Assessment of Health Service Delivery to Address Cardiovascular Diseases in Nepal

Background
A health care delivery system is the organization of people, institutions, and resources designed to deliver health services. A comprehensive study to explore cardiovascular health service delivery in Nepal is lacking.
Objective
This study attempted to assess Nepal’s health system gap on organization and delivery of cardiovascular disease prevention and management services.
Method
This mixed-method study used the six building blocks of the World Health Organization health system framework: organization; access; coverage, utilization and demand; equity; quality of services; and outcomes. We conducted the desk reviews of national and international documents, performed several key informant interviews, calculated the relevant indicators, and assessed the Strengths, Weaknesses, Opportunities, and Threats of the cardiovascular health service delivery.
Result
We found that most of the cardiovascular services are concentrated in urban areas, and suffer from poor access, quality, utilization, and coverage in most of the areas resulting in poor health outcomes. Though the services have recently improved due to increased primary care interventions, there is scope for the development of competent human resources, advancement of technologies, development of national protocols, and improved monitoring and supervision. Improved disease system including the medical recording and reporting mechanism to incorporate and reflect the true burden of CVD in Nepal is lacking.
Conclusion
Despite having health facilities from grassroots to the central level, availability, access, and quality of cardiovascular health services are poor. Further improvement and equitable expansion of promotive, preventive, diagnostic, referral, and rehabilitative cardiovascular services are needed to ensure universal health coverag

Needs Assessment of Leadership and Governance in Cardiovascular Health in Nepal

Background
Good governance and leadership are essential to improve healthy life expectancy particularly in low and middle-income countries (LMICs). This study aimed to epitomize the challenges and opportunities for leadership and good governance for the health system to address non-communicable diseases particularly cardiovascular diseases (CVD) in Nepal.
Objective
The objective of this study was to understand and document CVD programs and policy formulation processes and to identify the government capacity to engage stakeholders for planning and implementation purposes.
Method
A national-level task force was formed to coordinate and steer the overall need assessment process. A qualitative study design was adopted using “The Health System Assessment Approach”. Eighteen indicators under six topical areas in leadership and governance in cardiovascular health were assessed using desk review and key informant interviews.
Result
Voice and accountability exist in planning for health from the local level. The government has shown a strong willingness and has a strategy to work together with the private and non-government sectors in health however, the coordination has not been effective. There are strong rules in place for regulatory quality, control of corruption, and maintaining financial transparency. The government frequently relies on evidence generated from large-scale surveys for health policy formulation and planning but research in cardiovascular health has been minimum. There is a scarcity of cardiovascular disease-specific protocols.
Conclusion
Despite plenty of opportunities, much homework is needed to improve leadership and governance in cardiovascular health in Nepal. The government needs to designate a workforce for specific programs to help monitor the enforcement of health sector regulations, allocate enough funding to encourage CVD research, and work towards developing CVD-specific guidelines, protocols, and capacity building.

Knowledge, awareness, attitudes and screening practices towards breast and cervical cancer among women in Nepal: a scoping review

Aim
Breast and cervical cancers have emerged as major global health challenges and disproportionately affect women in low- and middle-income countries, including Nepal. This scoping review aimed to map the knowledge, attitudes and screening practices for these cancers among Nepali women to improve cancer outcomes and reduce inequality.

Methods
Five electronic databases (CINAHL, Embase, Global Health, PsycINFO and PubMed), grey literature, and reference and citation lists were searched for articles published in English up to June 2021. Articles were screened against inclusion/exclusion criteria, and data from eligible studies were extracted. Results were summarised narratively.

Results
The search yielded 615 articles, 38 of which were included in this scoping review (27 cervical cancer, 10 breast cancer, 1 both cancers). Levels of knowledge regarding breast and cervical varied widely. The main knowledge gaps were misconceptions about symptoms and risk factors, and poor understanding of screening behaviours. Screening practices were mostly inadequate due to socio-cultural, geographical or financial barriers. Positive attitudes towards cervical screening were associated with higher education and increased knowledge of screening modalities. Higher levels of knowledge, (health) literacy and participation in awareness campaigns facilitated breast cancer screening.

