Impact of Suaahara, an integrated nutrition programme, on maternal and child nutrition at scale in Nepal.

Suaahara was an innovative, complex, multi-sectoral, large-scale, nutrition programme in Nepal to increase exposure to nutrition-related information and services, improve nutrition-related knowledge and practices among pregnant women and mothers of infants and young children, and improve their nutrition. This study evaluated the effectiveness of Suaahara to improve nutrition and nutrition-related practices by comparing changes over 10 years between intervention and comparison districts. The samples of households at baseline in 2012 and endline in 2022 were 2040 and 2480, respectively, from 120 old wards. The impact was estimated using intent-to-treat regression models in which survey year, arm and their interaction were fixed effects, accounting for district clustering, with the interaction estimating differences between arms in changes over time. The intervention, relative to comparison, reduced maternal underweight by 8.43 percentage points (p < 0.001), consistent with improved maternal and fetal condition that was manifested as the greater length of 0.761 z-scores (p = 0.004) of infants 0-5.9 months. Complementary feeding practices with children between 6 and 23.9 months of age improved more in the intervention than comparison districts: child dietary diversity by 0.294 food groups (p = 0.072) and minimum dietary diversity by 9.51 percentage points (p = 0.028), feeding sick child more (p = 0.002) and administering oral rehydration solution and zinc for diarrhoea (p = 0.057) by about 17 percentage points each, and minimum meal frequency (p = 0.004) and minimum acceptable diet (p = 0.022) by about 15 percentage points each. Substantial impacts were demonstrated despite political restructuring, earthquakes, and other major challenges that Nepal and Suaahara faced and limitations in statistical power because of the reduced number of districts that then could be included in the study. Registered at clinicaltrials.gov with identifier NCT05448287.

Malnutrition matters: Association of stunting and underweight with early childhood development indicators in Nepal.

Malnutrition is a threat to optimal child development, with its occurrence during foetal and infancy stages associated with poor cognitive, motor and socio-emotional skills. However, information on the effects of various types of malnutrition on early childhood development (ECD) is limited in Nepal. To assess the association of stunting, wasting and underweight (three prominent forms of malnutrition) with the four domains of the ECD index (literacy-numeracy, physical, social-emotional and learning development) among children 36-59 months of age, we conducted an adjusted logistic regression using Nepal's national household Multiple Indicator Cluster Survey (MICS) 2019 data set. The study sample consisted of children aged 36-59 months (n = 2871). Children were considered developmentally on track if they met criteria in each of the four ECD domains. Regarding ECD status of children 36-59 months old, 35% of children were not developmentally on track for the ECD index. The adjusted odds ratio indicated that stunting was associated with lower odds of not being developmentally on track according to the ECD index as well as the literacy-numeracy, physical and learning domains of the ECD index. Likewise, underweight was associated with lower odds of not being developmentally on track according to the ECD index, primarily for ECD domains of literacy-numeracy, physical and learning. Notably, no association between wasting and ECD indicators was observed. Children's nutrition status impacts child development outcomes. Adding ECD interventions, such as responsive and stimulating caregiving, within nutrition programmes among children who are stunted and underweight could improve child development outcomes.

Unravelling adolescent girls' aspirations in Nepal: Status and associations with individual-, household-, and community-level characteristics.

BACKGROUND: Adolescents' aspirations have potential to influence their present and future well-being. Limited knowledge exists on adolescent girls' aspirations and their determinants, particularly in low-income contexts. METHODS AND FINDINGS: Using cross-sectional data, collected in 2018 in Nepal, within the Suaahara II Adolescent Panel Survey, (n = 840), adolescent girls' aspirations in several domains-education, occupation, marriage, fertility, health, and nutrition-were described. Regression models were estimated to explore associations between individual, household and community characteristics and these aspirations for all adolescents and separately for younger (10-14 years) and older (15-19 years) girls. Age, school attendance, and self-efficacy, as well as household wealth, caste/ethnicity, size, and agro-ecological zone of residence were significantly associated with aspirations, although effect sizes and significance varied by aspiration domain and age group. CONCLUSIONS: Findings underscore the curtailing effect of poverty on aspirations and the dynamic nature of aspirations. Initiatives to foster girls' aspirations must address both individual and contextual factors.

