Implementation of cervical cancer prevention and screening across five tertiary hospitals in Nepal and its policy implications: A mixed-methods study.

In Nepal, cervical cancer is the most common cancer among women despite the existing policies. This study intends to assess the implementation of cervical cancer prevention and screening through service utilization by women, knowledge and attitude among health professionals, and the perceptions of stakeholders in Nepal. This mixed-methods study was conducted in 2022 across five tertiary hospitals in Kathmandu, Nepal. The quantitative study comprised the health professionals and women attending gynecology outpatient clinics from the selected hospitals. The qualitative study comprised stakeholders including service providers and experts on cervical cancer from selected hospitals, civil societies, and the Ministry of Health and Population. The utilization of screening through pap smear among 657 women across five hospitals was 22.2% and HPV vaccination was 1.5%. The utilization of cervical cancer screening was associated with older age [adjusted odds ratio (AOR) = 1.09, CI: 1.07, 8.19], married (AOR = 3.024, CI: 1.12, 8.19), higher education (AOR = 3.024, CI:1.12, 8.42), oral contraceptives use (AOR = 2.49, CI: 1.36, 4.39), and ever heard of cervical cancer screening (AOR = 13.28, CI: 6.85, 25.73). Among 254 health professionals, the knowledge score was positively associated with them ever having a training [Standardized Beta (ß) = 0.20, CI: 0.44, 2.43)] and having outreach activities in their hospital (ß = 0.19 CI: 0.89, 9.53) regarding cervical cancer screening. The female as compared to male health professionals (ß = 0.16, CI: 0.41, 8.16, P = 0.03) and having a cervical cancer screening guideline as compared to none (ß = 0.19 CI: 0.89, 9.53, P = 0.026) were more likely to have a better attitude for screening. The qualitative findings among 23 stakeholders reflected implementation challenges in policy, supply, service delivery, providers, and community. This study showed low utilization of prevention and services by women and implementation gaps on cervical cancer prevention and screening services across five tertiary hospitals in Kathmandu, Nepal. The findings could help designing more focused interventions.

Autologous blood products: Leucocyte and Platelets Rich Fibrin (L-PRF) and Platelets Rich Plasma (PRP) gel to promote cutaneous ulcer healing - a systematic review.

OBJECTIVE: To summarise evidence on the effectiveness of Platelet-Rich Plasma (PRP) gel and Leucocyte and Platelet Rich Fibrin (L-PRF) gel as agents promoting ulcer healing compared with the standard wound dressing techniques alone. DESIGN: Systematic review. ELIGIBILITY CRITERIA: Individual patient randomised controlled trials on skin ulcers of all types excluding traumatic lesions.Intervention group: treatment with topical application of L-PRF gel or PRP gel to the wound surface. CONTROL GROUP: treatment with standard skin ulcer care using normal saline, normgel or hydrogel dressings. INFORMATION SOURCES: Medline (Ovid), Excerpta Medica Database (EMBASE), Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Web of Science and manual search of studies from previous systematic reviews and meta-analyses. The papers published from 1946 to 2022 with no restriction on geography and language were included. The last date of the search was performed on 29 August 2022. DATA EXTRACTION AND SYNTHESIS: Independent reviewers identified eligible studies, extracted data, assessed risk of bias using V.2 of the Cochrane risk-of-bias tool for randomised trials tool and assessed certainty of evidence by using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. MAIN OUTCOME MEASURES: Time to complete healing, proportion healed at a given time and rate of healing. RESULTS: Seven studies met the inclusion criteria, five using PRP gel and two using L-PRF gel. One study showed a better proportion of complete healing, three reported reduced meantime to complete healing and five showed improved rate of healing per unit of time in the intervention group. The risk of bias was high across all studies with one exception and the GRADE showed very low certainty of evidence. CONCLUSION: The findings show potential for better outcomes in the intervention; however, the evidence remains inconclusive highlighting a large research gap in ulcer treatment and warrant better-designed clinical trials. PROSPERO REGISTRATION NUMBER: CRD42022352418.

Effect of COVID-19 pandemic on internet gaming disorder among general population: A systematic review and meta-analysis.

