitative and qualitative approaches, the study sites included all levels of healthcare in Bhutan and involved doctors, nurses, physiotherapists, pharmacists, health assistants and Drungtshos (traditional physicians). Data were collected through surveys, focus group discussions and in-depth interviews. While the majority of the participants were directly involved in taking care of terminally ill and dying patients, only 14% had received some form of palliative care training for a duration ranging from one day to six weeks. Ninety five percent of the participants reported that they faced challenges related to lack of palliative care knowledge and skills; limited resources including analgesics; shortage of doctors and nurses and lack of a palliative care team; issues with low illiteracy and financial challenges among patients; and policies and other systemic issues. The qualitative data generated four major themes: past adverse experiences; unique and complex needs for palliative care; challenges faced while caring for terminally ill and dying patients; and the urgent need for palliative care in Bhutan. Bhutanese healthcare professionals had very limited exposure to palliative care. This study identified a crucial need for palliative care and informs the development of an appropriate palliative care model for Bhutan. [ABSTRACT FROM AUTHOR]

During continental collision, crustal rocks are buried, deformed, transformed and exhumed. The rates, timescales and tectonic implications of these processes are constrained through the sequence and conditions of metamorphic reactions in major and accessory phases. Petrographic, isotopic and elemental data from metabasite samples in NW Bhutan, eastern Himalaya, suggest initial equilibration under high‐pressure (plagioclase‐absent and rutile‐present) conditions, followed by decompression to lower pressure conditions at high‐temperatures that stabilized plagioclase, orthopyroxene and ilmenite. Field observations and chemical indicators suggest equilibration under the lower pressure conditions is likely linked to the infiltration of melt from the host metasedimentary rocks. The metabasites preserve two metamorphic growth stages of chemically‐and petrographically distinct allanite that temporally overlap two stages of zircon growth. Allanite cores and zircon mantles grew at c. 19 ± 2 and 17–15.5 Ma respectively, linked texturally and chemically to the high‐pressure evolution. Symplectitic rims on embayed allanite cores, wholly symplectized Aln–Ilm and Aln–Cpx grains, and high U zircon rims grew at c. 15.5–14.5 Ma, linked chemically to the presence of melt and lower pressure, high‐temperature conditions. A single garnet Lu–Hf date is interpreted as geologically meaningless, with the bulk rock composition modified by melt infiltration after garnet formation. The open system evolution of these rocks precludes precise determination of the reactive bulk composition during metamorphic evolution and thus absolute conditions, especially during the early high‐pressure evolution. Despite these limitations, we show that combined geochemical and petrographic datasets are still able to provide insights into the rates and timescales of deep orogenic processes. The data suggest a younger and shallower evolution for the NW Bhutan metabasites compared to similar rocks in the central and eastern Himalayas. [ABSTRACT FROM AUTHOR]