Conclusion
Knowledge and screening practices for breast and cervical cancer among Nepali women were poor and highlight the need for awareness and education programmes. Future research should explore community health worker-led awareness and screening interventions for cervical cancer, and programmes to increase the practice of breast self-examination and clinical breast examinations to support early diagnosis of breast cancer.

Building Capacity and Infrastructure at Hospitals Implementing Minimally Invasive Tissue Sampling: Experience and Lessons Learned From Nepal, Rwanda, and Tanzania

Background
Minimally invasive tissue sampling (MITS) is a useful tool to determine cause of death in low- and middle-income countries (LMICs). In 2019 the MITS Surveillance Alliance supported the implementation of small-scale postmortem studies using MITS in several LMICs.

Methods
In this article we describe the preparations, challenges, and lessons learned as part of implementing MITS across 4 study sites in 3 countries: Nepal, Rwanda, and Tanzania. We describe the process for building capacity to conduct MITS, which consisted of training in MITS sample collection, individual site assessment to determine readiness and gaps prior to implementation, site visits as sites began implementation of MITS, and feedback based on remote evaluation of histology slides via an online portal.

Results
The 4 study sites each conducted 100 MITS, for a total of 400. All 4 sites lacked sufficient infrastructure and facilities to conduct MITS, and upgrades were required. Common challenges faced by sites included that clinical autopsies were neither routinely conducted nor widely accepted. Limited clinical records made cause of death determination more difficult. Lessons learned included the importance of sensitization of the community and medical staff to MITS to enhance understanding and increase consent.

Conclusions
The study sites accomplished MITS and utilized the available support systems to overcome the challenges. The quality of the procedures was satisfactory and was facilitated through the organized capacity-building programs

Prevalence and Factors Associated With Caesarean Delivery in Nepal: Evidence From a Nationally Representative Sample

Background
Caesarian sections (CS) are life-saving management for a pregnant mother and fetus subject to obstetric complications. The World Health Organization (WHO) expected CS rates not to exceed 10 to 15 per 100 live births in any country. This study aimed to assess the prevalence of CS and its associated factors from the 2016 Nepal Demographic and Health Survey (NDHS), building on previous studies mentioned in detail in the latter part of the paper.

Methods
This study analyzed the secondary data from the 2016 Nepal Demographic and Health Survey (NDHS), conducted from June 19, 2016, to January 31, 2017. The survey is undertaken every five years; consequently, the data capture the information in the previous five years from the data collection period. We used the 2016 NDHS, which is implemented by the new Enumeration Area (EA) under the support of the Ministry of Health (MOH) and funded by the U.S. Agency for International Development (USAID). In the rural areas, the sample is stratified and selected in two stages. In the first stage, wards are selected as the primary sampling units (PSU), with households subsequently chosen from the PSUs. In the urban areas, the sample is nominated in three stages. In the first stage, wards are selected as PSUs; in the second stage, one EA is chosen from each PSU, and finally, households are selected from the EAs. Then data were collected from the women in the reproductive age group within the selected households.

Results
The prevalence of CS in Nepal conforms to the WHO standard with 7.8, 7.5, and 8.1 per 100 deliveries, or 9.8, 8.9, and 9.1 per women’s last births in the previous one, three, and five years, respectively. Older mothers of 30 years old or more, having high incomes, being overweight and obese, using the internet, ante-natal care (ANC) visits of more than four times, ANC by doctors, twin delivery, and having babies of 4 kg or more, had higher odds for a CS while having two or more children seemed to be protective towards CS.

