Situational analysis to inform development of primary care and community-based mental health services for severe mental disorders in Nepal.

BACKGROUND: Nepal is representative of Low and Middle Income Countries (LMIC) with limited availability of mental health services in rural areas, in which the majority of the population resides. METHODS: This formative qualitative study explores resources, challenges, and potential barriers to the development and implementation of evidence-based Comprehensive Community-based Mental Health Services (CCMHS) in accordance with the mental health Gap Action Programme (mhGAP) for persons with severe mental health disorders and epilepsy. Focus Group Discussions (FGDs, n = 9) and Key-Informant Interviews (KIIs, n = 26) were conducted in a rural district in western Nepal. Qualitative data were coded using the Framework Analysis Method employing QSR NVIVO software. RESULTS: Health workers, general community members, and persons living with mental illness typically attributed mental illness to witchcraft, curses, and punishment for sinful acts. Persons with mental illness are often physically bound or locked in structures near their homes. Mental health services in medical settings are not available. Traditional healers are often the first treatment of choice. Primary care workers are limited both by lack of knowledge about mental illness and the inability to prescribe psychotropic medication. Health workers supported upgrading their existing knowledge and skills through mhGAP resources. Health workers lacked familiarity with basic computing and mobile technology, but they supported the introduction of mobile technology for delivering effective mental health services. Persons with mental illness and their family members supported the development of patient support groups for collective organization and advocacy. Stakeholders also supported development of focal community resource persons to aid in mental health service delivery and education. CONCLUSION: Health workers, persons living with mental illness and their families, and other stakeholders identified current gaps and barriers related to mental health services. However, respondents were generally supportive in developing community-based care in rural Nepal.

Pathways and access to mental health care services by persons living with severe mental disorders and epilepsy in Uganda, Liberia and Nepal: a qualitative study.

BACKGROUND: Access to mental health care services for patients with neuropsychiatric disorders remains low especially in post-conflict, low and middle income countries. Persons with mental health conditions and epilepsy take many different paths when they access formal and informal care for their conditions. This study conducted across three countries sought to provide preliminary data to inform program development on access to care. It thus sought to assess the different pathways persons with severe mental disorders and epilepsy take when accessing care. It also sought to identify the barriers to accessing care that patients face. METHODS: Six in depth interviews, 27 focus group discussions and 77 key informants' interviews were conducted on a purposively selected sample of health care workers, policy makers, service users and care takers in Uganda, Liberia and Nepal. Data collected along predetermined themes was analysed using Atlas ti software in Uganda and QSR Nvivo 10 in Liberia and Nepal RESULTS: Individual's beliefs guide the paths they take when accessing care. Unlike other studies done in this area, majority of the study participants reported the hospital as their main source of care. Whereas traditional healers lie last in the hierarchy in Liberia and Nepal, they come after the hospital as a care option in Uganda. Systemic barriers such as: lack of psychotropic medicines, inadequate mental health specialists and services and negative attitudes of health care workers, family related and community related barriers were reported. CONCLUSION: Access to mental health care services by persons living with severe mental disorders and epilepsy remains low in these three post conflict countries. The reasons contributing to it are multi-faceted ranging from systemic, familial, community and individual. It is imperative that policies and programming address: negative attitudes and stigma from health care workers and community, regular provision of medicines and other supplies, enhancement of health care workers skills. Ultimately reducing the accessibility gap will also require use of expert clients and families to strengthen the treatment coalition.

Determinants of pelvic organ prolapse among the women of the western part of Nepal: a case-control study.

AIM: This study was carried out in order to identify the determinants of pelvic organ prolapse (POP) among the women of the western part of Nepal. METHODS: This was a matched case-control study. Cases were defined as women diagnosed with third and fourth degree POP, and the control group consisted of women who were screened and confirmed of not having any degree of POP. Cases (n = 183) and controls (n = 183) were randomly selected and for each case, one control was selected, matched by age and place of residence. A semistructured interview was carried out to obtain the information for both groups. Bivariate analysis along with conditional logistic regression analysis was carried out to identify the association between selected variables with POP. RESULTS: The results showed the significant association between number of vaginal deliveries, tear of vagina in the last childbirth, sphincter damage in the last childbirth and duration of labor in the last childbirth with POP, after adjusting for educational status of the women, carrying heavy loads, type of usual work and incidence of diarrhea. CONCLUSION: The results suggest that prolonged labor along with vaginal delivery having sphincter and vaginal tear are the determinants of POP and program managers should strongly consider these factors to develop interventions targeting the prevention of POP.