Introduction: Postoperative nausea and vomiting (PONV) are common distressing symptoms experienced after laparoscopic cholecystectomy. We report the rate, and the factors associated with postoperative nausea and vomiting, the patterns of prophylactic antiemetic prescription, and the anesthetic techniques used among patients who underwent laparoscopic cholecystectomy at the Jigme Dorji Wangchuck (JDW) National Referral Hospital, Bhutan. Methods: A cross-sectional study was conducted at the JDW National Referral Hospital, from January to December 2018. All the patients who underwent laparoscopic cholecystectomy under general anesthesia were included in the study. The demographic variables, premedication, induction agents, muscle relaxants, inhalational agents for maintenance, opioid and adjuvant analgesics, the reversal agents used, and the occurrence of PONV within 24 h were recorded. Data were analyzed using SPSS (version 23). Continuous variables were compared using a t-test or Mann-Whitney test, categorical variables were tested using chi-square or Fisher's exact tests. Binary logistic regression analysis was performed to determine the factors associated with postoperative nausea and vomiting. Results: 190 patients underwent laparoscopic cholecystectomy under general anesthesia. The rate of PONV after laparoscopic cholecystectomy was 31.1% (59/190). Over half (53.7%, 102/190) of the study population were within 21–40 years of age, over 80% (157/190) were female, and 2/3rd were overweight and obese. The most frequently used premedication was ranitidine (39%, 34/87) and metoclopramide (31%, 27/87). More than half (57.4%, 109/190) of the patients received morphine as an opioid analgesic before induction. Sodium thiopentone was a commonly used induction agent (65.8%, 125/190). Succinylcholine and atracurium were mostly preferred muscle relaxants. Isoflurane and air were the most used inhalational anesthetic agents for the maintenance of anesthesia. Ondansetron was the most preferred anti-emetics during the intraoperative period. Previous history of motion sickness (OR 5.8, 95%CI 2.9–11.2, p < 0.001), and use of sodium thiopental (OR 4.1, 95%CI 1.9–9.1, p < 0.001) were independent risk factors for PONV. The use of antiemetics (OR 0.1, 95%CI 0.0-0.4, p = 0.002), propofol (OR 0.2, 95%CI 0.1–0.5, p < 0.001), adjuvant analgesic paracetamol (OR 0.4, 95%CI 0.2–0.8, p = 0.026), and adequate hydration with IV fluids (OR 0.9, 95%CI 0.9-1.0, p = 0.042) were preventive factors for PONV. Conclusion: The rate of PONV after laparoscopic cholecystectomy was high. History of motion sickness and use of sodium thiopental for induction were independent risk factors of PONV. The use of multimodal prophylactic antiemetics was robust and superior to monotherapy in preventing PONV. This finding re-emphasizes the need for risk stratification and appropriate use of antiemetics and anesthetic agents to prevent PONV. [ABSTRACT FROM AUTHOR]

School teaching is widely acknowledged to be a highly demanding profession. Consequentially, an emerging academic literature deals with the stress levels teachers face. While existing studies predominantly focus on quantifying relevant stressors, this study investigates the subjective perceptions and interpretations of stressors by teachers. Data comes from Bhutan, a country with a high teacher resignation rate primarily due to teacher stress, despite being one of the highest-paid occupations. The results show that teacher stress in Bhutan predominantly emanates from heightened job demands. These demands are perceived differently in terms of how individuals view teaching responsibilities and non-academic obligations (e.g., Class Teacher). The pervasive impact of inadequate leadership and management exacerbates stress levels, directly encroaching upon psycho-social wellbeing. Ten teachers in Bhutan were interviewed using a semi-structured format. The interview data was recorded, transcribed, and coded using MAXQDA. Thematic analysis was then conducted based on the generated codes. By adopting a qualitative lens, this research enriches our understanding of teacher stress by unraveling how stressors are interconnected and how different teachers perceive the same stressor differently, providing insights on targeted interventions and support mechanisms. The results also show that supportive leadership can sometimes be viewed as a source of stress as opposed to the popular notion of perceiving it entirely as a stress-mitigating factor. [ABSTRACT FROM AUTHOR]

Aflatoxins are mycotoxins that contaminate staple foods globally and pose a significant health risk. To the best of our knowledge, information on the occurrence of aflatoxins in Bhutanese diets is scarce. This study aimed to estimate the aflatoxin levels in selected foodstuffs in Bhutan and determine the health risk associated with aflatoxin exposure. Ten different types of food commodities were randomly collected from farmers’ markets, shelves of supermarkets, and wholesale and retail shops from 20 districts of the country. The samples were subjected to analysis by an enzyme-linked immunosorbent assay for both total aflatoxins (B1, B2, G1 and G2) and aflatoxin B1. Among the 315 samples included, 48.81% and 79.35% were positive for total aflatoxins and aflatoxin B1, respectively. The overall mean total aflatoxin concentration was 11.49 ± 12.83 µg/kg, and that for B1 was 17.62 ± 23.99 µg/kg. The most prevalent food commodity with the highest aflatoxin contamination was chili products. In addition, the estimated daily intake and margin of exposure to aflatoxin B1 via the consumption of chili products ranged from 0.98 to 5.34 ng kg−1 bw day−1 and from 74.90 to 408.10, indicating a risk for public health. The liver cancer risk was estimated to be 0.01 and 0.007 cancers per year per 100,000 population resulting from the consumption of chili products. The present findings revealed the presence of total aflatoxins and aflatoxin B1 in the selected samples. The margin of exposure values was exorbitant, demanding a stringent public health measure. Notably, these results suggest the need for routine monitoring of aflatoxin contamination in the region and stress rigorous safety management strategies to reduce exposure. [ABSTRACT FROM AUTHOR]