Self-reported psychological distress during the COVID-19 outbreak in Nepal: findings from an online survey.

BACKGROUND: A lower respiratory tract infection caused by novel coronavirus termed as Corona Virus Disease (COVID-19) was first identified in China and subsequently took the form of pandemic. Studies on disease outbreak in the past and recent COVID-19 outbreak have demonstrated increased psychological distress and adverse impacts on mental health and psychological wellbeing of people. However, the impact of COVID-19 on psychological wellbeing of people in Nepal hasn't been studied adequately. So, this paper aims to report the findings from a social media survey on psychological impacts of COVID-19 in Nepal. METHODS: Data were collected through social media from 2082 Nepalese respondents between 23rd April, 2020 and 3rd May, 2020. A total of 2014 respondents who were currently residing in Nepal were included in the analysis. RESULTS: The study suggested that half of the respondents suffered from at least one symptom of psychological distress whereas 32% suffered from two or more symptoms of psychological distress such as restlessness, fearfulness, anxiety and worry and sadness in the past 2 weeks preceding the survey date. The findings further suggested that respondents having lower family income, residing in rented room, and participants from province 2 were more likely to suffer from both single and multiple symptoms of psychological distress. CONCLUSION: The study has shown high prevalence of psychological distress amongst the Nepalese respondents following COVID-19 outbreak. Appropriate mental health and psychosocial support response needs to be instituted to adequately respond to psychological impacts of the epidemic.

Evaluating the integration of chronic care elements in primary health care for people with mental illness: a longitudinal study in Nepal conducted among primary health care workers.

BACKGROUND: Despite many important developments in the global mental health arena in the past decade, many people with mental health problems still do not have access to good quality mental health care. The aim of this study was to evaluate the perceived impact of a mental health care package (MHCP) in integrating chronic care elements in primary health care for people with mental illness. METHODS: A controlled pre-post study design was used in 20 primary health care facilities in Chitwan, Nepal. We compared 10 health facilities that had implemented a MHCP (intervention group), with 10 health facilities that had not implemented the MHCP (comparative control group) but provided regular physical health services. We administered the Assessment of Chronic Illness Care (ACIC) tool on a group basis within all 20 health facilities among 37 health workers. Data was collected at three time points; at baseline, midline (at 13 months from baseline) and end line (at 25 months from baseline). RESULTS: From baseline to end line, we see a notable shift in the level of support reported by the intervention health facilities compared to those in the comparative control group. While at baseline 10% of the intervention health facilities had basic support for the implementation of chronic illness care, at the end line, 90% of the intervention group reported having reasonable support with the remaining 10% of the intervention facilities reporting that they had full support. In contrast, 20% of the health facilities in the comparative control group at end line still reported having limited support for the implementation of chronic illness care, with the remaining 80% only managing to shift to the next level which is basic support. CONCLUSIONS: These findings suggest that training and supervision of primary health care workers in the implementation of MHCP interventions can lead to strengthening of the system to better address the needs of patients with chronic mental health problems. However, substantial financial and coordination inputs are needed to implement the MHCP. The comparative control group also demonstrated improvements, possibly due to the administration of the ACIC tool and components of counselling services for family planning and HIV/AIDS services.

Intimate partner violence and nutritional status among nepalese women: an investigation of associations.