Conclusion
These findings can be used to update health policies surrounding CS delivery to limit unnecessary CS and ensure better health as CS is not without complications

Mobile Surgical Scouts Increase Surgical Access for Patients with Cleft Lip and Palate in Nepal

Background: In Nepal’s remote regions, challenging topography prevents patients with cleft lip and palate (CLP) from seeking care.

Objective: To measure the effect of a mobile surgical scout program on CLP surgical care in remote regions of Nepal.

Methods: Forty-four lay people were trained as mobile surgical scouts and over 5 months traversed remote districts of Nepal on foot to detect and refer CLP patients for surgical care. Surgical patients from remote districts were compared with matched time periods in the year before intervention. Diagnostic accuracy of the surgical scouts was assessed.

Findings: Mobile surgical scouts accurately diagnosed (90%) and referred (82%) patients for cleft surgery. Before the intervention, CLP surgeries from remote districts represented 3.5% of cleft surgeries performed. With mobile surgical scouting, patients from remote districts comprised 8.2% of all cleft surgeries (p = 0.007). When transportation and accompaniment was provided in addition to mobile surgical scouts, patients from remote districts represented 13.5% (p ≤ 0.001) of all cleft surgeries.

Conclusion: Task-shifting the surgical screening process to trained scouts resulted in accurate diagnoses, referrals, and increased access to cleft surgery in remote districts of Nepa

Role of General Practitioners in transforming surgical care in rural Nepal – A descriptive study from eastern Nepal.

Introduction: Nepal is a low-to-middle-income country (LMIC) with a predominantly rural population. Almost 10-20% of patients presenting to hospital require surgical care. The availability of skilled human resources in managing surgical care in rural areas of Nepal has to expand to meet this need. The objective of this study is to describe and demonstrate how General Practitioners (GPs) can be upskilled to provide surgical care in rural district hospitals in Nepal.

Method: It is a retrospective review of all surgical procedures performed by GPs from 1st February 2016 to 31st January 2021 at Charikot hospital. Data was collected from a prospectively maintained Electronic Health Record (EHR) system (Bahmini). Details of data collected included name of the procedure and its respective specialty. GP Task shifting and targeted surgical training programs for common orthopedic procedures and pediatric herniotomy were described in detail.

Result: A wide range of surgical procedures were performed by GPs over 5 years. This included interventions for obstetric emergencies, trauma and orthopedics, gynecological issues, general surgery of adult and childhood. A total of 2037 surgeries were performed by GPs including: Cesarean section 25%, 19.7% were orthopedics surgeries followed by 13.5% of mesh repair for abdominal hernia, 9.3% eversion of sac for Hydrocele, 8.7% appendectomy, 5.2% hysterectomy, 3% of pediatric herniotomy and others.

Conclusion: GPs can be further trained to perform important common surgical procedures to improve access to surgical care for rural communities.

Predictors of Rehabilitation Service Utilisation among Children with Cerebral Palsy (CP) in Low- and Middle-Income Countries (LMIC): Findings from the Global LMIC CP Register

Background: We assessed the rehabilitation status and predictors of rehabilitation service utilisation among children with cerebral palsy (CP) in selected low- and middle-income countries (LMICs). Methods: Data from the Global LMIC CP Register (GLM-CPR), a multi-country register of children with CP aged <18 years in selected countries, were used. Descriptive and inferential statistics (e.g., adjusted odds ratios) were reported. Results: Between January 2015 and December 2019, 3441 children were registered from Bangladesh (n = 2852), Indonesia (n = 130), Nepal (n = 182), and Ghana (n = 277). The proportion of children who never received rehabilitation was 49.8% (n = 1411) in Bangladesh, 45.8% (n = 82) in Nepal, 66.2% (n = 86) in Indonesia, and 26.7% (n = 74) in Ghana. The mean (Standard Deviation) age of commencing rehabilitation services was relatively delayed in Nepal (3.9 (3.1) year). Lack of awareness was the most frequently reported reason for not receiving rehabilitation in all four countries. Common predictors of not receiving rehabilitation were older age at assessment (i.e., age of children at the time of the data collection), low parental education and family income, mild functional limitation, and associated impairments (i.e., hearing and/or intellectual impairments). Additionally, gender of the children significantly influenced rehabilitation service utilisation in Bangladesh. Conclusions: Child’s age, functional limitation and associated impairments, and parental education and economic status influenced the rehabilitation utilisation among children with CP in LMICs. Policymakers and service providers could use these findings to increase access to rehabilitation and improve equity in rehabilitation service utilisation for better functional outcome of children with CP