Objectives This article describes Pathologists Overseas (PO) experience supporting external quality assessment (EQA) programs in 10 clinical laboratories across 3 countries between 2009 and 2017. Methods Laboratories were enrolled in the condensed chemical pathology EQA program provided by the Royal College of Pathologists of Australasia Quality Assurance Program. Participants were given an initial 2- to 4-day in-person training, followed by 1 year of active feedback on performance via emails or phone calls by a PO volunteer. Results There were 2 performance metrics: percentage of reported results as a measure of compliance and percentage of acceptable reported results as a measure of accuracy. Laboratories demonstrated high compliance with result reporting, with medians of 69.9%, 71.7%, and 81.3% before, during, and after feedback, respectively. Concomitant medians for the percentage of acceptable reported results were 41.2%, 57.3%, and 53.5%, respectively. Six laboratories had low performance in terms of accuracy at baseline (<60%). Active feedback improved the percentage of acceptable reported results for these lower-performing laboratories. Conclusions External quality assessment programs can be successfully adopted long term by laboratories in low-resource settings. Active feedback requires significant time and effort but could be especially beneficial for laboratories with poor baseline performance. [ABSTRACT FROM AUTHOR]

Action research has gained widespread recognition as a tool to improve teaching practices in many countries, and action research based on Kemmis and McTaggart's model was recently introduced in Bhutan to raise teaching quality. This study explored how Bhutanese secondary science teachers carried out the process of action research and the factors which supported or constrained them. Focusing on one case study school in Bhutan, data were collected progressively, using interviews, teachers' diaries, and classroom observations, as three science teachers carried out their first action research project over a period of seven weeks. Data were analysed using the coding procedures of grounded theory. The findings showed that the teachers used a messy process of action research which was not consistent with the linear process depicted in Kemmis and McTaggart's model. The constraints they faced included concerns about science curriculum coverage, lack of time, inadequate knowledge, the hierarchical education system, and the Buddhist value of Driglam Namzha. However, teachers' collaboration, motivation, and Buddhist values of Tha Dam Tshig and Zhenphen facilitated their progress. In response to the influence of cultural factors on action research in Bhutan, the study proposes a new context-sensitive model called the Sherig Action Research (SAR) model for Bhutanese teachers. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Rheumatic heart disease is a preventable disease. Patients may not present with a typical history of sore throat and polyarthritis but may present with Sydenham's chorea. We should not rely completely on clinical findings to rule out carditis. Echocardiography should be done to rule out subclinical carditis. Sydenham's chorea is a major manifestation of rheumatic fever. It occurs primarily in children and is seen rarely after the age of 20 years. We describe a 16‐year‐old girl who presented with purposeless involuntary movements of her upper and lower limbs. Laboratory blood reports showed raised erythrocyte sedimentation rate and anti‐streptolysin O. 2D Doppler Echocardiography confirmed subclinical carditis, thickened mitral and aortic valve with mild mitral regurgitation. She was managed as Acute Rheumatic Fever with oral Phenoxymethyl penicillin and Carbamazepine. At the latest follow‐up interviewing the caregiver, the patient had no sequelae. Early diagnosis is key to preventing late consequences of acute rheumatic fever and rheumatic heart disease. Sydenham's chorea is a rare presentation of acute rheumatic fever. The absence of clinical carditis does not rule out carditis. [ABSTRACT FROM AUTHOR]