BACKGROUND: Malnutrition among women in Nepal persists as a major public health burden. Global literature suggests that domestic violence may have a negative impact on women's nutritional status. The contribution of intimate partner violence (IPV) to increased stress levels, poor self-care including the consumption of less food and, in turn, malnutrition has been documented. However, there is little empirical evidence on IPV and its relationship with women's nutritional status in Nepal and thus, this paper assesses these associations. METHODS: We used data on non-pregnant married women (n = 3293) from the 2016 Nepal Demographic and Health Survey (NDHS). The primary exposure variable was whether the women had ever experienced physical, sexual, or emotional violence or controlling behaviours by a current or former partner, based on her responses to the NDHS domestic violence questions. The primary outcome variables were three indicators of malnutrition: under-weight (BMI < 18.5), over-weight (BMI > 25), and anemia (Hb < 11.0 g dL). We used logistic and multinomial regression models, adjusted for potential socio-demographic and economic confounders, as well as clustering, to examine associations between IPV exposure and malnutrition. RESULTS: Approximately 44% of women had experienced at least one of the four types of IPV. Among them, around 16, 25%. and 44% were underweight, overweight, or anemic, respectively, compared to 13, 29, and 35% of women never exposed to IPV. We did not find any associations between underweight and any of the four types of IPV. Overweight was associated with physical violence (adjusted RRR = 0.67, P < 0.01, CI = 0.50-0.88) and severe physical violence (adjusted RRR = 0.53, P < 0.05, CI = 0.32-0.88) Controlling behaviors were associated with anemia (adjusted RRR = 1.31, P < 0.01, CI = 1.11-1.54). CONCLUSIONS: Among married Nepalese women, physical violence appears to be a risk factor for one's weight and controlling behaviors for one's anemia status. Additional, rigorous, mixed-methods research is needed to understand the reporting of IPV and what relationships do or do not exist between IPV experience and nutrition both in Nepal and in other settings.

Determinants of stunting among children aged 0-59 months in Nepal: findings from Nepal Demographic and health Survey, 2006, 2011, and 2016.

BACKGROUND: Stunting is one of the most commonly used indicators of child nutrition and health status. Despite significant efforts by the government and external development partners to improve maternal and child health and nutrition, stunting is consistently high in Nepal. This paper assesses the potential determinants of stunting among children aged 0-59 months using the last three successive Nepal Demographic and Health Surveys (NDHS). METHODS: We used three nationally representative cross-sectional household surveys, known as the NDHS- 2006, 2011 and 2016. Logistic regression was used to identify the potential determinants of stunting. The sub sample for this study includes n = 5083 in 2006, n = 2485 in 2011, and n = 2421 in 2016. RESULTS: Rates of stunting decreased from nearly 50% in 2006 to about 36% in 2016. The prevalence of stunting was higher among children from larger families (51.0% in 2006, 41.1% in 2011, 38.7% in 2016), poor wealth quintile households (61.2% in 2006, 56.0% in 2011, 49.2% in 2016), and severely food insecure households (49.0% in 2011, 46.5% in 2016). For child stunting, the common determinants in all three surveys included: being from the highest equity quintile (OR: 0.58 in 2006, 0.26 in 2011, 0.28 in 2016), being older (OR: 2.24 in 2006, 2.58 in 2011, 1.58 in 2016), being below average size at time of birth (OR: 1.64 in 2006, 1.55 in 2011, 1.60 in 2016), and being affected by anemia (OR: 1.32 in 2006, 1.59 in 2011, 1.40 in 2016). CONCLUSIONS: This study found that household wealth status, age of child, size of child at time of birth, and child anemia comprised the common determinants of stunting in all three surveys in Nepal. Study findings underscore the need for effective implementation of evidence-based nutrition interventions in health and non-health sectors to reduce the high rates of child stunting in Nepal.

Validation of a cross-cultural instrument for child behavior problems: the Disruptive Behavior International Scale - Nepal version.