Internet gaming disorder (IGD) has been rising in recent years. The COVID-19 pandemic has led to a noticeable shift in the way people interact with technology, which could have further contributed to an increase in IGD. Post-pandemic, the concern for IGD is likely to continue as people have become increasingly reliant on online activities. Our study aimed to assess the prevalence of IGD among the general population globally during the pandemic. Relevant studies that assessed IGD during COVID-19 were identified using PubMed, EMBASE, Scopus, CINAHL, and PsycNET between 2020, Jan 1 and 2022, May 23. We used NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies to assess the risk of bias, and GRADEpro for the certainty of the evidence. Three separate meta-analyses were performed using Comprehensive meta-analysis software and Revman 5.4. In total, 362 studies were identified, of which 24 observational (15 cross-sectional and 9 longitudinal) studies among 83,903 population were included in the review, and 9 studies in the meta-analysis. The risk of bias assessment showed an overall fair impression among the studies. The meta-analysis for a single group of 3 studies showed the prevalence rate of 8.00% for IGD. Another meta-analysis of 4 studies for a single group showed a pooled mean of 16.57 which was lower than the cut-off value of the IGDS9-SF tool. The two-group meta-analysis of 2 studies showed no significant difference between the groups before and during COVID-19. Our study showed no clear evidence of increased IGD during COVID-19 due to limited number of comparable studies, substantial heterogeneity, and low certainty of evidence. Further well-designed studies are needed to provide stronger evidence to implement suitable interventions to address IGD worldwide. The protocol was registered and published in the International Prospective Register for Systematic Review (PROSPERO) with the registration number CRD42021282825.

Arterial hypertension and its covariates among nomadic Raute hunter-gatherers of Western Nepal: a mixed-method study.

OBJECTIVES: To determine the prevalence of, and understand the factors associated with, hypertension among the nomadic Raute hunter-gatherers of Western Nepal. DESIGN: A mixed-method study. SETTING: The study was carried out at Raute temporary campsites in the Surkhet District of Karnali Province between May and September 2021. PARTICIPANTS: The questionnaire-based survey included all males and non-pregnant females of the nomadic Raute group aged 15 years and above. In-depth interviews were conducted among purposively selected 15 Raute participants and four non-Raute key informants to help explain and enrich the quantitative findings. OUTCOME MEASURES: The prevalence of hypertension (defined as brachial artery blood pressure of systolic ≥140 mm Hg and/or diastolic ≥90 mm Hg) and its sociodemographic, anthropometric and behavioural covariates. RESULTS: Of the 85 eligible participants, 81 (median age 35 years (IQR: 26-51), 46.9% female) were included in the final analysis. Hypertension was found in 10.5% of females, 48.8% of males and 30.9% of the total population. Current alcohol and tobacco use were high (91.4% and 70.4%, respectively), with concerning high rates among youths. Males, older people, current drinkers and current tobacco users were more likely to have hypertension. Our qualitative analysis suggests that the traditional forest-based Raute economy is gradually transitioning into a cash-based one that heavily relies on government incentives. Consumption of commercial foods, drinks and tobacco products is increasing as their market involvement grows. CONCLUSION: This study found a high burden of hypertension, alcohol and tobacco use among nomadic Raute hunter-gatherers facing socioeconomic and dietary transitions. Further research is needed to assess the long-term impact of these changes on their health. This study is expected to help appraise concerned policymakers of an emerging health concern and formulate context-specific and culturally sensitive interventions to limit hypertension-related morbidities and mortalities in this endangered population.

How positive deviants helped in fighting the early phase of COVID-19 pandemic? A qualitative study exploring the roles of frontline health workers in Nepal.