Societal Impact Statement: Bhutan is an ancient kingdom in the Himalayan range and one of the most rugged, geodiverse, and mountainous agricultural countries in the world. Historically secluded and geographically isolated, Bhutan is a hotspot for Himalayan agrobiodiversity where small‐scale agriculture supports the livelihoods of a large share of the resident population. Here, Bhutanese maize agrobiodiversity is explored to unlock its adaptation potential using genomics and participatory variety selection in combination with climate research. We show that Bhutanese traditional farmers maintain a wealth of diversity that may support the sustainable intensification of maize cropping in the Himalayas and beyond. Summary: Bhutan, an ancient kingdom enshrouded in the Himalayas, hosts largely untapped agrobiodiversity that may harness genetic variation useful for adaptation to local climates and user needs.Here, we genotyped‐by‐sequencing 351 pooled samples of local maize (Zea mays L.) landraces, the entire collection of the Bhutan National Gene Bank, comparing their genomic diversity with maize from other countries in the Himalayan range. We reconstructed the adaptation of Bhutanese maize to historical and projected climates, identifying areas of future maladaptation. We then run a common garden experiment involving local smallholder farmers in a participatory evaluation of landraces' performance, aiming at the identification of quantitative trait nucleotides (QTNs) contributing to adaptation, performance, and farmers' choice.We found that Bhutanese maize agrobiodiversity is unique in the Himalayan range, and a locus on Chromosome 5 supports the differentiation of three distinct genetic clusters. We found that a portion of current genomic diversity can be associated with the Bhutanese landscape and that maize cultivation in the southwest of the country may be negatively impacted by projected climates. We also found that Bhutanese maize agrobiodiversity is large and may contribute to adaptation and improvement. A genome‐wide association study identified 117 QTNs for climatic adaptation, agronomic performance, and farmers' preferences.Our results show that Bhutanese maize landraces are a unique source of genetic agrobiodiversity for local adaptation. We found that the integration of genomics, climate science, and participatory methods can speed up the identification of genetic factors contributing to the sustainable intensification of maize cultivation in the Himalayas and beyond. [ABSTRACT FROM AUTHOR]

Bhutan sits across a geopolitical fault line in South Asia. To its south lies its traditional partner—India. To its north lies China: a country whose economic power could significantly benefit Bhutan but whose regional orientation is strategically opposed to that of India. This article explores how Bhutan manages its growing relationship with China and seeks to chart where the relationship might go in the future. It shows how increasing economic and commercial ties with China are exerting growing pressure on Bhutan, a country with few developmental opportunities. These ties—in parallel to increasing political engagements—are moving Bhutan closer to diplomatic recognition of China; a decision that will impact on the regional balance of power well beyond the country's borders. How and when this policy shift will occur is unclear, as Bhutan has been able to successfully prioritize its own interests over Chinese agendas. In doing so, Bhutan has managed to exert a higher degree of agency than other small states in the region. This outcome challenges traditional notions of small state agency in international relations. This study finds that this has been possible due to both material power considerations and the perceptional value accorded to the relationship. [ABSTRACT FROM AUTHOR]

Climate change is intensifying the risks faced by children's lives, as well as impacting their learning and education. How school communities in Bhutan are dealing with issues related to climate change is largely uncharted. This study examined how Bhutanese schools have been affected by the changing climate and how they were responding to it. The data sources included interviews with school principals, teachers, and district education officers, as well as observations, and document analysis. The global comprehensive school safety framework, along with a whole school approach to climate action framed the results of this study. Findings included that schools experienced multiple climate impacts and shocks affecting their children's health, education, and the school system itself. Adaptation and mitigation measures including climate change education have yet to gain traction at the sector and school's level. Schools, however, have attempted some actions such as through disaster management, and participatory environmental conservation and green school initiatives. Social capital was critical in filling the resource gap for initiating environmental and climate change actions, carried out through collective school, community, and student-based activities. Human capacities, policy and institutional structures, technical capacities, and capital (cultural and economic) constraints as well as slow mainstreaming into local development processes impeded efforts to build climate-resilient schools, including practices to contribute to greenhouse gases reduction. This study not only shed light on how climate change was affecting schools and children but also provided strong evidence for policymakers and relevant agencies to scale up interventions to enhance adaptation and mitigation practices. [ABSTRACT FROM AUTHOR]

