Feasibility of implementing public-private mix approach for tuberculosis case management in Pokhara Metropolitan City of western Nepal: a qualitative study.

Background: The Public-Private Mix (PPM) approach is a strategic initiative that involves engaging all private and public health care providers in the fight against tuberculosis using international health care standards. For tuberculosis control in Nepal, the PPM approach could be a milestone. This study aimed to explore the barriers to a public-private mix approach in the management of tuberculosis cases in Nepal. Methods: We conducted key informant interviews with 20 participants, 14 of whom were from private clinics, polyclinics, and hospitals where the PPM approach was used, two from government hospitals, and four from policymakers. All data were audio-recorded, transcribed, and translated into English. The transcripts of the interviews were manually organized, and themes were generated and categorized into 1. TB case detection, 2. patient-related barriers, and 3. health-system-related barriers. Results: A total of 20 respondents participated in the study. Barriers to PPM were identified into following three themes: (1) Obstacles related to TB case detection, (2) Obstacles related to patients, and (3) Obstacles related to health-care system. PPM implementation was challenged by following sub-themes that included staff turnover, low private sector participation in workshops, a lack of trainings, poor recording and reporting, insufficient joint monitoring and supervision, poor financial benefit, lack of coordination and collaboration, and non-supportive TB-related policies and strategies. Conclusion: Government stakeholders can significantly benefit by applying a proactive role working with the private in monitoring and supervision. The joint efforts with private sector can then enable all stakeholders to follow the government policy, practice and protocols in case finding, holding and other preventive approaches. Future research are essential in exploring how PPM could be optimized.

Prevalence of and risk factors for overweight among adolescents of a sub-metropolitan city of Nepal.

BACKGROUND: Overweight is a global public health problem with increasing trend especially in middle to lower socioeconomic country like Nepal. The nutritional status of adolescents being shaped by socio-cultural, environmental, and economic factors has also been impacted by their food habits and level of physical activity. The current nutritional shift and rapid urbanization had emerged overweight as an additional burden for consistently prevalent undernutrition issues. So, the study aimed to identify the prevalence of and risk factors for overweight among school adolescents. METHODS: A cross-sectional analytical study was carried out among random sample of 279 adolescents from nine schools of a Sub-metropolitan city of Nepal. The anthropometric measurement of the height and the weight were taken as per the standard. The odds ratio with a 95% CI was calculated and a p-value of ≤0.05 was considered as cut off for statistical significance by fitting into the final multivariable logistic regression. RESULTS: The overall prevalence of overweight was obtained as 9.31% (95% CI: 6.40-13.3). The early aged adolescents were more overweight than compared to middle-aged adolescents (AOR: 0.27, CI: 0.028-2.67) and late adolescents (AOR: 0.66, CI: 0.068-6.44) respectively. Similarly, adolescents residing in rural areas had 0.35 (AOR = 0.33, CI: 0.030-3.71) odds of being overweight compared to their counterparts. Adolescents with sedentary behavior were about 4 times (AOR = 3.51, CI: 0.79-15.54) more likely of being overweight than their counterparts. CONCLUSION: Overweight among adolescents residing in urban areas has emerged as an alarming issue due to their unhealthy lifestyle habits. It is therefore pertinent to emphasize adolescents to maintain healthy weight status through health food habits and physical activity.

Perceptions around COVID-19 and vaccine hesitancy: A qualitative study in Kaski district, Western Nepal.

