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.

Neonatal lupus erythematosus manifested as a complete heart block: A case report.

Key Clinical Message: Fetal bradycardia and congenital complete heart block could be the presentation of neonatal lupus. A high index of suspicion of this condition helps to identify an asymptomatic mother. Abstract: Neonatal lupus erythematosus (NLE) is a rare acquired autoimmune disease of newborns due to placental transfer of Ro/SSA or La/SSB autoantibodies. Though cardiac, cutaneous, hematological, and hepatobiliary abnormalities are detected, cardiac defects cause significant morbidity and mortality. We report a case of complete congenital heart block due to NLE.

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.

Refractory Cardiogenic Shock Secondary to Acute Myocarditis in a Child with Multisystem Inflammatory Syndrome Associated with COVID-19: A Case Report.

Children with Coronavirus disease 2019 infection usually have mild symptoms but rarely may present with a life-threatening condition called a multisystem inflammatory syndrome. We report a case of COVID-19-related multisystem inflammatory syndrome in an 8-year-old boy who presented with cardiogenic shock due to acute myocarditis with no features of Kawasaki disease. Cardiogenic shock was refractory to fluids and inotropes. Later, this case was successfully managed with hydrocortisone and intravenous immunoglobulin. Therefore, this case report highlights keeping a lookout for such atypical presentations and early referral to a higher center for timely intervention and aggressive therapy specifically directed against the underlying inflammatory process to ameliorate the outcomes. Keywords: cardiogenic shock; COVID-19; kawasaki disease; myocarditis; Nepal.

Assessment of hospitalization costs and its determinants in infants with clinical severe infection at a public tertiary hospital in Nepal.

Sepsis, an important and preventable cause of death in the newborn, is associated with high out of pocket hospitalization costs for the parents/guardians. The government of Nepal's Free Newborn Care (FNC) service that covers hospitalization costs has set a maximum limit of Nepalese rupees (NPR) 8000 i.e. USD 73.5, the basis of which is unclear. We aimed to estimate the costs of treatment in neonates and young infants fulfilling clinical criteria for sepsis, defined as clinical severe infection (CSI) to identify determinants of increased cost. This study assessed costs for treatment of 206 infants 3-59 days old, enrolled in a clinical trial, and admitted to the Kanti Children's Hospital in Nepal through June 2017 to December 2018. Total costs were derived as the sum of direct costs for bed charges, investigations, and medicines and indirect costs calculated by using work time loss of parents. We estimated treatment costs for CSI, the proportion exceeding NPR 8000 and performed multivariable linear regression to identify determinants of high cost. Of the 206 infants, 138 (67%) were neonates (3-28 days). The median (IQR) direct costs for treatment of CSI in neonates and young infants (29-59 days) were USD 111.7 (69.8-155.5) and 65.17 (43.4-98.5) respectively. The direct costs exceeded NPR 8000 (USD 73.5) in 69% of neonates with CSI. Age <29 days, moderate malnutrition, presence of any sign of critical illness and documented treatment failure were found to be important determinants of high costs for treatment of CSI. According to this study, the average treatment cost for a newborn with CSI in a public tertiary level hospital is substantial. The maximum limit offered for free newborn care in public hospitals needs to be revised for better acceptance and successful implementation of the FNC service to avert catastrophic health expenditures in developing countries like Nepal. Trial Registration: CTRI/2017/02/007966 (Registered on: 27/02/2017).

Zinc as an adjunct treatment for reducing case fatality due to clinical severe infection in young infants: study protocol for a randomized controlled trial.

BACKGROUND: An estimated 2.7 of the 5.9 million deaths in children under 5 years of age occur in the neonatal period. Severe infections contribute to almost a quarter of these deaths. Mortality due to severe infections in developing country settings is substantial despite antibiotic therapy. Effective interventions that can be added to standard therapy for severe infections are required to reduce case fatality. METHODS/DESIGN: This is a double-blind randomized placebo-controlled parallel group superiority trial to investigate the effect of zinc administered orally as an adjunct to standard therapy to infants aged 3 days up to 2 months (59 days) hospitalized with clinical severe infection, that will be undertaken in seven hospitals in Delhi, India and Kathmandu, Nepal. In a 1:1 ratio, we will randomly assign young infants to receive 10 mg of elemental zinc or placebo orally in addition to the standard therapy for a total of 14 days. The primary outcomes hospital case fatality, which is death due to any cause and at any time after enrolment while hospitalized for the illness episode, and extended case fatality, which encompasses the period until 12 weeks after enrolment. DISCUSSION: A previous study showed a beneficial effect of zinc in reducing the risk of treatment failure, as well as a non-significant effect on case fatality. This study was not powered to detect an effect on case fatality, which this current study is. If the results are consistent with this earlier trial, we would have provided strong evidence for recommending zinc as an adjunct to standard therapy for clinical severe infection in young infants. TRIAL REGISTRATION: Universal Trial Number: U1111-1187-6479, Clinical Trials Registry - India: CTRI/2017/02/007966 : Registered on February 27, 2017.

Nebulised hypertonic saline (3%) among children with mild to moderately severe bronchiolitis--a double blind randomized controlled trial.

BACKGROUND: To Assess the efficacy of nebulised hypertonic saline (HS) (3%) among children with mild to moderately severe bronchiolitis. METHODS: Infants aged 6 weeks to 24 months, with a first episode of wheezing and Clinical Severity scores (Arch Dis Child 67:289-93, 1992) between 1 and 8, were enrolled over 4 months duration. Those with severe disease, co-morbidities, prior wheezing, recent bronchodilator and steroid use were excluded. Patients were randomized in a double-blind fashion, to receive two doses of nebulized 3% HS (Group 1) or 0.9% normal saline (Group 2) with 1.5 mg of L-Epineprine, delivered 30 min apart. Parents were contacted at 24 h and 7 days. The principal outcome measure was the mean change in clinical severity score at the end of 2 h of observation. RESULTS: A total of 100 infants (mean age 9.6 months, range 2-23 months; 61 % males) were enrolled. Patients in both groups had mild to moderately severe disease at presentation. On an intention-to-treat basis, the infants in the HS group had a significant reduction (3.57 ± 1.41) in the mean clinical severity score compared to those in the NS group (2.26 ± 1.15); [p < 0.001; CI: 0.78-1.82]. More children in the HS group (n = 35/50; 70.0%) were eligible for ER/OPD discharge at the end of 2 h than those in the NS group (n = 15/50; 30%; p < 0.001), and less likely to need a hospital re-visit (n = 5/50; 10.0%) in the next 24 h as compared to the NS group (n = 15/50, 30.0%; p < 0.001). The treatment was well tolerated, with no adverse effects. CONCLUSIONS: Nebulized 3% HS is effective, safe and superior to normal saline for outpatient management of infants with mild to moderately severe viral bronchiolitis in improving Clinical Severity Scores, facilitating early Out-Patient Department discharge and preventing hospital re-visits and admissions in the 24 h of presentation. TRIAL REGISTRATION: Clinicaltrials.gov NCTID012766821. Registered on January 12, 2011.