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.

The prevalence of exclusive breastfeeding practice in the first six months of life and its associated factors in Nepal: A systematic review and meta-analysis.

Despite the global emphasis on breastfeeding, exclusive breastfeeding (EBF) in the first six months of life still lag behind the global recommendations in low- and middle-income countries, such as Nepal. This systematic review aims to determine the prevalence of EBF in the first six months of life and the associated factors determining EBF practices in Nepal. The databases PubMed/MEDLINE, Embase, Scopus, Web of Science, Cochrane Library, MIDIRS, DOAJ, and the NepJOL were searched for peer-reviewed literature published up to December 2021. The JBI quality appraisal checklist was used to assess the quality of studies. Analyses were performed by pooling together studies using the random-effect model, and the I2 test was used to assess the heterogeneity of the included studies. A total of 340 records were found, out of which 59 full-text were screened. Finally, 28 studies met the inclusion criteria and were selected for analysis. The pooled prevalence of EBF was 43 % (95 % confidence interval: 34-53). The odds ratio for the type of delivery was 1.59 (1.24-2.05), for ethnic minority groups 1.33 (1.02-1.75) and for first-birth order 1.89 (1.33-2.67). We found a lower prevalence of exclusive breastfeeding practice in Nepal compared to the national target. Multifaceted, effective, evidence-based interventions would encourage individuals in the exclusive breastfeeding journey. Incorporating the BEF counselling component into Nepal's existing maternal health counselling package may help promote exclusive breastfeeding practice. Further research to explore the reasons for the suboptimal level of EBF practice would help develop the targeted interventions pragmatically.

Factors affecting on compliance of childhood immunization in Ilam District of Nepal; A case-control study.

Childhood immunization is one of the most important public health interventions to reduce child morbidity and mortality. Reaching all children with full immunization services is critical to meet Nepal's commitment to Sustainable Development Goals (SDGs). This study aimed to identify factors affecting compliance with childhood immunization in children aged 16 to 36 months in Nepal. A community-based unmatched case-control study was conducted with 250 (83 cases and 167 controls) respondents in the Ilam district of Nepal. Respondents were randomly selected using a multi-stage cluster sampling technique. Data were collected using a structured questionnaire and analysed using SPSS version 16 statistical software. Bivariate and multivariate logistic regression analyses were done to identify the factors influencing compliance with childhood immunization of the sampled respondents. More than two-thirds (66.8%) of the sampled children were fully immunized, and 19.3% of the children defaulted to the Measles-Rubella vaccines. Only 19.2% of the respondents had good knowledge about the type of vaccine, and more than half (59.2%) of the respondents had a positive attitude towards immunization. Multivariate logistic regression analysis revealed that lack of knowledge about vaccines (AOR = 49.4, 95% CI = 12.94 to 188.59), father's level of education (AOR = 2.1, 95% CI = 1.05 to 4.30), not getting immunization on the day of the appointment (AOR = 4.8, 95% CI = 2.30 to 9.89), lack of knowledge about immunization schedule (AOR = 2.4, 95% CI = 1.14 to 4.84), and negative attitude towards immunization (AOR = 2.1, 95% CI = 1.03 to 4.19) were independently impeded on compliance on the childhood immunization. Targeted intervention in health promotion activities at the household level should be promoted and integrated immunization services into the existing primary health care services.

Migrant workers' health-related research in Nepal: A bibliometric study.

Background: In recent years, the health of migrants has become an important global public health issue. However, less is known about the current status of research activity among Nepalese migrants' health. This study aimed to assess the current status of research activity by analysing published peer review literature on Nepalese migrants' health. Methods: A systematic search of published literature on Nepalese migrant workers' health was conducted in Scopus, Medline, CINAHL, Embase, PsycINFO and Web of Science, and a bibliometric analysis methodology was used. The search of databases retrieved 520 records, and a total of 161 papers were included in the analysis. Bibliometric analyses were performed in R and VoSViewer to create visualisation maps. Results: The retrieved documents were published in the last three decades, and a total of 533 researchers originating from 24 countries contributed to the literature. A large proportion of papers (n=22) were published in a single year, in 2019, and the number of authors per journal ranged from one to 14. The topmost preferred journals for publications in Nepalese migrants' health were PLoS One (n=9), followed by the Journal of Immigration and Minority Health (n=6). The retrieved articles received 2425 citations, with an average of 15.1 citations per article. The study identified nine overlapping research domains (thematic areas) - infectious disease, non-communicable diseases, health and lifestyle, sexual and reproductive health, access to health services, workplace safety, maternal health, gender-based violence, and health system and policy. Conclusion: The present bibliometric study fills an analytical gap in the field of migrat's health research in Nepal and provides evidence and insights to advocate the formulation of strategies to promote the migrants' health vulnerabilities often associated with individual-related hazards such as working in 'difficult, dirty, and dangerous (3Ds) working conditions.