Positive deviance is an approach wherein learnings from persons who fare better than their peers under similar circumstances are used to enable behavioral and social change. Such behaviors and solutions are likely affordable, acceptable, sustainable, and fit into the socio-cultural milieu. Despite the wide use of positive deviance in many public health programs and research, it has yet to be used to study frontline workers in the context of COVID-19. Therefore, this study aimed to explore the positive deviance traits among frontline health workers during the early days of the COVID-19 pandemic in Nepal. This qualitative study followed a grounded theory approach. The data was collected through in-depth interviews among the 17 identified participants representing different cadres of the health workforce, types of health facilities, and regions across Nepal purposively. The findings are structured around four major themes: challenges, finding solutions and innovations, positive lessons, and motivations. The personal challenges included fear and anxiety about the uncertainties. The professional challenges included stigma, infection control, and changing work style with the use of personal protective equipment. Despite the challenges, they managed available resources and innovated low-cost, technological, and practice-based solutions. They were able to reflect upon the positive lessons learned, such as self-sustainability, teamwork, and policy direction and research, and self-reflection of personal growth and patient care. The intrinsic motivation included their inherent value system, and the extrinsic motivation included appreciation and acknowledgment, family and social support, psychosocial support from peers, and support from higher authorities. This study provides insights into how the positive deviance approach can help identify the solution amid the most challenging circumstances, such as the COVID-19 pandemic in low-resource settings. However, more extensive studies are warranted to explore deeper into positive deviance and its long-term effects in bringing positive outcomes during the pandemic.

Intimate Partner Violence During Pregnancy in South Asia: Systematic Review and Meta-Analysis.

BACKGROUND: This systematic review collated the literature on the prevalence rate of different types of intimate partner violence (IPV) during pregnancy in South Asia. METHODS: Systematic literature searches were conducted in four major databases (Embase, Scopus, PubMed, PubMed Central) to identify relevant articles published from the inception of each database to May 2021, which reported data on the prevalence of intimate partner violence during pregnancy in South Asia. The Joanna Briggs Institute critical appraisal tool for prevalence studies was used to assess the risk of bias in individual studies. A random-effects model was used to calculate the pooled prevalence and corresponding 95% confidence interval due to significant between-study heterogeneity. RESULTS: Thirty-seven studies were reviewed which showed an overall prevalence of IPV from South Asian countries was 23.4% (physical violence: 13.6%; sexual violence: 8.5%; emotional violence: 20.2%). CONCLUSIONS: There was a higher prevalence of intimate partner violence during pregnancy reported, with an overall prevalence ranging from 1.7% to 66.4% across studies. Emotional violence was more prevalent form when compared to sexual or physical violence.

Experiences of COVID-19 patients admitted in a government infectious disease hospital in Nepal and its implications for health system strengthening: A qualitative study.

INTRODUCTION: The COVID-19 pandemic has affected the health systems in many ways. It has put unprecedented strain on health systems worldwide and exposed gaps in public health infrastructure. A health system comprises all institutions and resources working towards improving and maintaining health. Among the different aspects of health system strengthening, a patient's experiences and expectations play a crucial role in determining how well the health facilities function. This study aims to explore health system strengthening's implications based on experiences and feedback provided by COVID-19 patients admitted to a government tropical and infectious disease hospital in Nepal. METHODS: In this qualitative study, we collected the voluntary handwritten feedback by the admitted COVID-19 patients to document the feedback and experiences from a book, maintained by the hospital. We performed thematic content analysis using the World Health Organization's six building blocks of health system as a theoretical framework which included service delivery, health workforce, information, leadership and governance, financing, and access to medicines. RESULTS: Most patients in this study had positive experiences on service delivery and health workforce. Some also highlighted the gaps in infrastructure, cleanliness, and hygiene. Many suggested positive experiences on other dimensions of the health system such as financing, governance and leadership, and access to medicines reflected upon by the patients' thankfulness to the hospital and the government for the treatment they received. The responses also reflected the inter-connectedness between the different building blocks of health system. CONCLUSION: This study approached a unique way to strengthen the health system by exploring patients' feedback, which suggested an overall positive impression on most building blocks of health system. However, it also highlighted certain gaps in infrastructure, cleanliness, and hygiene. It reinforces the hospital management and government's role to continue its efforts to strengthen the health system.

Evaluating the impact of female community health volunteer involvement in a postpartum family planning intervention in Nepal: A mixed-methods study at one-year post-intervention.

