Participatory policy analysis in health policy and systems research: reflections from a study in Nepal.

BACKGROUND: Participatory policy analysis (PPA) as a method in health policy and system research remains underexplored. Using our experiences of conducting PPA workshops in Nepal to explore the impact of the country's move to federalism on its health system, we reflect on the method's strengths and challenges. We provide an account of the study context, the design and implementation of the workshops, and our reflections on the approach's strengths and challenges. Findings on the impact of federalism on the health system are beyond the scope of this manuscript. MAIN BODY: We conducted PPA workshops with a wide range of health system stakeholders (political, administrative and service-level workforce) at the local and provincial levels in Nepal. The workshops consisted of three activities: river of life, brainstorming and prioritization, and problem-tree analysis. Our experiences show that PPA workshops can be a valuable approach to explore health policy and system issues - especially in a context of widespread systemic change which impacts all stakeholders within the health system. Effective engagement of stakeholders and activities that encourage both individual- and system-level reflections and discussions not only help in generating rich qualitative data, but can also address gaps in participants' understanding of practical, technical and political aspects of the health system, aid policy dissemination of research findings, and assist in identifying short- and long-term practice and policy issues that need to be addressed for better health system performance and outcomes. Conducting PPA workshops is, however, challenging for a number of reasons, including the influence of gatekeepers and power dynamics between stakeholders/participants. The role and skills of researchers/facilitators in navigating such challenges are vital for success. Although the long-term impact of such workshops needs further research, our study shows the usefulness of PPA workshops for researchers, for participants and for the wider health system. CONCLUSIONS: PPA workshops can effectively generate and synthesize health policy and system evidence through collaborative engagement of health system stakeholders with varied roles. When designed with careful consideration for context and stakeholders' needs, it has great potential as a method in health policy and systems research.

Gender and caste inequalities in primary healthcare usage by under-5 children in rural Nepal: an iterative qualitative study into provider perspectives and the potential role of implicit bias.

OBJECTIVE: This study explored provider perspectives on: (1) why inequalities in health service usage persist; and (2) their knowledge and understanding of the role of patient experience and implicit bias (also referred to as unconscious bias). DESIGN: A three stage, iterative qualitative study was conducted involving two rounds of in-depth interviews and a training session with healthcare staff. Interview transcripts were analysed using a reflexive thematic approach in relation to the study's aims. SETTING: Participants were recruited from rural hill districts (Mugu, Humla, Bajura, Gorkha and Sindhupalchok) of Nepal. PARTICIPANTS: Clinical staff from 22 rural health posts. RESULTS: Healthcare providers had high levels of understanding of the cultural, educational and socioeconomic factors behind inequalities in healthcare usage in their communities. However, there was less knowledge and understanding of the role of patient experience-and no recognition at all of the concept of implicit bias. CONCLUSION: It is highly likely that implicit bias affects provider behaviours in Nepal, just as it does in other countries. However, there is currently not a culture of thinking about the patient experience and how that might impact on future usage of health services. Implicit bias training for health students and workers would help create greater awareness of unintended discriminatory behaviours. This in turn may play a part in improving patient experience and future healthcare usage, particularly among disadvantaged groups.

Management of COVID-19 and vaccination in Nepal: A qualitative study.

OBJECTIVE: The aim of this research is to investigate the perspective of citizens of Nepal on the management COVID-19, the roll-out of the vaccine, and to gain an understanding of attitudes towards the governments' handling of the COVID-19 pandemic. METHOD: A qualitative methodology was used. In-depth interviews were conducted with 18 males and 23 females aged between 20 and 86 years old from one remote and one urban district of Nepal. Interviews were conducted in November and December 2021. A thematic approach was used to analyse the data, utilising NVivo 12 data management software. RESULT: Three major themes were identified: (1) Peoples' perspective on the management of COVID-19, (2) people's perception of the management of COVID-19 vaccination and (3) management and dissemination of information. It was found that most participants had heard of COVID-19 and its mitigation measures, however, the majority had limited understanding and knowledge about the disease. Most participants expressed their disappointment concerning poor testing, quarantine, vaccination campaigns and poor accountability from the government towards the management of COVID-19. Misinformation and stigma were reported as the major factors contributing to the spread of COVID-19. People's knowledge and understanding were mainly shaped by the quality of the information they received from various sources of communication and social media. This heavily influenced their response to the pandemic, the preventive measures they followed and their attitude towards vaccination. CONCLUSION: Our study concludes that the study participants' perception was that testing, quarantine centres and vaccination campaigns were poorly managed in both urban and rural settings in Nepal. Since people's knowledge and understanding of COVID-19 are heavily influenced by the quality of information they receive, we suggest providing contextualised correct information through a trusted channel regarding the pandemic, its preventive measures and vaccination. This study recommends that the government proactively involve grassroots-level volunteers like Female Community Health Volunteers to effectively prepare for future pandemics. PATIENT AND PUBLIC CONTRIBUTION: This study was based on in-depth interviews with 41 people from diverse socioeconomic backgrounds. This study would not have been possible without their participation.

Mental Health Risks Among Informal Waste Workers in Kathmandu Valley, Nepal.

Informal waste workers are a vulnerable population group who are often socio-economically marginalized and disadvantaged, with more likelihood of experiencing ill health than the general population. To explore the determinants of mental ill health in this group, we conducted a cross-sectional survey of 1278 informal waste-workers in Nepal in 2017, using a demographic health assessment questionnaire and a modified Patient Health Questionnaire (PHQ-9). We looked at the potential associations between various exposure factors and mental health outcomes and found that 27.4% of waste-workers had depressive symptoms, more likely to be reported by female (OR 2.290), older person (OR 7.757), divorced/separated (5.859), and those with ill health (OR 2.030), or disability (OR 3.562). Waste-workers with access to social protection (OR 0.538) and financial savings (OR 0.280) were less likely to have depressive symptoms. There are key risk factors that may enable identification of particularly vulnerable persons within this group and also protective factors that may help improve their mental health resilience.