BACKGROUND: Obtaining accurate and valid measurements of disruptive behavior disorders remains a challenge in non-Western settings due to variability in societal norms for child behavior and a lack of tools developed outside of Western contexts. This paper assesses the reliability and construct validity of the Disruptive Behavior International Scale - Nepal version (DBIS-N)-a scale developed using ethnographic research in Nepal-and compares it with a widely used Western-derived scale in assessing locally defined child behavior problems. METHODS: We assessed a population-based sample of 268 children ages 5-15 years old in Nepal for behavior problems with a pool of candidate items developed from ethnographic research. We selected final items for the DBIS-N using exploratory factor analysis in a randomly selected half of the sample and then evaluated the model fit using confirmatory factor analysis in the remaining half. We compared the classification accuracy and incremental validity of the DBIS-N and Eyberg Child Behavior Inventory (ECBI) using local defined behavior problems as criteria. Local criteria were assessed via parent report using: 1) local behavior problem terms, and 2) a locally developed vignette-based assessment. RESULTS: Ten items were selected for the final scale. The DBIS-N had good internal consistency (Cronbach's α: 0.84) and excellent test-retest reliability (intraclass correlation 0.93, r = .93). Classification accuracy and area under the curve (AUC) were similar and high for both the ECBI (AUC: 0.83 and 0.85) and DBIS-N (AUC: 0.83 and 0.85) on both local criteria. The DBIS-N added predictive value above the ECBI in logistic regression models, supporting its incremental validity. CONCLUSIONS: While both the DBIS-N and the ECBI had high classification accuracy for local idioms for behavior problems, the DBIS-N had a more coherent factor structure and added predictive value above the ECBI. Items from the DBIS-N were more consistent with cultural themes identified in qualitative research, whereas multiple items in the ECBI that did not fit with these themes performed poorly in factor analysis. In conjunction with practical considerations such as price and scale length, our results lend support for the utility of the DBIS-N for the assessment of locally prioritized behavior problems in Nepal.

Feasibility study of a family- and school-based intervention for child behavior problems in Nepal.

BACKGROUND: This study evaluates the feasibility, acceptability, and outcomes of a combined school- and family-based intervention, delivered by psychosocial counselors, for children with behavior problems in rural Nepal. METHODS: Forty-one children participated at baseline. Two students moved to another district, meaning 39 children, ages 6-15, participated at both baseline and follow-up. Pre-post evaluation was used to assess behavioral changes over a 4-month follow-up period (n = 39). The primary outcome measure was the Disruptive Behavior International Scale-Nepal version (DBIS-N). The secondary outcome scales included the Child Functional Impairment Scale and the Eyberg Child Behavior Inventory (ECBI). Twelve key informant interviews were conducted with community stakeholders, including teachers, parents, and community members, to assess stakeholders' perceptions of the intervention. RESULTS: The study found that children's behavior problems as assessed on the DBIS-N were significantly lower at follow-up (M = 13.0, SD = 6.4) than at baseline (M = 20.5, SD = 3.8), p < 0.001, CI [5.57, 9.35]. Similarly, children's ECBI Intensity scores were significantly lower at follow-up (M = 9.9, SD = 8.5) than at baseline (M = 14.8, SD = 7.7), p < 0.005, 95% CI [1.76, 8.14]. The intervention also significantly improved children's daily functioning. Parents and teachers involved in the intervention found it acceptable and feasible for delivery to their children and students. Parents and teachers reported improved behaviors among children and the implementation of new behavior management techniques both at home and in the classroom. CONCLUSIONS: Significant change in child outcome measures in this uncontrolled evaluation, alongside qualitative findings suggesting feasibility and acceptability, support moving toward a controlled trial to determine effectiveness.

Psychotropic drugs in Nepal: perceptions on use and supply chain management.

BACKGROUND: Psychotropic drugs play an important role in the treatment of mental, neurological and substance use disorders. Despite the advancement of the use of psycho-pharmaceuticals in the developed countries, the psychotropic drug production and supply chain management in low- and middle- income countries are still poorly developed. This study aims to explore the perceptions of stakeholders involved in all stages of the psychotropic drug supply chain about the need, quality, availability and effectiveness of psychotropic drugs, as well as barriers to their supply chain management. The study was conducted among 65 respondents from the Kathmandu, Chitwan and Pyuthan districts, grouped into four categories: producers, promoters and distributors (N = 22), policy makers and government actors (N = 8), service providers (N = 21) and service users/family members (N = 14). RESULTS: The respondents reported that psychotropic drugs, despite having side effects, are 1) needed, 2) available in major regional centers and 3) are effective for treating mental health problems. The stigma associated with mental illness, however, forces patients and family members to hide their use of psychotropic drugs. The study found that the process of psychotropic drug supply chain management is similar to other general drugs, with the exceptions of strict pre-approval process, quantity restriction (for production and import), and mandatory record keeping. Despite these regulatory provisions, respondents believed that the misuse of psychotropic drugs is widespread and companies are providing incentives to prescribers and retailers to retain their brand in the market. CONCLUSIONS: The production and supply chain management of psychotropic drugs is influenced by the vested interests of pharmaceutical companies, prescribers and pharmacists. In the context of the government of Nepal's policy of integrating mental health into primary health care and increased consumption of psychotropic drugs in Nepal, there is a need for massive education and awareness as well as strict monitoring and supervision to avoid the misuse of psychotropic drugs.