INTRODUCTION: This is a one-year post-intervention study following an initiative to provide orientation to female community health volunteers (FCHVs) on postpartum family planning in Nepal. In light of positive results in the earlier post-intervention study, this study was designed to provide a more long-term perspective on sustainability by assessing the effect at one-year post-intervention. METHODS: This mixed-methods study was conducted in January 2020 in Morang district, Nepal. We collected quantitative data from a knowledge assessment of FCHVs who had participated in the intervention on postpartum family planning, data on their community-based counseling coverage and through interviews with postpartum mothers in two selected hospitals. Qualitative data were collected through six key informant interviews with health providers and four focus group discussions with FCHVs involved in the intervention. We performed descriptive and multivariate analyses for quantitative data and thematic analysis for qualitative data. RESULTS: In total, 206 FCHVs participated in the one-year post-intervention study with significant improvement in knowledge of postpartum family planning as compared to pre-intervention period. The adjusted odds ratios (AOR) for knowledge of the 5 key messages on postpartum family planning as compared to the pre-intervention period included 1) knowledge on postpartum family planning can be used immediately after birth (AOR = 18.1, P<0.001), 2) postpartum intra-uterine device (PPIUD) can provide protection up to 12 years (AOR = 2.9, P = 0.011), 3) mothers who undergo cesarean section can use PPIUD (AOR = 2.3, P<0.001), 4) PPIUD can be inserted immediately after birth (AOR = 6.2, P <0.001), and 5) women should go for follow-up immediately if the IUD strings are seen outside vulva (AOR = 2.0, P = 0.08). The FCHVs answering 4 or more questions correctly was 10 times higher (AOR = 10.1, P<0.001) at one-year post-intervention, whereas it was 25 times higher at immediate-post-test (AOR = 25.1, p<0.001) as compared to pre-intervention phase. The FCHVs had counseled 71% of the pregnant women (n = 538) within their communities at one-year post-intervention. The postpartum mothers in hospitals had a 2 times higher odds of being counseled by FCHVs during their pregnancy at one-year post-intervention (AOR = 1.8, P = 0.039) than in pre-intervention phase. The qualitative findings suggested a positive impression regarding the FCHV's involvement in postpartum family planning counseling in the communities, however, supervision and monitoring over a longer term was identified as a key challenge and that may influence sustainability of community-based and hospital-based postpartum family planning services. CONCLUSION: The FCHVs' knowledge and community-based activities on postpartum family planning remained higher than in the pre-intervention. However, it declined when compared to the immediate post-intervention period. We propose regular supervision and monitoring of the work of the FCHVs to sustain progress.

Witchcraft allegations and untouchability as forms of violence upon women in Nepal: A 7-year study.

The Nepalese constitution guarantees equal rights to both men and women regardless of caste, race, or ethnicity. However, the centuries-old superstitious practice of caste-based hierarchy in the Hindu community and discrimination against people of lower caste are still prevalent. Furthermore, witchcraft allegations are also not uncommon. Both these practices are derogatory and humiliating and violate human rights, and the law can penalise them in both instances. Due to the intersection of gender and caste, women often face multiple forms of discrimination and violence as the patriarchal society considers them a weaker gender. The present study aimed to see the trend of crimes upon women reported by Nepal Police in the form of witchcraft allegations and untouchability between the fiscal years 2013/14 and 2019/20.

An alarming rise in rape in Nepal: A 20-year review.

Criminal justice in Nepal is stringent when it deals with cases of sexual offence. The law protects the victims' rights and fast tracks trials. Notwithstanding, there has been an increase in the number of reported cases recently. This study highlights the increasing number of reported rape and attempted rape cases in Nepal over the past 20 years and discusses the public health measures aimed at preventing these crimes.

Should female community health volunteers (FCHVs) facilitate a response to gender-based violence (GBV)? A mixed methods exploratory study in Mangalsen, Nepal.