In this work, a desilting chamber of the Kholongchhu Hydroelectric Project, Bhutan, was used to test the settling efficiency using physical model and Flow-3D, a three-dimensional computational fluid dynamics (CFD) software. As sediment particles greater than a particular size can cause erosion and damage to underwater machinery, the estimation of settling efficiency is essential during the planning, designing and implementation phases of hydropower projects. These studies were carried out using 12 distinct particle sizes (0.25 mm, 0.24 mm, 0.23 mm, 0.22 mm, 0.21 mm, 0.2 mm, 0.19 mm, 0.18 mm, 0.17 mm, 0.16 mm, 0.15 mm and 0.1 mm). The settling efficiency for the particle size 0.2 mm obtained by physical model and CFD simulations were 92.2% and 93.6%, respectively. [ABSTRACT FROM AUTHOR]

Abstract Background Star anise fruit has been used in spice in Asian cuisine, ingredient for traditional medicines, component for antiviral drugs and as parts of tea and beverage across the globe. Toxicity from these plants has been reported due to adulteration with similar toxic species and from consumption with high toxic dose. Most physician and public are unaware of these adverse effects. Cases We present two cases of star anise toxicity. Both of the patients presented with gastrointestinal and neurological symptoms after consumption of the said fruit. All of the labs and imaging test was negative for other causes and star anise toxicity diagnosis was made after detailed history, events and related symptoms. They were managed supportively and discharged after 24 h of observation. Conclusion Emergency department doctors should be vigilant about possible star anise toxicity in patient presenting with suggestive symptoms, negative investigation for other possible cause and in area where these plant species is available. A detailed drug and ingestion history is essential.

Abstract Aflatoxins are mycotoxins that contaminate staple foods globally and pose a significant health risk. To the best of our knowledge, information on the occurrence of aflatoxins in Bhutanese diets is scarce. This study aimed to estimate the aflatoxin levels in selected foodstuffs in Bhutan and determine the health risk associated with aflatoxin exposure. Ten different types of food commodities were randomly collected from farmers’ markets, shelves of supermarkets, and wholesale and retail shops from 20 districts of the country. The samples were subjected to analysis by an enzyme-linked immunosorbent assay for both total aflatoxins (B1, B2, G1 and G2) and aflatoxin B1. Among the 315 samples included, 48.81% and 79.35% were positive for total aflatoxins and aflatoxin B1, respectively. The overall mean total aflatoxin concentration was 11.49 ± 12.83 µg/kg, and that for B1 was 17.62 ± 23.99 µg/kg. The most prevalent food commodity with the highest aflatoxin contamination was chili products. In addition, the estimated daily intake and margin of exposure to aflatoxin B1 via the consumption of chili products ranged from 0.98 to 5.34 ng kg−1 bw day−1 and from 74.90 to 408.10, indicating a risk for public health. The liver cancer risk was estimated to be 0.01 and 0.007 cancers per year per 100,000 population resulting from the consumption of chili products. The present findings revealed the presence of total aflatoxins and aflatoxin B1 in the selected samples. The margin of exposure values was exorbitant, demanding a stringent public health measure. Notably, these results suggest the need for routine monitoring of aflatoxin contamination in the region and stress rigorous safety management strategies to reduce exposure.

