Browsing by Subject "Nepal"

Background: Hypertension and related complications are major contributors to deaths and disabilities in Nepal. We aim to explore existing work flows, needs and challenges to hypertension care coordination and assess feasibility of establishing a FCHV-based hypertension management program in Kavre, Nepal.

Design: We conducted 23 in depth-interviews and one focus group discussion that consists of nine patients with hypertension, six health workers, four health officials, and 12 FCHVs in two village development committees of Kavre district, Nepal. Applied thematic analysis was performed using NVivo 12.

Results: Health literacy related to hypertension was low. Delay in treatment initiation and lost to follow up were common patterns despite comply with antihypertensive medication. Underutilization of primary healthcare institutions, communication gap and lack of grass-roots level educational campaigns were identified as major health system-related barriers. Community pharmacies, monthly health camps and increasing governmental attention to NCDs were favorable for hypertension management. This study also showed FCHVs have the potential to promote hypertension educational, screening and referral in their catchments, with adequate training and proper motivation.

Conclusions: Barriers and facilitators identified in this study have implications for future hypertension management intervention design. We recommend grassroot level hypertension education and screening across the Nepal. FCHVs have the potential to take on these responsibilities, once they are empowered with appropriate training and motivated by proper incentives.

Keywords: hypertension management, barriers, facilitators, community health workers, female community health volunteers, Nepal, qualitative research

Background: Emotions are shaped through the internalization of culturally relevant values. Contextualized systems of meaning influence an individual’s experience of emotion, the consequences of a given response, and their connection to long-term functional outcomes. The present study aims to explore the socioemotional world of Nepali adolescents, in order to understand emotional needs and identify opportunities for psychosocial intervention. Methods: A tablet-based battery of quantitative assessments was administered to 102 students in grades 7-9 (age 12-18) in an earthquake affected region of the Kathmandu Valley. Assessments included measures of anxiety, PTSD, functional impairment, and a local idiom of distress (problems in the heart-mind). Semi-structured interviews were conducted with 21 students and explored the emotional experience of a recent stressor. Results: Three domains of emotion experience emerged: cognitive, physical, and social. While key differences in emotional distress across gender and cultural groups emerged, similarities in the overarching model suggest a shared understanding of negative emotion among Nepali adolescents. Of particular note is the social domain, involving both interpersonal and communal elements, which included the local idiom of distress, which has previously been linked to depression risk. Conclusion: This tripartite conceptualization of emotion is a critical step toward understanding cultural meanings of emotional wellbeing, and the connection between socially experienced emotion and psychopathology underlines the importance of psychosocial integration in future interventions.

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Background: The relationship between mental health and climate change are poorly understood. Participatory methods represent ethical, feasible, and culturally-appropriate approaches to engage community members for mental health promotion in the context of climate change. Aim: Photovoice, a community-based participatory research methodology uses images as a tool to deconstruct problems by posing meaningful questions in a community to find actionable solutions. This community-enhancing technique was used to elicit experiences of climate change among women in rural Nepal and the association of climate change with mental health. Subjects and methods: Mixed-methods, including in-depth interviews and self-report questionnaires, were used to evaluate the experience of 10 women participating in photovoice. Quantitative tools included Nepali versions of Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI) and a resilience scale. Results: In qualitative interviews after photovoice, women reported climate change adaptation and behavior change strategies including environmental knowledge-sharing, group mobilization, and increased hygiene practices. Women also reported beneficial effects for mental health. The mean BDI score prior to photovoice was 23.20 (SD=9.00) and two weeks after completion of photovoice, the mean BDI score was 7.40 (SD=7.93), paired t-test = 8.02, p<.001, n=10. Conclusion: Photovoice, as a participatory method, has potential to inform resources, adaptive strategies and potential interventions to for climate change and mental health.

Abstract

BACKGROUND: Cardiovascular disease (CVD) is the greatest killer of mankind. In Nepal, a small, landlocked country in South Asia and one of the poorest countries in the world, the burden of cardiovascular disease is high; national CVD monitoring has substantial gaps; and CVD risk factors are poorly controlled. Primary healthcare (PHC) is often at the front lines of prevention and control of CVD. Thus, strengthening local and national primary healthcare systems is an essential step toward prevention and management of CVD in low- and middle-income countries (LMICs). To inform further research and policy development, we conducted an exploratory, mixed-methods study to understand patient-side utilization of CVD services in rural and urban areas in Nepal.

METHODS: We surveyed 114 CVD patients from 10 PHC facilities across two regions of Nepal. Survey contents included sociodemographic information, disease history, and data on accessibility, affordability, availability, and utilization of PHC services. We further completed 20 in-depth interviews within our sample to understand patient-side perceptions of CVD-related PHC care.

RESULTS: In the final cohort, 23% had experienced a stroke, 26% had some form of existing heart disease, 76% presented with hypertension, and 67% had diabetes. For all conditions, hospitals were a more common place of diagnosis than PHC facilities. The mean visitation frequency to PHC facilities in the past year was 10.7 times, with healthier patients having higher visitation rates than those with poorer health. 69% of patients reported difficulty obtaining CVD medicine from their local PHC facility. Qualitative data revealed that PHC facilities lacked resources for diagnosing and managing CVD conditions. Additionally, behavior of physicians and affordability were both considered important components of PHC satisfaction. Patient recommendations included increased diagnostic equipment in PHC facilities, free essential medicines, and community awareness initiatives for cardiovascular disease.