Burgeoning morbidity and mortality due to COVID-19 pandemic including the peaks in outbreaks due to different variants have attracted global attention. Although the development and rolling out of vaccines have been impressive, low- and middle-income countries suffer from a double burden: (1) lack of adequate vaccines; and (2) low vaccine uptake (vaccine hesitancy). The main objective of this study was to explore perceptions around COVID-19 and vaccine hesitancy among urban and rural population in Western Nepal. A qualitative study was conducted in six urban wards of Pokhara municipality and four rural municipalities in Kaski district of Nepal. A semi-structured interview guide was used to interview participants who were selected purposively to explore the perceived burden of COVID-19 pandemic, roles, and contributions of vaccine. Nineteen interviews were conducted by telephone following a government recommendation to avoid face-to-face meetings. Audio-recorded interviews were thematically analysed after transcription and translation into English. COVID-19 is a major (public) health concern and affects people at an individual, societal and national level. People dreaded its health hazards and consequences and seemed to be compliant with public health measures such as maintaining social distance, wearing masks and maintaining hygiene. Vaccine was considered to be a major intervention to fight the pandemic, nonetheless, the rationale and benefits of vaccines were blemished by the perceived lack of the vaccine's effectiveness, duration of protection, and its potential side-events. Expedited development of vaccine was embraced with suspicion that vaccine may have incurred compromise in quality. Science and rationale behind vaccine were smeared by misinformation and clearly counteracting the misinformation were deemed critical. Providing information about vaccines through government entities (who are trusted) and respected individuals may engender trust and uptake of vaccine. Fighting off misinformation of COVID-19 is critical to curb the course of pandemic. Increased attention towards monitoring and investing in legitimacy of information and offering information through trusted sources can help improve the vaccine coverage.

Prevalence of Left Ventricular Diastolic Dysfunction in Patients with Essential Hypertension.

BACKGROUND: Left Ventricular Diastolic Dysfunction is considered a critical link between hypertension and heart failure, particularly in individuals with heart failure and preserved ejection fraction. The aim of this study is to assess the prevalence and factors associated with clinical parameters of left ventricular diastolic dysfunction in patients with essential hypertension. METHODS: A hospital-based cross-sectional study was done among 68 newly diagnosed and known hypertensive patients visiting out patientdepartmentat Bir hospital. Patients who meet the inclusion criteria were chosen alternatively by referring OPD register. Patients with hypertension had undergone echocardiography to see whether left ventricular diastolic dysfunction was present and was compared to other clinical parameters like age, sex, body mass index, and dyslipidemia using the student t-test/chi-square test. RESULTS: The prevalence of left ventricular diastolic dysfunction in essential hypertensive patients was 33.8%. About 25% patients had grade 1; 7.4% and 1.5% of patients had grade 2 and grade 3 diastolic dysfunction respectively. Patients who had a duration of hypertension of more than five years were more than nine times (OR 9.14; 2.89-28.87) more likely to have Left ventricular diastolic dysfunction. Age and Body Mass Index were found statistically significant with diastolic dysfunction (P<0.05). CONCLUSIONS: Left ventricular diastolic dysfunction was found prevalent in hypertensive patients.  Age, Body mass index, Dyslipidemia and Duration of hypertension were found to be statistically significant with diastolic dysfunction  Keywords: Diastolic dysfunction; hypertension; Nepal; prevalence.

Morphometric Study of Sub Axial Cervical Spine Pedicles in Nepalese Population.

BACKGROUND: Mal-positioning of cervical screws risks neurovascular injury so, it is necessary to understand cervical pedicle morphology for pedicle screw fixation in the region. The risks of pedicle screw insertion in the cervical spine can be mitigated by a three-dimensional appreciation of pedicle anatomy. The study aims to determine the morphology of the sub axial cervical spine pedicles in Nepalese Population based on computerized tomography. METHODS: A cross-sectional study using computerized tomography scans of the spine was made among the randomly selected 87 patients who had visited National Trauma center, Kathmandu, Nepal with vertebral fracture other than cervical vertebrae. Patient was examined as per Advanced Trauma Life support protocol and neurological assessment. Measurement was done from the third cervical vertebra down to the seventh cervical vertebra in computer with standard software in the department of radiology from where all the computerized tomography scan reporting are done. RESULTS: The mean pedicle length ranged from 4.41 mm at C3 to 4.96 mm at C7 where mean pedicle height ranged from 4.64 at C3 to 5.12 at C7. Pedicle length, pedicle height and pedicle width were observed to be statistically significant with gender. The pedicle axial length of C3 and C7 vertebra were found significant with gender. All parameters were found to be greater in male compared to female. CONCLUSIONS: The study revealed that pedicle length, pedicle height, pedicle width, pedicle axial length increased from third to seventh cervical however, transverse angulation increased up to fifth vertebra and decreased to seventh vertebra.