Fear, Stigma and Othering: The Impact of COVID-19 Rumours on Returnee Migrants and Muslim Populations of Nepal.

The paper explores how COVID-19-related moral panics have led to fear and othering practices among returnee Nepalese migrants from India and Muslims living in Nepal. This qualitative study included in-depth interviews with 15 returnee migrants, 15 Muslims from Kapilvastu and Banke districts of Nepal, and eight interviews with media and health professionals, and representatives from migration organisations. Four themes emerged from our data analysis: (1) rumours and mis/disinformation; (2) impact of rumours on marginalised groups (with three sub-themes: (i) perceived fear; (ii) othering practices; (iii) health and social impact); (3) resistance; and (4) institutional response against rumours. Findings suggest that rumours and misinformation were fuelled by various media platforms, especially social media (e.g., Facebook, YouTube) during the initial months of the lockdown. This created a moral panic which led to returnee migrants and Muslim populations experiencing fear and social isolation. Resistance and effective institutional responses to dispel rumours were limited. A key contribution of the paper is to highlight the lived experiences of COVID-19 related rumours on marginalised groups. The paper argues that there is a need for clear government action using health promotion messages to tackle rumours (health-related or otherwise), mis/disinformation and mitigating the consequences (hatred and tensions) at the community level.

Burden of tuberculosis and hepatitis co-infection among people living with HIV in Nepal: a systematic review and meta-analysis.

People living with HIV (PLHIV) are prone to tuberculosis (TB) and hepatitis co-infections, which cause substantial burden on morbidity and mortality. However, data on the burden of HIV co-infection from a specific low- and middle-income country are limited. To address this gap in evidence, a meta-analysis of published literature and country surveillance report was conducted to estimate the burden of TB, hepatitis B (HBV) and hepatitis C (HCV) co-infection among PLHIV in Nepal. Twenty-three studies, including 5900 PLHIV, were included in the meta-analysis. The pooled prevalence of HIV-TB, HIV-HBV and HIV-HCV co-infection was 19% (95% CI, 10-28%), 3% (2-5%) and 19% (4-33%), respectively. Low CD4 cell count (pooled odds ratio [OR] 4.38, 95% CI 1.11-17.25), smoking (3.07, 1.48-6.37) and alcohol drinking (3.12, 1.52-6.43) were significantly correlated with HIV-TB co-infection. The odds of HCV co-infection was greater in PLHIV, who were male (5.39, 1.54-18.89) and drug users (166.26, 15.94-1734.44). PLHIV who were on antiretroviral therapy had a reduced risk of HCV co-infection (0.49, 0.36-0.66) than the general PLHIV population. The burden of TB and hepatitis co-infection among PLHIV in Nepal was high. Regular screening of PLHIV for co-infections and prompt initiation of treatment are essential to reduce the transmission of infection and improve quality of life.

Fear, Risk Perception, and Engagement in Preventive Behaviors for COVID-19 during Nationwide Lockdown in Nepal.

The world has faced huge negative effects from the COVID-19 pandemic between early 2020 and late 2021. Each country has implemented a range of preventive measures to minimize the risk during the COVID-19 pandemic. This study assessed the COVID-19-related fear, risk perception, and preventative behavior during the nationwide lockdown due to COVID-19 in Nepal. In a cross-sectional study, conducted in mid-2021 during the nationwide lockdown in Nepal, a total of 1484 individuals completed measures on fear of COVID-19, COVID-19 risk perception, and preventive behavior. A multiple linear regression analysis was used to identify factors associated with COVID-19 fear. The results revealed significant differences in the fear of COVID-19 in association with the perceived risk of COVID-19 and preventive behaviors. Age, risk perception, preventive behavior, and poor health status were significantly positively related to fear of COVID-19. Perceived risk and preventive behaviors uniquely predicted fear of COVID-19 over and above the effects of socio-demographic variables. Being female and unmarried were the significant factors associated with fear of COVID-19 among study respondents. Higher risk perception, poor health status, and being female were strong factors of increased fear of COVID-19. Targeted interventions are essential to integrate community-level mental health care for COVID-19 resilience.