Psychosocial and Mental Health Problems of Older People in Postearthquake Nepal.

OBJECTIVE: To identify community perceptions on psychosocial and mental health problems of older people in postearthquake situation in Nepal. METHOD: A qualitative methodology was adopted to explore the experience and opinions of older people, social workers, school teachers, health workers, and nongovernmental organization workers on the psychosocial and mental health problems of older people in Nepal, using key informant interviews. RESULTS: Major local vocabulary for older peoples' psychosocial and mental health problems were "bichalan" (variation in mood and feeling), "ekohoro" (becoming single minded), "athmabiswasko kami" (low self-esteem), and "bina karan rune" (crying without any reason). The major causes attributed to older people's problems were physical injury, disability, family conflict, and economic problems. Forgetfulness, tiredness, loss of concentration, restlessness, and isolation were observed in older people since the 2015 earthquake. DISCUSSION: The findings suggest that earthquake had negative impact on older people's psychosocial well-being; however, little support or treatment options have been made available to these individuals. The tailor-made community-based psychosocial and mental health programs for older people are needed.

Current situations and future directions for mental health system governance in Nepal: findings from a qualitative study.

BACKGROUND: Assessing and understanding health systems governance is crucial to ensure accountability and transparency, and to improve the performance of mental health systems. There is a lack of systematic procedures to assess governance in mental health systems at a country level. The aim of this study was to appraise mental health systems governance in Nepal, with the view to making recommendations for improvements. METHODS: In-depth individual interviews were conducted with national-level policymakers (n = 17) and district-level planners (n = 11). The interview checklist was developed using an existing health systems governance framework developed by Siddiqi and colleagues as a guide. Data analysis was done with NVivo 10, using the procedure of framework analysis. RESULTS: The mental health systems governance assessment reveals a few enabling factors and many barriers. Factors enabling good governance include availability of mental health policy, inclusion of mental health in other general health policies and plans, increasing presence of Non-Governmental Organizations (NGOs) and service user organizations in policy forums, and implementation of a few mental health projects through government-NGO collaborations. Legal and policy barriers include the failure to officially revise or fully implement the mental health policy of 1996, the existence of legislation and several laws that have discriminatory provisions for people with mental illness, and lack of a mental health act and associated regulations to protect against this. Other barriers include lack of a mental health unit within the Ministry of Health, absence of district-level mental health planning, inadequate mental health record-keeping systems, inequitable allocation of funding for mental health, very few health workers trained in mental health, and the lack of availability of psychotropic drugs at the primary health care level. CONCLUSIONS: In the last few years, some positive developments have emerged in terms of policy recognition for mental health, as well as the increased presence of NGOs, increased presence of service users or caregivers in mental health governance, albeit restricted to only some of its domains. However, the improvements at the policy level have not been translated into implementation due to lack of strong leadership and governance mechanisms.

Psychological resilience and the gene regulatory impact of posttraumatic stress in Nepali child soldiers.

Adverse social conditions in early life have been linked to increased expression of proinflammatory genes and reduced expression of antiviral genes in circulating immune cells-the conserved transcriptional response to adversity (CTRA). However, it remains unclear whether such effects are specific to the Western, educated, industrialized, rich, and democratic (WEIRD) cultural environments in which previous research has been conducted. To assess the roles of early adversity and individual psychological resilience in immune system gene regulation within a non-WEIRD population, we evaluated CTRA gene-expression profiles in 254 former child soldiers and matched noncombatant civilians 5 y after the People's War in Nepal. CTRA gene expression was up-regulated in former child soldiers. These effects were linked to the degree of experienced trauma and associated distress-that is, posttraumatic stress disorder (PTSD) severity-more than to child soldier status per se. Self-perceived psychological resilience was associated with marked buffering of CTRA activation such that PTSD-affected former child soldiers with high levels of personal resilience showed molecular profiles comparable to those of PTSD-free civilians. These results suggest that CTRA responses to early life adversity are not restricted to WEIRD cultural contexts and they underscore the key role of resilience in determining the molecular impact of adverse environments.