Expression of the Group A Streptococcus Fibrinogen-Binding Protein Mrp Is Negatively Regulated by the Small Regulatory RNA FasX.

The group A Streptococcus (GAS; Streptococcus pyogenes) causes an elaborate array of human diseases. In part, such variability in disease potential is a consequence of GAS manipulating the expression of a catalogue of virulence factors, with regulation occurring at both the transcriptional and posttranscriptional levels. The GAS small regulatory RNA (sRNA) FasX contributes to this regulatory activity, enhancing expression of the thrombolytic agent streptokinase, and reducing expression of collagen (pili) and fibronectin (PrtF1 and PrtF2) -binding adhesins. Here, we expand insight into the regulatory targets of FasX by identifying the M-related protein (Mrp), a fibrinogen-binding adhesin with anti-phagocytic activity, as a negatively-regulated target of FasX. Importantly, investigation of the consequences of FasX-mediated regulation led to the discovery that FasX is a major positive regulator of GAS survival and proliferation in non-immune whole human blood, with a 30-fold difference in GAS cell numbers between a fasX mutant strain and isogenic parental and complemented mutant strains. No difference in cell numbers were observed when these strains were grown in human serum, consistent with the protective phenotype associated with FasX occurring due to the inhibition of cell (e.g., neutrophil) - mediated GAS killing. The FasX-regulated factor/s responsible for the blood survival phenotype remain to be defined. In summary, we expand the known FasX regulon and identify a new phenotype associated with the regulatory activity of this key GAS sRNA. IMPORTANCE Small regulatory RNAs (sRNAs) represent a major class of regulatory molecule that promotes the ability of the group A Streptococcus (GAS) and other pathogens to regulate virulence factor expression. Despite FasX being the best-described sRNA in GAS, there remains much to be learned. Here, we highlight the importance of FasX, identifying for the first time that the loss of this sRNA results in a major reduction in the ability of GAS to survive in human blood, a phenotype critical to the ability of this human-specific pathogen to cause severe invasive infections. We also identified a novel regulatory target of FasX, thereby expanding the known regulon of this key sRNA.

Health System Preparedness for COVID-19 and Its Impacts on Frontline Health-Care Workers in Nepal: A Qualitative Study Among Frontline Health-Care Workers and Policy-Makers.

BACKGROUND: Rapidly growing coronavirus disease 2019 (COVID-19) pandemic has brought unprecedented challenges to the health system in Nepal. The main objective of this study was to explore the health system preparedness for COVID-19 and its impacts on frontline health-care workers in Nepal. METHODS: Semi-structured interviews were conducted among 32 health-care workers who were involved in clinical care of COVID-19 patients and four policy-makers who were responsible for COVID-19 control and management at central and provincial level. Interviews were conducted through telephone or Internet-based tools such as Zoom and Skype. All interviews were audio-recorded, transcribed into English, and coded using inductive and deductive approaches. RESULTS: Both health-care workers and policy-makers reported failure to initiate pre-emptive control measures at the early stages of the outbreak as the pivot in pandemic control. Although several measures were rolled out when cases started to appear, the overall health system preparedness was low. The poor governance, and coordination between three tiers of government was compounded by the inadequate personal protective equipment for health-care workers, insufficient isolation beds for patients, and poor engagement of the private sector. Frontline health-care workers experienced various degrees of stigma because of their profession and yet were able to maintain their motivation to continue serving patients. CONCLUSION: Preparedness for COVID-19 was affected by the poor coordination between three tiers of governance. Specifically, the lack of human resources, inadequate logistic chain management and laboratory facilities for testing COVID-19 appeared to have jeopardized the health system preparedness and escalated the pandemic in Nepal. Despite the poor preparedness, and health and safety concerns, health-care workers maintained their motivation. There is an urgent need for an effective coordination mechanism between various tiers of health structure (including private sector) in addition to incentivizing the health-care workers for the current and future pandemics.

Health related quality of life and associated factors with medication adherence among tuberculosis patients in selected districts of Gandaki Province of Nepal.