ABSTRACTAs part of a multisectoral response to gender-based violence (GBV), Nepal is testing the feasibility of having female community health volunteers (FCHVs) play a formal role in identifying GBV survivors and referring them to specialised services at health facilities. This study followed 116 FHCVs in Mangalsen municipality who attended a one-day orientation on GBV. Over the following year, data were collected from knowledge and attitude assessments of FCHVs, focus group discussions with FCHVs, and members of Mothers' Groups for Health. Most Significant Change stories were collected from FCHVs, in-depth interviews with stakeholders, and service statistics. Results show that the FCHVs' knowledge increased, attitudes changed, and confidence in addressing GBV grew. During the study period, FCHVs identified 1,253 GBV survivors and referred 221 of them to health facilities. In addition to assisting GBV survivors, FCHVs worked to prevent GBV by mediating conflicts and curbing harmful practices such as menstrual isolation. Stakeholders viewed FCHVs as a sustainable resource for identifying and referring GBV survivors to services, while women trusted them and looked to them for help. Results show that, with proper training and safety mechanisms, FCHVs can raise community awareness about GBV, facilitate support for survivors, and potentially help prevent harmful practices.

Prevalence of Postpartum Family Planning Service Coverage in Selected Referral Facilities of Nepal.

INTRODUCTION: Nepal Society of Obstetricians and Gynecologists jointly with the Nepalese government and with the support from the International Federation of Obstetrics and Gynecology has implemented an initiative to institutionalize postpartum family planning services in selected major referral facilities of Nepal to address the gap of low uptake of postpartum family planning in Nepal. The aim of the study is to find the prevalence of the service coverage of postpartum contraception in the selected facilities. METHODS: A descriptive cross-sectional study was conducted in seven major referral facilities across Nepal. Data were collected from the hospital records of all women who delivered in these facilities between October 2018 and March 2019. Ethical approval for this study was obtained from Nepal Health Research Council. Data analysis was done with SPSS version 23. RESULTS: Among the 29,072 deliveries from all the facilities, postpartum family planning counseling coverage was 27,301 (93.9%). The prevalence of uptake of Postpartum Intrauterine Device is 1581 (5.4%) and female sterilization is 1830 (6.3%). In total 11387 mothers (52.2%) had the intention to choose a postpartum family planning method. However, 36% of mothers neither used nor had the intention to choose a postpartum family planning method. CONCLUSIONS: The coverage of Postpartum Intrauterine Device counseling service coverage in Nepal is higher in 2018 as compared to 2016-2017 and in other countries implementing Postpartum Intrauterine Device initiatives. However, the prevalence of service coverage of immediate Postpartum Family Planning methods, mainly Postpartum Intrauterine Device in 2018 is lower in Nepal as compared to 2016-2017, and other countries implementing Postpartum Intrauterine Device initiative. More efforts are needed to encourage mothers delivering in the facilities to use the postpartum family planning method.

Improving post-partum family planning services provided by female community health volunteers in Nepal: a mixed methods study.

BACKGROUND: Family planning services in the post-partum period, termed post-partum family planning (PPFP) is critical to cover the unmet need for contraception, especially when institutional delivery rates have increased. However, the intention to choose PPFP methods such as post-partum intrauterine devices (PPIUD) remains low in countries such as Nepal. Community health workers such as Female Community Health Volunteers (FCHVs) could play an important role in improving the service coverage of PPFP in Nepal. However, their knowledge of PPFP and community-based services related to PPFP remain unclear. This study aims to assess the effect on community-based PPFP services by improving FCHV's knowledge through orientation on PPFP. METHODS: We conducted this mixed-methods study in Morang District in Nepal. The intervention involved orientation of FCHVs on PPFP methods. We collected quantitative data from three sources; via a survey of FCHVs that assessed their knowledge before and after the intervention, from their monthly reporting forms on counseling coverage of women at different stages of pregnancy from the communities, and by interviewing mothers in their immediate post-partum period in two selected hospitals. We also conducted six focus group discussions with the FCHVs to understand their perception of PPFP and the intervention. We performed descriptive and multivariable analyses for quantitative results and thematic analysis for qualitative data. RESULTS: In total, 230 FCHVs participated in the intervention and their knowledge of PPFP improved significantly after it. The intervention was the only factor significantly associated with their improved knowledge (adjusted odds ratio = 24, P < 0.001) in the multivariable analysis. FCHVs were able to counsel 83.3% of 1872 mothers at different stages of pregnancy in the communities. In the two hospitals, the proportion of mothers in their immediate post-partum period whom reported they were counseled by FCHVs during their pregnancy increased. It improved from 7% before the intervention to 18.1% (P < 0.001) after the intervention. The qualitative findings suggested that the intervention improved their knowledge in providing PPFP counseling. CONCLUSION: The orientation improved the FCHV's knowledge of PPFP and their community-based counseling. Follow-up studies are needed to assess the longer term effect of the FCHV's role in improving community-based PPFP services.