Abstract Background and objective On the trajectory towards universal health coverage in Bhutan, health equity requires policy attention as significant disparities exist between urban and rural health outcomes. This paper examines health services utilization patterns, inequalities and their socio-economic determinants in rural and urban areas and decomposes the factors behind these differences. Methods We used the Bhutan Living Standard Survey 2017 to profile health services utilization patterns and equalities. We employed two different decomposition analyses: decomposition of mean differences in utilization using the Oaxaca–Blinder decomposition framework and differences in the income-related distribution in utilization using recentered influence function regressions between rural and urban areas. Results Significant differences exist in the type of outpatient services used by the rural and urban population groups, with those living in rural areas having 3.4 times higher odds of using primary health centers compared to outpatient hospital care. We find that the use of primary health care is pro-poor and that outpatient hospital resources is concentrated among the more affluent section of the population, with this observed inequality consistent across settings but more severe in rural areas. The rural–urban gap in utilization is primarily driven by income and residence in the eastern region, while income-related inequality in utilization is influenced, aside from income, by residence in the central region, household size, and marriage and employment status of the household head. We do not find evidence of significant mean differences in overall utilization or inequality in utilization of inpatient health care services. Conclusions While the differences in average contacts with health services are insignificant, there are prominent differences in the level of services availed and the associated inequality among rural and urban settings in Bhutan. Besides, while there are obvious overlaps, factors influencing income-related inequality are not necessarily the same as those driving the utilization gaps. Cognizance of these differences may lead to better informed, targeted, and potentially more effective future research and policies for universal health coverage.

Helicobacter pylori infection is a major global health concern, and its management has witnessed a revolutionary shift with the emergence of antibiotic resistance. In this review, I explore the mechanisms of H. pylori antibiotic resistance and highlight the critical need for susceptibility‐based eradication treatments. The increasing prevalence of antibiotic‐resistant strains requires innovative approaches to combat this resilient pathogen. I also delve into the importance of mass screening as a preventive strategy for early detection and intervention, describing my experience in Bhutan. Additionally, I explore promising alternatives, such as vaccination. The aim of this review is to provide insight into the evolving landscape of H. pylori treatment and highlight the need for a paradigm shift in the approach to combating this persistent bacterial infection. [ABSTRACT FROM AUTHOR]

The Arunachal and Bhutan Himalaya, which are tectonically distinct from other regions of the Himalaya, have a structure that is quite intricate. The eastern Himalayan segment is a component of the region where the Indian and Eurasian plates collided 50 Myr. The Indian Plate goes beneath the Eurasian Plate in the north, and in the eastern part of the region, the Indian Plate subducts under the Burmese Plate. Here, we studied the seismic attenuation of the uppermost mantle by measuring the quality factor of the Sn wave (Sn Q) to understand the dynamics of the lithospheric mantle and the cause of the seismic anomalies found in this area. The upper mantle Q structure has significant lateral differences in Arunachal and the Bhutan Himalaya. Arunachal Himalaya's central region is characterized by a very low |$Q\, (\le 150)$|⁠. The successive low-high-low Sn Q values in eastern Arunachal Himalaya near Siang region have been observed. The western Arunachal region, close to the Bhutan border, exhibits a contrast in Q values. We notice that low Q values (≤200) predominate in the central to eastern Bhutan Himalaya. The western part of Bhutan Himalaya exhibits relatively high |$Q\, (\ge 200)$| values, mostly near Paro and Thimpu. Interestingly, a clear boundary between low and high Q has been observed near Kakthang thrust (KT) in the Bhutan Himalaya. We found significant lateral variation of frequency dependent parameter (η) across the study region. They range from 0.25 to 0.75, with low values (≤0.5) found mostly in the central Bhutan Himalaya and in a few isolated areas of the Arunachal Himalaya. Low Q and a relatively higher |$\eta \, (\ge 0.5)$| might suggest that the scattering attenuation is the controlling mechanism for Sn wave attenuation in the upper mantle beneath Arunachal Himalaya. On the contrary, dominant low Q values across the central segment of the Bhutan Himalaya, along with a low to moderate body wave velocity and dominating low η values, subsequently corroborate that intrinsic attenuation is the dominant factor in the upper mantle of the central Bhutan Himalaya. [ABSTRACT FROM AUTHOR]