BACKGROUND: Tuberculosis is one of the significant public health problems of Nepal. Adherence to medication is very important for improving quality of life and preventing complication. Adherence to tuberculosis medications has significant economic and therapeutic consequences as non-adherence patients are at greater risk of developing complications which affect their health status and overall quality of life. The study aims to determine the factors associated with medication adherence and its effect on health related quality of life among tuberculosis patients in selected districts of Gandaki Province. METHODS: A health facility based cross-sectional study was carried out among 180 tuberculosis patients registered under DOTS and receiving treatment more than or equal to 60 days. WHOQOL-BREF tools to assess quality of life and Morisky medication adherence scale (MMAS-8) was adopt to assess medication adherence. Data was entered in Epi-data and analysis was performed with the help of the Statistical Package for Social Science (SPSS). The odds ratio with a 95% CI was calculated and p-value of <0.05 was considered as cutoff for statistical significance. RESULTS: A total 180 TB patients were participated in this study. Overall quality of life ranges from 10.75 to 89.25 with Mean ± SD as 55.96 ± 14.65. More than three-fourth (79.4%) respondents were adhere to medication. Medication adherence and health related quality of life was found statistically significant with relationship with health workers, favourable time at DOTS centre, absence of co-infection. Participants who were highly adhered to medication had good quality of life. CONCLUSION: Majority of tuberculosis patients adhering to medication had good quality of life. Especial emphasis should be given to tuberculosis patients with co-infection, health workers should behave friendly and provide appropriate counselling in order to maintain the medication adherence and quality of life.

Anxiety and Depression Among Health Sciences Students in Home Quarantine During the COVID-19 Pandemic in Selected Provinces of Nepal.

Aim: This study aimed to assess anxiety and depression among health sciences students at home quarantine during the COVID-19 pandemic in selected provinces of Nepal. Methods: A web-based cross-sectional study was conducted among 409 health science students enrolled at graduate and post-graduate levels in selected universities and their affiliated colleges. Students from selected colleges were asked to fill out a survey, that was made available through email and social media outlets such as Facebook and Viber. The data were downloaded in Excel and imported to SPSS version 16 for analysis. Results : The prevalence of anxiety and depression was 15.7 and 10.7%, respectively. The study showed significant associations between (i) place of province and anxiety; (ii) sleep per day and depression; (iii) hours spent on the internet per day for education and depression; (iv) postponement of final exams and depression. There were no significant associations with the socio-demographic variables. Conclusion: Anxiety and depression in health science students showed correlation with the province, internet use for education, and postponement of exams. These correlations could be common among students in other fields as well. A large-scale study covering a wider geographical area and various fields of education is necessary to further evaluate the impact of COVID-19 on (health sciences) students. The integration of mental health programs both as an intervention and a curriculum level among students is critical to ensure the health of the students.

Barriers to Treatment Compliance of Directly Observed Treatment Shortcourse among Pulmunary Tuberculosis Patients.

BACKGROUND: Treatment compliance is an important aspect for tuberculosis prevention and control. Poor compliance to treatment can lead to the development of drug-resistant tuberculosis. The aim of this study was to explore the factors affecting treatment compliance for tuberculosis patients. METHODS: Facility based unmatched case control study was done among the forty non-compliance and eighty compliance pulmonary tuberculosis patients registered at selected directly observed treatment short-course centers of six districts. Data were collected using in-depth interview guideline with the tuberculosis focal person and Focus Group Discussion with tuberculosis patients. RESULTS: A total of 120 respondents, 40 cases and 80 controls were enrolled in the study. About 72.5% of the cases and 56.2% of the controls were male. Five significant independent risk factors for non-compliance to TB treatment were identified. The qualitative session confirmed geographical barriers, inaccessibility to health facility, economic barriers, difficulty in convincing people, knowledge about Directly observed treatment shortcourse program, longer medication period, migration and stigma as a major barrier for treatment compliance. CONCLUSIONS: Wider ranges of barriers are prevalent in context of tuberculosis treatment pathway and outcome. Knowledge of the tuberculosis patients and attitude of the family plays a vital role in treatment compliance. Directly observed treatment shortcourse playing tremendous role to ensure treatment adherence has been identified as major barrier to adherence as well. Enablers of adherence need to be emphasized to address the barriers.