Effect of psycho-social support by teachers on improving mental health and hope of adolescents in an earthquake-affected district in Nepal: A cluster randomized controlled trial.

INTRODUCTION: Adolescents can be prone to mental health problems such as post-traumatic stress disorder (PTSD) and depression following disasters. School teachers can provide timely psycho-social support that could instill hope and improve mental health among adolescents in a post-earthquake situation in a low-resource setting. This study examined the effect of training for school teachers on psycho-social support on adolescents' mental health and hope in an earthquake affected district in Nepal. METHODS: This cluster randomized controlled trial was conducted in 15 schools in Dhading, a severely affected district by the 2015 earthquake in Nepal. The schools were randomized, as a result, 8 were in the intervention group and 7 in the control group. A total of 1,220 adolescents were recruited at baseline of which 605 adolescents belonged to intervention group and 615 to control group. The follow-up rate at 6 months was 83%. This trial was registered with Clinicaltrials.gov with registration number NCT03387007. RESULTS: The intervention did not show significant effects for PTSD symptoms (Intervention*time, ß = 0.33, p = 0.536), depression symptoms (Intervention*time, ß = 0.30, p = 0.249), and hope (Intervention*time, ß = -0.23, p = 0.588), among the adolescents at 6 months follow-up. CONCLUSION: The intervention did not improve mental health symptoms and hope among adolescents at 6 months follow-up. More focused and longer training could be necessary to address mental health among adolescents affected by earthquake. Additionally, longer follow-up could be necessary to assess the changes taking place over time. TRIAL REGISTRATION: ClinicalTrials.gov NCT03387007.

Assessing knowledge and behavioural changes on maternal and newborn health among mothers following post-earthquake health promotion in Nepal.

INTRODUCTION: Disasters can disrupt the existing health system affecting the whole population, but especially vulnerable people such as pregnant women, new mothers and their babies. Despite the global progress in maternal, newborn and child health (MNCH) programmes over the years, emergency responses after a disaster are often poor. Post-disaster health promotion could play an important role in improving MNCH outcomes. However, evidence remains limited on the effect of post disaster health promotion activities in low-income countries such as Nepal. METHODS: This is an uncontrolled before and after study conducted in Dhading district which was severely affected by the 2015 earthquake in Nepal. The study participants were mothers who had a child in the previous 12 months. The intervention was implemented between 2016 and 2018 and included community-engagement health promotion activities where the local stakeholders and resources were mobilized. The outcome variables included: knowledge of danger signs of pregnancy, childbirth and in newborns; and behaviours including ever attending antenatal care (ANC), a minimum of four ANC sessions and having an institutional delivery. Data were analysed using chi-squared tests, independent sample t-tests and multiple logistic regression models. RESULTS: In total 364 mothers were recruited in the pre-intervention group and 377 in the post-intervention group. The post-intervention group was more likely to have knowledge of at least three danger signs in pregnancy (AOR [Adjusted Odds Ratio] = 2.96, P<0.001), at least three danger signs in childbirth (AOR = 3.8, P<0.001), and at least five danger signs in newborns (AOR = 1.56, P<0.001) compared to the pre-intervention group. The mothers in the post-intervention group were also more likely to ever attend ANC (AOR = 7.18, P<0.001), attend a minimum of four ANC sessions (AOR = 5.09, P<0.001), and have institutional deliveries (AOR = 2.56, P<0.001). Religious minority groups were less likely to have knowledge of all danger signs compared to the majority Hindu group. Mothers from poorer households were also less likely to attend four ANC sessions. Mothers with higher education were more likely to have knowledge of all the danger signs. Mothers whose husbands had achieved higher education were also more likely to have knowledge of danger signs and have institutional deliveries. CONCLUSION: Health promotion intervention helped the disaster-affected mothers in improving the knowledge and behaviours related to MNCH. However, the vulnerable population would need more support to gain benefit from such intervention.