Men on the move and the wives left behind: the impact of migration on family planning in Nepal.

Nepali migration is longstanding, and increased from 2.3% of the total population in 2001 to 7.2% in 2011. The estimated 1.92 million migrants are predominantly men. Consequently, 32% of married women have husbands working abroad. Social structures are complicated as many married women live with their in-laws who typically assume decision-making power, including access to health services. This study compares access to reproductive health services, fertility awareness, and decision-making power among a sample of married women aged 15-24 years (n = 1123) with migrant husbands (n = 485), and with resident husbands (n = 638). Predictably, women with migrant husbands had significantly lower contraceptive use than other married women (9.3% vs 30.3%, respectively), and expressed a higher intention to become pregnant in the next year. Despite their intentions, women with migrant husbands scored lower on a fertility awareness index, were less likely to discuss pregnancy planning with their spouse, and less likely to describe their relationships positively. Decision-making for both groups of married women was dominated by both husbands and in-laws in different ways. Yet, across multiple normative scales, fewer women with migrant husbands felt pressure to conform to existing social norms. Married women with migrant husbands reflect a subset of women, with unique fertility issues and desires. Interventions that increase knowledge of fertility among this subset of women, promote healthy preconception behaviours. Linking women for counselling opportunities throughout the pre and postnatal periods may help improve health outcomes for mothers and children.

Life expectancy and disparities in survival among HIV-infected people receiving antiretroviral therapy: an observational cohort study in Kathmandu, Nepal.

INTRODUCTION: The advent of antiretroviral therapy (ART) has dramatically slowed down the progression of HIV. This study assesses the disparities in survival, life expectancy and determinants of survival among HIV-infected people receiving ART. METHODS: Using data from one of Nepal's largest population-based retrospective cohort studies (in Kathmandu, Nepal), we followed a total of 3191 HIV-infected people aged 15 years and older who received ART over the period of 2004-2015. We created abridged life tables with age-specific survival rates and life expectancy, stratified by sex, ethnicity, CD4 cell counts and the WHO-classified clinical stage at initiation of ART. RESULTS: HIV-infected people who initiated ART with a CD4 cell count of >200 cells/cm3 at 15 years had 27.4 (22.3 to 32.6) years of additional life. People at WHO-classified clinical stage I and 15 years of age who initiated ART had 23.1 (16.6 to 29.7) years of additional life. Life expectancy increased alongside the CD4 cell count and decreased as clinical stages progressed upward. The study cohort contributed 8484.8 person years, with an overall survival rate of 3.3 per 100 person years (95% CI 3.0 to 3.7). CONCLUSIONS: There are disparities in survival among HIV-infected people in Nepal. The survival payback of ART is proven; however, late diagnosis or the health system as a whole will affect the control and treatment of the illness. This study offers evidence of the benefits of enrolling early in care in general and ART in particular.

A survey of health problems of Nepalese female migrants workers in the Middle-East and Malaysia.

BACKGROUND: Nepal is a key supplier of labour for countries in the Middle East, India and Malaysia. As many more men than women leave Nepal to work abroad, female migrant workers are a minority and very much under-researched. The aim of the study was to explore the health problems of female Nepalese migrants working in the Middle-East and Malaysia. METHODS: The study was conducted among 1010 women who were registered as migrant returnees at an organisation called Pourakhi Nepal. Secondary data were extracted from the records of the organisation covering the five-year period of July 2009 to July 2014. RESULTS: The 1010 participants were aged 14 to 51 with a median age of 31 (IQR: 38-25) years. A quarter of respondents (24%) reported having experienced health problems while in the country of employment. Fever, severe illness and accidents were the most common health problems reported. Working for unlimited periods of time and not being able to change one's place of work were independently associated with a greater likelihood of health problems. Logistic regression shows that migrant women who are illiterate [OR = 1.56, 95% CI: 1.02 to 2.38, p = 0.042], who had changed their workplace [OR = 1.63, 95% CI: 1.14 to 2.32, p = 0.007], who worked unlimited periods of time [OR = 1.64, 95% CI: 1.44 to 1.93, p = 0.020], had been severely maltreated or tortured in the workplace [OR = 1.84, 95% CI: 1.15 to 2.92, p = 0.010], were not being paid on time [OR = 2.38, 95% CI: 1.60 to 3.55, p = 0.038] and migrant women who had family problems at home [OR = 3.48, CI 95%: 1.22 to 9.98, p = 0.020] were significantly associated with health problems in their host country in the Middle East. CONCLUSION: Female migrant workers face various work-related health risks, which are often related to exploitation. The Government of Nepal should initiate awareness campaigns about health risks and rights in relation to health care services in the host countries. Recruiting agencies/employers should provide information on health risks and training for preventive measures. Raising awareness among female migrant workers can make a change in their working lives.