Medical and Nursing Students’ Perception and Experience of Virtual Classrooms during the COVID-19 Pandemic in Nepal

Background: On March 9, 2020, the government of Nepal declared suspension of all academic activities in line with a nationwide lockdown following the COVID-19 outbreak. To keep pace with the academic calendar, medical universities resumed their teaching and learning activities through virtual means on account of nonfeasibility of holding physical classes. The present study sought to identify the perception and experiences of undergraduate medical and nursing students regarding the virtual classrooms.
Methods: We adopted a sequential explanatory mixed method design whereby data were collected in two phases. Quantitative data were gathered from a survey (n=737) and qualitative data from focused group discussion (n=14). The participants were recruited using a non-probability Peer Esteem Snowballing technique. Quantitative data were analyzed using descriptive and inferential statistics, whereas qualitative data was examined using a narrative thematic analytic approach.
Results: Mean age of participants was 22±2.01 with (81%) female participation. The quantitative findings revealed that the “synchrony” domain had the highest mean score (4.10±0.47) and “course interaction” had the lowest mean score (2.93±0.81) amongst the four domains. The domains were significantly correlated to each other (P=0.01) and (P=0.05). Results from focus group discussion indicated that interactions were lower in the virtual classes and there was a great variation between the learners’ perception and their experiences of virtual classrooms. Students preferred blended classes to be implemented in future sessions.
Conclusion: In spite of various challenges, the students perceived the transition from traditional to virtual classrooms in a positive and enthusiastic way. An effective virtual learning experience requires a modified instructional approach on the part of educators and a consistent attitude from learners.

Epidemiologic Pattern of Cancer in Kathmandu Valley, Nepal: Findings of Population-Based Cancer Registry, 2018

PURPOSE
Although cancer is an important and growing public health issue in Nepal, the country lacked any population-based cancer registry (PBCR) until 2018. In this study, we describe the establishment of the PBCR for the first time in Nepal and use the registry data to understand incidence, mortality, and patterns of cancer in the Kathmandu Valley (consisting of Kathmandu, Lalitpur, and Bhaktapur districts), which comprises 10.5% of the estimated 29 million population of Nepal in 2018.

MATERIALS AND METHODS
The PBCR collects information from facilities and communities through the active process. The facilities include cancer or general hospitals, pathology laboratories, hospice, and Ayurvedic centers. In the communities, the field enumerators or female community health volunteers collected the data from the households. In addition, the Social Security and Nursing Division under the Department of Health Services, which provides subsidy for cancer treatment of underprivileged patients, was another major source of data. The collected data were verified for residence, accuracy, and completeness and then entered and analyzed using CanReg5 software.

RESULTS
In the Kathmandu Valley, the PBCR registered 2,156 new cancer cases with overall age-adjusted incidence rate for all cancers of 95.7 per 100,000 population (95.3 for males and 98.1 for females). The age-adjusted mortality rate for males was 36.3 (n = 365) and for females 27.0 (n = 305) per 100,000 population. We found that the commonest cancers in males were lung and stomach, whereas in females, they were breast and lung cancer. Gallbladder cancer was among the top five common cancers in both sex.

CONCLUSION
These findings provide a milestone to understand the cancer burden in the country for the first time using the PBCR and will be helpful to develop and prioritize cancer control strategies.