Bhutanese vernacular stone masonry architecture proved highly vulnerable to the recent seismic events affecting Bhutan since 2009. The isolation of rural communities, due to the site geomorphology, the precarious roads networks condition, the local labour limited skills, and the scarce resources availability, largely influence the applicability of strengthening technologies for traditional stone masonry architecture's seismic vulnerability mitigation. Following up the collaboration with the Royal Government of Bhutan, within an international research project, the paper aims to analyse the appropriateness and suitability of strengthening intervention strategies to the local context. The identified strategies have been associated with the analysis of the stresses causing the failure mechanisms occurred during the 2009 earthquake and tailored to local construction technologies. A full-scale static test carried-out on a stone masonry-building mock-up, allowed to evaluate its behaviour under static loads. As a final result, the suitability of the interventions has been evaluated through qualitative indicators. [ABSTRACT FROM AUTHOR]

Summary: A new rank and combination, Berberis setifolia (Ahrendt) Bharali, B.Hajong & Harber is proposed for B. macrosepala var. setifolia Ahrendt, based on a morphological examination of herbarium specimens from Me La, NE Bhutan and Se La, Arunachal Pradesh, India and living plants from Se La. The treatment of B. macrosepala Hook.f. & Thomson by Ahrendt in his two monographic treatments of Berberis (i.e. Ahrendt 1941, 1961), is shown to not fully reflect the protologue, which describes the taxon as not just one-flowered, but also fascicled. Some specimens that Ahrendt cites, including those of the three varieties of B. macrosepala he proposed, are determined to belong to other species, some of which are unrecognised. Herbarium specimens of Ahrendt's B. macrosepala var. setifolia from Bhutan are shown to be the same as those of a hitherto unidentified species from Arunachal Pradesh. A detailed taxonomic description, notes on habitat and ecology, and colour photographs are provided for B. setifolia. [ABSTRACT FROM AUTHOR]

An online questionnaire investigating the attitudes of Bhutanese school leaders towards inclusive education was conducted in 2016. The respondents were 20 school leaders, 16 males and 4 females, with an average age of 41 years, and teaching experience ranging from 8 to 32 years. Responses revealed that this group of school leaders had generally positive attitudes towards inclusive education; however, they were uncertain about including children with high support needs resulting from socio-emotional, cognitive and behavioural difficulties. Results confirmed that the school leaders' religious beliefs did not negatively influence their perceptions of disability and inclusive education. The findings from this exploratory study highlight the need for a legal and educational framework to underpin inclusive education in Bhutan. Such a framework will guide the provision of adequate professional learning for school leaders, appropriate resourcing, and the implementation of further systemic support. [ABSTRACT FROM AUTHOR]

Bovine tuberculosis (bTB) is a chronic zoonotic disease affecting cattle of all age groups including wild animals. It poses a significant threat to public health and high economic losses to dairy farmers. While the disease has been eradicated from most of the developed countries through extensive surveillance, testing and culling strategy, it is endemic in Africa, Asia, and the Middle East countries. Currently, there is limited research regarding the prevalence of bTB in cattle in Bhutan. This study aimed to determine the seroprevalence of bTB in cattle in six districts of eastern Bhutan. A two-stage probability proportional to size (PPS) sampling strategy was used to determine the number of animals from which serum samples needed to be collected in each district and sub-district. All farms and cattle for sampling were randomly selected from the data in the annual livestock census of 2020. The samples were tested using bTB ELISA test kit. The seroprevalence and their 95% confidence intervals were calculated. Logistic regression models were constructed to assess the influence of various individual animal and environmental risk factors (breed, age, sex, source of animal, body condition scores of animals, respiratory system status) associated with sero-positivity in animals. The study revealed an apparent seroprevalence of 2.57% (25/971 cattle; 95% CI:1.58–3.57), with an estimated true seroprevalence of 0.91% (95% CI: 0.0–2.81). However, none of the variables were found to be significantly associated with bTB seroprevalence in cattle. We recommend, further sampling and employment of confirmatory testing to fully ascertain the extent of bTB in the cattle herds in eastern Bhutan for prevention and control. Author summary: Bovine tuberculosis (bTB) is a bacterial zoonotic disease caused by Mycobacterium bovis, affecting cattle of all ages. Mycobacterium bovis imposes significant economic burdens on livestock farmers, primarily through reduced production, trade restrictions for live animals and animal products, and the costs of control measures. The disease can be transmitted to humans via consumption of raw milk or through inhalation of infected aerosols. Worldwide, the bovine tuberculosis accounts for 10% of the human tuberculosis cases. In Bhutan, the prevalence and incidence of bTB in both cattle and humans are unknown. In this study, we estimated the seroprevalence of bTB among cattle in six eastern districts of Bhutan. We collected serum samples from 971 cattle and tested them for bovine tuberculosis using ELISA. Our study demonstrated an apparent prevalence of 2.57% (95% CI:1.58–3.57) and a true prevalence of 0.91% (95% CI: 0.0–2.81). Additionally, we assessed factors such as age, breed and farm location that could affect the prevalence of bTB, but none of these factors were significantly associated with the prevalence of bTB. Our study revealed a very low seroprevalence of bTB, among cattle in eastern Bhutan. The findings from this study will contribute to design prevention and control measures for bTB in cattle in Bhutan. [ABSTRACT FROM AUTHOR]

