Determinants affecting utilisation of health services and treatment for children under-5 in rural Nepali health centres: a cross-sectional study.

BACKGROUND: Large inequalities in child health remain in Nepal, with caste, ethnicity and sex being major determinants of deprivation and negative outcomes. The purpose of this study was to explore whether key demographics of under 5s were associated with health seeking behaviours, utilisation of health care, and treatment received. METHODS: Data came from Integrated Management of Neonatal & Childhood Illness (IMNCI) records of 23 health centres across five districts. After digitising the paper records, the data was analysed by district, caste/ethnicity, sex, and age to investigate differences in the time taken to present at a health facility after the onset of symptoms of ARI, diarrhoea and fever; accuracy of diagnosis for pneumonia; and whether the correct treatment was prescribed for pneumonia as per IMNCI guidelines. RESULTS: From 116 register books spanning 23 health centres, 30,730 child patient records were considered for analysis. The median age of attendance was 18 months (Inter-Quartile Range = 10, 32), while were more male children that attended (55.7% vs. 44.3% for females). There were statistically significant differences for the time taken to attend a health centre between different districts for ARI, diarrhoea and fever, with children in the remote Humla and Mugu districts taking significantly longer to present at a health facility after the onset of symptoms (all p < 0.001, except Mugu for ARI days). Children from underprivileged ethnic groups, Madhesi and Dalit, were less likely to be given a correct diagnosis of pneumonia (p = 0.014), while males were more likely to receive a correct diagnosis than females (73% vs. 67%, p = 0.001). This sex difference remained in the adjusted regression models for diagnosis of pneumonia (p < 0.001) but not for treatment of pneumonia (p = 0.628). All districts, in comparison to Gorkha, had increased odds of correct diagnosis and treatment of pneumonia, but only significant in children from Mugu after adjustment (p ≤ 0.001). CONCLUSION: Significant demographic differences were found based on ethnicity, sex, and district when examining health seeking behaviours for ARI, diarrhoea, and fever. Significant associations were seen for these same factors when exploring accuracy of diagnoses of pneumonia, but not for treatment. This study has emphasised the importance of a digitalised healthcare system, where inequalities can be identified without the reliance on anecdotal evidence.

Dalit's livelihoods in Nepal: income sources and determinants.

This paper focuses on the lack of income opportunities for Dalits in Nepal, as they are the most affected group in any disaster. The presence of vulnerable family members in Dalit households may further increase their income deprivation. We therefore studied Dalit households' income sources and identified income determinants in Gandaki Rural Municipality in Gorkha District-the epicentre of the 2015 earthquake. We observed a higher dependency of Dalit households on daily wages, livestock sales, social security allowances, and vegetables sales; however, remittance and seasonal job earnings represented the largest share of household incomes. We observed a significant difference in per capita income between farm (US$46) and non-farm (US$273) income sources, with the difference smallest in the lowest income quantile and the largest in the highest quantile. When the household head was a single woman, we observed a reduction in non-farm (by 29%) and total incomes (by 23%). Likewise, when the household head had a chronic health problem, or the household included an elderly family member, there was a reduction in the household's income. We suggest economic interventions for Dalit households to prevent increased social exclusion in the development process, specifically focusing on vulnerable individuals and households in the lowest income quantile.

Groundwater implications on methane emission from non-sewered sanitation systems in Nepal.

Non-sewered sanitation systems (NSSS) are identified as significant contributors of greenhouse gases (GHGs), primarily due to biological processes occurring within the containment systems. In unsealed or unlined containment systems like pit latrines, the emissions are influenced by moisture. This work quantified the GHG emission from unlined or unsealed containments prevalent in Nepal and compared it with sealed containment-like septic tanks, where the chances of groundwater (GW) inundation are low. The modeled GW data extracted from the secondary sources were validated with available national data. The emissions were quantified using the Intergovernmental Panel for Climate Change (IPCC) model for different ecological and provincial divisions of Nepal. Spatial representation for the results was done using the Geographical Information System (GIS) tool. The total methane (CH4) emission occurring from the various NSSS was determined to be 2618 Gg CO2 e per year which is almost twice the emission from the waste sector in 2011, as reported by the recent national communication submitted to the United Nations Framework Convention on Climate Change (UNFCC). Variation of the CH4 emission was found to be prominent in lowlands (Terai region) with total national emissions of 1329.37 Gg CO2e per year. The lowland has a shallow GW table that can easily inundate the unlined containments like pit latrines thus contributing to more anaerobic conditions which may lead to higher CH4 emissions compared to containments in mid and highlands. This study concludes that the GHG emissions occurring from NSSS are substantial and addressing these emissions can help fulfil the Nationally Determined Contributions (NDCs) in the waste sector.

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.

Field-based methods for measuring greenhouse gases emissions from on-site sanitation systems: A systematic review of published literature.

On-site sanitation systems (OSS) are a source of greenhouse gas (GHG) emissions. Although efforts have been made recently to measure and quantify emissions from septic tanks using various field-based methods, the vast majority of published literature reporting GHG emissions from OSS units (e.g., pits and tanks) is based on non-empirical evidence. This systematic review presents an overview and limitations of field-based methods used for the quantification of GHG emissions from OSS. Papers published in English were searched in three databases: Google Scholar, PubMed, and Directory of Articles and Journals. Peer-reviewed papers that reported field-based methods applied to containment units in OSS were included in this study. Only eight out of 2085 papers met the inclusion criteria with septic tanks as the sole technology reported and were thus, considered for the review. Most of the studies have been conducted in middle- and high-income countries. Field-based measurements of GHGs are conducted using a flux chamber (FC) and the most commonly used FC methods are (a) the modified simple static FC, (b) automated static FC, and (c) floating FC. Data reported in published studies do not provide sufficient information on the calibration and validation of the results from the FCs used. The complex FC designs, laborious fieldwork operations, and reliance on expensive, specialist equipment, suggest that such methods may not be suitable in Low and Middle-Income countries (LMICs), where resources and access to laboratory facilities are limited. Also, the complexity of pits and tank typology in LMICs (i.e., unstandardised designs and sizes) may be a challenge to the use of FCs with fixed dimensions and set operational conditions. The variation in the quantification methods and resulting emission rates among the studies indicates that gaps prevail in the use of existing methods. Therefore, there is still a need for a simple field-based, easily adaptable FC method with adequate calibration and validation that can help in reliably quantifying the emissions from different OSS in any LMICs.

Infrastructure alone cannot ensure resilience to weather events in drinking water supplies.

Climate resilient water supplies are those that provide access to drinking water that is sustained through seasons and through extreme events, and where good water quality is also sustained. While surface and groundwater quality are widely understood to vary with rainfall, there is a gap in the evidence on the impact of weather and extremes in rainfall and temperature on drinking water quality, and the role of changes in water system management. A three-country (Bangladesh, Nepal and Tanzania) observational field study tracked 2353 households clustered around 685 water sources across seven different geographies over 14 months. Water quality (E. coli) data was modelled using GEE to account for clustering effects and repeated measures at households. All types of infrastructure were vulnerable to changes in weather, with differences varying between geographies; protected boreholes provided the greatest protection at the point of collection (PoC). Water quality at the point of use (PoU) was vulnerable to changes in weather, through changes in PoC water quality as well as changes in management behaviours, such as safe storage, treatment and cleaning. This is the first study to demonstrate the impact of rainfall and temperature extremes on water quality at the PoC, and the role that weather has on PoU water quality via management behaviours. Climate resilience for water supplies needs to consider the infrastructure as well as the management decisions that are taking place at a community and household level.