School health and nutrition program implementation, impact, and challenges in schools of Nepal: stakeholders' perceptions.

BACKGROUND: The School Health and Nutrition (SHN) program is a cost-effective intervention for resource-poor countries. SHN program aims to provide timely support and preventive measures to improve the health of school children, which can be associated with their cognitive development, learning, and academic performance. Stakeholders at different tiers can play significant roles in the program implementation and its success. Their perceptions are equally important to provide information on the factors influencing the implementation process and help to identify the gaps in the process. However, the evidence is scarce on the school health and nutrition policy and program implementation in developing countries. No study has yet explored stakeholders' perceptions on the SHN program implementation process in low-income countries, including Nepal. Therefore, we conducted a qualitative study to explore (1) the SHN program implementation, (2) its impact, and (3) challenges in Nepal. METHODS: We conducted a qualitative study through 32 in-depth interviews of the key informants who were actively involved in SHN program implementation in Nepal. The key informants were identified through personal network and snowballing procedure. We adopted a thematic approach for the data analysis. RESULTS: We categorized interview data into three broad themes: (1) SHN program implementation, (2) its impact, and (3) challenges during implementation. Almost all the key informants appreciated the program for its positive impact on students, schools, and communities. The positive impacts included improved students' health and school environment and enhanced community awareness. However, the key impediments in implementing the program included a lack of coordination between stakeholders, lack of resources, limited training opportunities, and doubts regarding the sustainability of the program. CONCLUSIONS: This study provided a deeper understanding of the linkage between the SHN program implementation, impact, and challenges in Nepal. Despite the challenges, all the stakeholders acknowledged that the SHN program had positive impacts on students, schools, and communities. Our findings highlighted that stakeholders from all tiers should coordinate, collaborate, and continue their efforts to effectively implement and expand the program nationwide. Awareness campaigns and advocacy for the program are indispensable to pull more resources from relevant stakeholders.

Factors affecting the behavior outcomes on post-partum intrauterine contraceptive device uptake and continuation in Nepal: a qualitative study.

BACKGROUND: The use of post-partum family planning (PPFP) methods such as post-partum intrauterine device (PPIUD) in general remains low despite its benefits for the women. The reasons or factors affecting the uptake and continuation of such PPFP methods in developing countries such as Nepal remains unclear. This qualitative research aims to explore the factors affecting PPIUD uptake and continuation related behaviors among post-partum mothers within 6 weeks of childbirth in Nepal. METHODS: This qualitative study was conducted through 43 in-depth interviews among post-partum mothers who delivered in 3 selected hospitals in Nepal. Data were analyzed through content analysis using the theory of planned behavior (TPB) as the theoretical framework. RESULTS: The themes and categories were structured around the three major components of the TPB on attitude, subjective norms, and behavioral control. Majority of the women in this study, irrespective of their behavioral outcome expressed a positive attitude towards PPIUD use. However, the women who expressed an unfavorable attitude towards PPIUD influenced their behavior to not choose or discontinue PPIUD. Subjective norms such as the family, peer, and societal influences against PPIUD negatively affected the women's intention and behavior related to PPIUD. Whereas, the positive influence of the health providers positively affected their behavior. Regarding the behavior control, women who had their own control over decisions tended to use PPIUD. However, external factors such as their husband's preference or medical conditions also played a prominent role in preventing many to use PPIUD despite their positive intentions. CONCLUSION: As suggested in TPB, this study shows that multiple factors that are interlinked affected the behaviors related to uptake and continuation of PPIUD. The attitude helped in s`haping intention but did not always lead to the behavioral outcome of PPIUD uptake and continuation. Subjective norms had a strong influence on both intention and behavior. Behavior control belief also had an important role in the outcome with respect to PPIUD uptake and continuation. Thus, a more layered, multidimensional and interlinked intervention is necessary to bring positive behavior changes related to PPIUD.