CONCLUSION: There are clear shortcomings between national aims and objectives – such as free essential medicines and universal PHC services – and the reality faced by CVD patients in resource-limited settings in Nepal. Despite PHC facilities generally being close to patients, participants reported inadequate resources when seeking care for CVD and expressed a strong desire that such services could be provided locally. Based on the challenges articulated by CVD patients in our study, mhealth may be a relevant direction of future research for connecting hospital-based specialists to CVD patients in rural areas, improving follow-up, and decreasing expensive visits to far away tertiary care centers. Overall, we recommend increased national CVD monitoring, prioritization of NCDs and CVDs in national policymaking and strategizing, and continued provision of PHC facilities close to patients in their communities.

Keywords: primary care, cardiovascular, utilization, Nepal, public healthcare facilities

DEDICATION

Purpose. Suicide is the second leading cause of death globally among young adults 15-29 years old. Addressing adolescent suicidal thoughts and behavior (STB) is especially important in low and middle income countries (LMIC) where 46% of suicides occur before 25 years of age. This burden is highest in Asia, with adolescent rates two times greater than the global average. This study examines the role of gender in influencing the relationship between coping dysfunction, self-validation, and suicidality among adolescents in the context of a school-based mental health promotion program in post-earthquake Nepal.

Methods. In this mixed-methods study, adolescents (N = 102, 50% female) attending secondary school (12 – 18 years old, average age 14.3 years) in a highly earthquake-affected region near Kathmandu, Nepal, completed the Ways of Coping Checklist, Self-Validation/Self-Invalidation Questionnaire, and the Suicide Screener Questionnaire. Participants of semi-structured interviews included 23 students, 2 teachers, and 3 caregivers. Gender-stratified focus group discussions (n = 2) were also conducted among students.

Results. The stressor that students identified most frequently (71.4% of interviewees) in qualitative interviews was academic-related sources. Scores on the Ways of Coping Checklist skills and dysfunction scales did not differ significantly by gender. However, girls scoring high in coping dysfunction (t = -2.511, p = 0.015) and low in self-validation (t = 2.916, p = 0.005) were significantly more likely to endorse suicidal ideations in the past two weeks compared to boys with similar dysfunction (t = -0.237, p = 0.813; and self-validation scores t = 1.087, p = 0.282).

Conclusions. Although gender differences in coping skills and coping dysfunction were not quantitatively observed, qualitative analyses revealed that dysfunctional coping was more frequently reported by girls. Future studies should examine the temporal relationship between coping strategies and suicidality. Suicide risk reduction programs should evaluate enhancing adaptive coping skills usage as a mechanism of action to reduce suicidality among girls. Additional research is needed to identify salient risk factors for boys.

Background: Faced with the surging trends of cardiovascular diseases (CVDs) and the limited numbers of health professionals in Nepal, more innovative measures should be explored to tackle the challenges of CVD prevention and control. This study explored the feasibility of shifting some CVD-related tasks to the community by engaging female community health volunteers (FCHVs) for CVD risk screening. Methods: This study was conducted in a rural and an urban study site in Lalitpur (Kathmandu Valley), Nepal. Mixed methods were employed in this study. Ten FCHVs were recruited and trained to use the Cardiovascular Risk Scoring Chart adapted from the World Health Organization’s Package for Essential Non-Communicable Diseases (PEN). After the training, FCHVs administered cardiovascular risk factor questionnaires and used the risk scoring chart to screen eligible community residents in their catchment area. Using the data collected by FCHVs, a medical doctor calculated the second risk score with the same risk scoring chart. A kappa concordance test was used to compare these two sets of risk screening results for agreement, and a sensitivity and specificity test was conducted to assess the reliability of the FCHVs’ CVD risk screening results. Two focus group discussions were administered to investigate the FCHVs’ training and fieldwork experiences during the study. Results: There were 491 community residents screened for cardiovascular risk at two study sites. The mean level of agreement between the two sets of risk screening results was 94.5% (Kappa = 0.77, P < 0.05). The sensitivity of the FCHV screening test was 90.3% (95% CI [0.801, 0.964]); and the specificity was 97% (95% CI [0.948, 0.984]). In the FGD, FCHVs expressed a strong enthusiasm and readiness for NCD related work. Besides, all FCHVs agreed that they could manage their current workload and were confident that they could perform more tasks for the prevention and control of NCDs with the proper training. More NCD-related programs and training are called for by FCHVs. Conclusions: It is feasible to train FCHVs to use the simple cardiovascular scoring chart to screen and identify community residents at high risk of developing CVDs. Although FCHVs expressed interests in taking on more responsibility regarding the prevention and control of NCDs, further studies are needed to assess the feasibility of engaging FCHVs within the existing healthcare system.