Assessing the knowledge of and attitudes towards species is critical for shaping the next generation of conservationists and environmentally conscious citizens to foster a sense of responsibility and engagement with the natural world. However, no studies have been undertaken from Bhutan to date concerning the knowledge of and attitude towards waterbirds. We conducted an online survey of 741 students encompassing 185 middle and 556 higher secondary schools. The results indicated that the majority of students have a poor level of knowledge but a strong positive attitude towards the waterbirds. Conditional inference tree (CIT) analysis revealed that the most statistically significant factor associated with knowledge was region followed by age, gender and grade, respectively. Similarly, CIT analysis showed that the female students exhibited a stronger positive attitude than males and others. Further, there was a statistically significant but weak positive correlation between knowledge and attitude. The current study suggests that there is a pressing need to address the substantial knowledge gap concerning waterbirds among Bhutanese middle and higher secondary students. Therefore, we recommend that emphasis should also be placed on teaching outdoor waterbird biology, potentially infusing it into school curricula, which would foster a deeper understanding of Bhutan’s waterbirds and their habitats. [ABSTRACT FROM AUTHOR]

Background: Indigenous and non-indigenous people in subtropical and temperate areas of Bhutan share an intricate relationship with stingless bees for diverse purposes including ethno-medicinal uses. Stingless bees hold significant importance in the realms of social, economic, cultural, and spiritual aspects. Bhutan's cultural traditions demonstrate a strong bond with the environment, exemplified by the regular use of honey from stingless bees for remedies such as treating the common cold, cough, and sore throat. Methods: Ethnographic research was conducted to document the ethno-medicinal uses and cultural importance of stingless bees in Bhutan. We deployed semi-structured interviews with stingless beekeepers and honey collectors including traditional healers who perform religious rituals for curing and preventing physical and mental illness. Results: We documented 22 different uses of stingless bee honey in food, medicine, veterinary medicine, crafts, beliefs, and religious purposes. The relative cultural importance (RCI) of stingless bees among Bhutan's ethnic communities was assessed through our calculations. It was determined that these bees hold notably greater significance for the Lhotshampa communities compared to other ethnic groups in Bhutan. This finding demonstrates the dependence of Hindu ethnic communities on natural resources in their everyday life. All participant communities largely exploit these bees through destructive extraction practices. They often find the natural nests in nearby forests, transfer them as a log hive to their backyards, and practice traditional meliponiculture. Conclusion: The ethnic communities of Bhutan use stingless bees for various purposes and the local knowledge are persistent. However, significant efforts should be made to address the ethno-medicinal, ecological, biological, and commercial perspectives of meliponiculture in Bhutan. [ABSTRACT FROM AUTHOR]

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