Institutionalizing postpartum family planning and postpartum intrauterine device services in Nepal: Role of training and mentorship.

OBJECTIVE: To explore the perceptions of key stakeholders on different modalities of training and mentoring activities for healthcare providers of postpartum family planning and postpartum intrauterine devices (PPFP/PPIUD). METHODS: In this qualitative study, data were collected from 40 participants in December 2017 via focus group discussions (FGD) and in-depth interviews (IDI) in three hospitals implementing PPFP/PPIUD services and government line agencies in Nepal. Data were analyzed through content analysis and grouped into themes and categories. RESULTS: The majority of participants reported that PPFP/PPIUD training and mentoring was useful and contributed to their professional development. Most found that on-the-job training (OJT) was more effective than group-based training (GBT). CONCLUSION: Training and mentoring activities were perceived to be useful by health providers and OJT was the approach preferred by the majority. Further studies are necessary to explore the existing challenges and long-term effects of each modality of training and mentoring on health providers' competency and attitudes and on the uptake of PPIUD by postpartum mothers.

Improving the quality of maternity services in Nepal through accelerated implementation of essential interventions by healthcare professional associations.

OBJECTIVE: To assess whether the implementation of a package of activities through the joint action of three international healthcare professional associations (HCPAs) increased the use of essential interventions (EIs) for delivery and neonatal care. METHODS: A noncontrolled pre-intervention versus post-intervention study was conducted from June 13 to December 13, 2016, among women older than 18 years of age, who had delivered at one of two urban tertiary hospitals in Nepal. RESULTS: The study included 9252 women. Minimal change was found after the implementation of EIs that were used frequently at baseline (e.g. social support during delivery in the emergency room, and promotion and support for early initiation of breastfeeding). By contrast, an increase was recorded for some EIs that had not been used regularly at baseline. For example, the rate of timely administration of prophylactic antibiotics before cesarean delivery increased from 0.0% (0/496) to 94.0% (409/435) at one hospital. Nonetheless, some EIs with low use at baseline did not show improvement after implementation (e.g. kangaroo mother care). CONCLUSION: The present study strengthened previous findings regarding the uptake of EIs following joint promotion by HCPAs in low-income settings.

Trends and inequities in use of maternal health care services in Indonesia, 1986-2012.

PURPOSE: Overall health status indicators have improved significantly over the past three decades in Indonesia. However, the country's maternal mortality ratio remains high with a stark inequality by region. Fewer studies have explored access inequity in maternal health care service over time using multiple inequality markers. In this study, we analyzed Indonesian Demographic and Health Survey (DHS) data to explore trends and inequities in use of any antenatal care (ANC), four or more ANC (ANC4+), institutional birth, and cesarean section (c-section) birth in Indonesia during 1986-2012 to inform policy for future strategies ending preventable maternal deaths. METHODS: Indonesian DHS data from 1991, 1994, 1997, 2002/3, 2007, and 2012 surveys were downloaded, merged, and analyzed. Inequity was measured in terms of variation in use by asset quintile, parental education, urban-rural location, religion, and region. Trends in use inequities were assessed plotting changes in rich:poor ratio, rich:poor difference, and concentration indices over period based on asset quintiles. Sociodemographic determinants for service use were explored using multivariable logistic regression analysis. FINDINGS: Between 1986 and 2012, institutional birth rate increased from 22% to 73% and c-section rate from 2% to 16%. Private sector was increasingly contributing in maternal health. There were significant access inequities by asset quintile, parental education, area of residence, and geographical region. The richest women were 5.45 times (95% CI: 4.75-6.25) more likely to give birth in a health facility and 2.83 times (95% CI: 2.23-3.60) more likely to give birth by c-section than their poorest counterparts. Urban women were 3 times more likely to use institutional birth and 1.45 times more likely to give birth by c-section than rural women. Use of all services was higher in Java and Bali than in other regions. Access inequity was narrowing over time for use of ANC and institutional birth but not for c-section birth. CONCLUSION: Ongoing pro-poor health-financing strategies should be strengthened with introduction of innovative ways to monitor access, equity, and quality of care in maternal health.