Development process of an assessment tool for disruptive behavior problems in cross-cultural settings: the Disruptive Behavior International Scale - Nepal version (DBIS-N).

Systematic processes are needed to develop valid measurement instruments for disruptive behavior disorders (DBDs) in cross-cultural settings. We employed a four-step process in Nepal to identify and select items for a culturally valid assessment instrument: 1) We extracted items from validated scales and local free-list interviews. 2) Parents, teachers, and peers (n=30) rated the perceived relevance and importance of behavior problems. 3) Highly rated items were piloted with children (n=60) in Nepal. 4) We evaluated internal consistency of the final scale. We identified 49 symptoms from 11 scales, and 39 behavior problems from free-list interviews (n=72). After dropping items for low ratings of relevance and severity and for poor item-test correlation, low frequency, and/or poor acceptability in pilot testing, 16 items remained for the Disruptive Behavior International Scale-Nepali version (DBIS-N). The final scale had good internal consistency (α=0.86). A 4-step systematic approach to scale development including local participation yielded an internally consistent scale that included culturally relevant behavior problems.

Perceived behavioral problems of school aged children in rural Nepal: a qualitative study.

BACKGROUND: Studies on child behavioral problems from low and middle income countries are scarce, even more so in Nepal. This paper explores parents', family members' and teachers' perceptions of child behavioral problems, strategies used and recommendations to deal with this problem. METHOD: In this study, 72 free list interviews and 30 Key Informant Interviews (KII) were conducted with community members of Chitwan district in Nepal. RESULT: The result suggest that addictive behavior, not paying attention to studies, getting angry over small issues, fighting back, disobedience, and stealing were the most commonly identified behavioral related problems of children, with these problems seen as interrelated and interdependent. Results indicate that community members view the family, community and school environments as being the causes of child behavioral problems, with serious impacts upon children's personal growth, family harmony and social cohesion. The strategies reported by parents and teachers to manage child behavioral problems were talking, listening, consoling, advising and physical punishment (used as a last resort). CONCLUSIONS: As perceived by children and other community dwellers, children in rural Nepalese communities have several behavioral related problems. The findings suggest that multi-level community-based interventions targeting peers, parents, teachers and community leaders could be a feasible approach to address the identified problems.

Suicide in South Asia: a scoping review.

BACKGROUND: Globally, suicide is an important cause of mortality. In low- and middle income settings, it is difficult to find unequivocal data to establish suicide rates. The objective of this review is to synthesize the reporting of suicide incidence in six south Asian countries. METHODS: We conducted a scoping review combining peer-reviewed studies (PubMed, PsycINFO, EMBASE) with in-country searches for grey literature in Afghanistan, Pakistan, Sri Lanka, India, Nepal and Bangladesh. The review included mapping reported suicide rates, quality appraisals of the studies, use of definitions of suicide and means of committing suicide. RESULTS: In total, 114 studies and reports were included in the review, including 50 peer-reviewed publications. Reported suicide rates varied widely from 0.43/100,000 to 331.0/100,000. The average suicide rate across studies was found to be high compared to the world average, however many studies were of poor quality or not representative. The majority of studies failed to explicitly define suicide (84% of the published articles and 92% of the grey literature documents). Poisoning and hanging were consistently the most common methods of committing suicide on the sub-continent. CONCLUSIONS: The reported suicide rates in South Asia are high compared to the global average, but there is a paucity of reliable data on suicide rates in South Asia. Reports are likely to diminish rather than exaggerate the magnitude of suicide rates. There is an urgent need to establish new, or evaluate existing, national suicide surveillance systems in the South Asian countries.