Prevalence of depressive symptoms and its associated factors in older adults: a cross-sectional study in Kathmandu, Nepal.

OBJECTIVE: Globally, depression is one of the most prevalent and burdensome conditions in older adults. However, there are few population-based studies of depression in older adults in developing countries. In this paper, we examine the prevalence of depressive symptoms and explore possible contributory risk factors in older adults living in Nepal. METHODS: A cross-sectional study was conducted in two semi-urban communities in Kathmandu, Nepal. Depression was assessed using the 15-item Geriatric Depression Scale in 303 participants, aged 60 years and over. Multivariate logistic regression was then used to assess associations between potential risk factors and depression. RESULTS: More than half of the participants (n = 175, 60.6%) had significant depressive symptomatology, with 27.7% having scores suggesting mild depression. Illiteracy (aOR = 2.01, 95% CI: 1.08-3.75), physical immobility (aOR = 5.62, 95% CI: 1.76-17.99), the presence of physical health problems (aOR = 1.97, 95% CI: 1.03-3.77), not having any time spent with family members (aOR = 3.55, 95% CI: 1.29-9.76) and not being considered in family decision-making (aOR = 4.02, 95% CI: 2.01-8.04) were significantly associated with depression in older adults. CONCLUSION: The prevalence of depression was significant in older adults. There are clear associations of depression with demographic, social support and physical well-being factors in this population. Strategies that increase awareness in the community along with the health and social care interventions are needed to address the likely drivers of depression in older adults.

Informed Consent in Health Research: Challenges and Barriers in Low-and Middle-Income Countries with Specific Reference to Nepal.

Obtaining 'informed consent' from every individual participant involved in health research is a mandatory ethical practice. Informed consent is a process whereby potential participants are genuinely informed about their role, risk and rights before they are enrolled in the study. Thus, ethics committees in most countries require 'informed consent form' as part of an ethics application which is reviewed before granting research ethics approval. Despite a significant increase in health research activity in low-and middle-income countries (LMICs) in recent years, only limited work has been done to address ethical concerns. Most ethics committees in LMICs lack the authority and/or the capacity to monitor research in the field. This is important since not all research, particularly in LMICs region, complies with ethical principles, sometimes this is inadvertently or due to a lack of awareness of their importance in assuring proper research governance. With several examples from Nepal, this paper reflects on the steps required to obtain informed consents and highlights some of the major challenges and barriers to seeking informed consent from research participants. At the end of this paper, we also offer some recommendations around how can we can promote and implement optimal informed consent taking process. We believe that paper is useful for researchers and members of ethical review boards in highlighting key issues around informed consent.

Comparative effectiveness and acceptability of home-based and clinic-based sampling methods for sexually transmissible infections screening in females aged 14-50 years: a systematic review and meta-analysis.

BACKGROUND: Home-based sampling is a strategy to enhance uptake of sexually transmissible infection (STI) screening. This review aimed to compare the screening uptake levels of home-based self-sampling and clinic-based specimen collection for STIs (chlamydia (Chlamydia trachomatis), gonorrhoea (Neisseria gonorrhoeae) and trichomoniasis) in females aged 14-50 years. Acceptability and effect on specimen quality were determined. METHODS: Sixteen electronic databases were searched from inception to September 2012. Randomised controlled trials (RCTs) comparing the uptake levels of home-based self-sampling and clinic-based sampling for chlamydia, gonorrhoea and trichomoniasis in females aged 14-50 years were eligible for inclusion. The risk of bias in the trials was assessed. Risk ratios (RRs) for dichotomous outcomes were meta-analysed. RESULTS: Of 3065 papers, six studies with seven RCTs contributed to the final review. Compared with clinic-based methods, home-based screening increased uptake significantly (P=0.001-0.05) in five trials and was substantiated in a meta-analysis (RR: 1.55; 95% confidence interval: 1.30-1.85; P=0.00001) of two trials. In three trials, a significant preference for home-based testing (P=0.001-0.05) was expressed. No significant difference was observed in specimen quality. Sampling was rated as easy by a significantly higher number of women (P=0.01) in the clinic group in one trial. CONCLUSIONS: The review provides evidence that home-based testing results in greater uptake of STI screening in females (14-50 years) than clinic-based testing without compromising quality in the developed world. Home collection strategies should be added to clinic-based screening programs to enhance uptake.

Factors influencing adherence to antiretroviral treatment in Nepal: a mixed-methods study.

BACKGROUND: Antiretroviral therapy (ART) is a lifesaver for individual patients treated for Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS). Maintaining optimal adherence to antiretroviral drugs is essential for HIV infection management. This study aimed to understand the factors influencing adherence amongst ART-prescribed patients and care providers in Nepal. METHODS: A cross-sectional mixed-methods study surveying 330 ART-prescribed patients and 34 in-depth interviews with three different types of stakeholders: patients, care providers, and key people at policy level. Adherence was assessed through survey self-reporting and during the interviews. A multivariate logistic regression model was used to identify factors associated with adherence, supplemented with a thematic analysis of the interview transcripts. RESULTS: A total of 282 (85.5%) respondents reported complete adherence, i.e. no missed doses in the four-weeks prior to interview. Major factors influencing adherence were: non-disclosure of HIV status (OR = 17.99, p = 0.014); alcohol use (OR = 12.89, p = <0.001), being female (OR = 6.91, p = 0.001), being illiterate (OR = 4.58, p = 0.015), side-effects (OR = 6.04, p = 0.025), ART started ≤24 months (OR = 3.18, p = 0.009), travel time to hospital >1 hour (OR = 2.84, p = 0.035). Similarly, lack of knowledge and negative perception towards ART medications also significantly affected non-adherence. Transport costs (for repeat prescription), followed by pills running out, not wanting others to notice, side-effects, and being busy were the most common reasons for non-adherence. The interviews also revealed religious or ritual obstacles, stigma and discrimination, ART-associated costs, transport problems, lack of support, and side-effects as contributing to non-adherence. CONCLUSION: Improving adherence requires a supportive environment; accessible treatment; clear instructions about regimens; and regimens tailored to individual patients' lifestyles. Healthcare workers should address some of the practical and cultural issues around ART medicine whilst policy-makers should develop appropriate social policy to promote adherence among ART-prescribed patients.

Factors influencing adherence to antiretroviral treatment in Asian developing countries: a systematic review.

OBJECTIVE: To systematically review the literature of factors affecting adherence to Antiretroviral treatment (ART) in Asian developing countries. METHODS: Database searches in Medline/Ovid, Cochrane library, CINAHL, Scopus and PsychINFO for studies published between 1996 and December 2010. The reference lists of included papers were also checked, with citation searching on key papers. RESULTS: A total of 437 studies were identified, and 18 articles met the inclusion criteria and were extracted and critically appraised, representing in 12 quantitative, four qualitative and two mixed-method studies. Twenty-two individual themes, including financial difficulties, side effects, access, stigma and discrimination, simply forgetting and being too busy, impeded adherence to ART, and 11 themes, including family support, self-efficacy and desire to live longer, facilitated adherence. CONCLUSION: Adherence to ART varies between individuals and over time. We need to redress impeding factors while promoting factors that reinforce adherence through financial support, better accessible points for medicine refills, consulting doctors for help with side effects, social support and trusting relationships with care providers.

Barriers to and facilitators of antiretroviral therapy adherence in Nepal: a qualitative study.

Patient's adherence is crucial to get the best out of antiretroviral therapy (ART). This study explores in-depth the barriers to and facilitators of ART adherence among Nepalese patients and service providers prescribing ART. Face-to-face semi-structured interviews were conducted with 34 participants. Interviews were audiotaped, transcribed, and translated into English before being analyzed thematically. ART-prescribed patients described a range of barriers for failing to adhere to ART. Financial difficulties, access to healthcare services, frequent transport blockades, religious/ritual obstacles, stigma and discrimination, and side-effects were the most-frequently discussed barriers whereas trustworthy health workers, perceived health benefits, and family support were the most-reported facilitators. Understanding barriers and facilitators can help in the design of an appropriate and targeted intervention. Healthcare providers should address some of the practical and cultural issues around ART whilst policy-makers should develop appropriate social policy to promote adherence among ART-prescribed patients.