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.

The unmet needs for modern family planning methods among postpartum women in Sub-Saharan Africa: a systematic review of the literature.

BACKGROUND: Sub-Saharan Africa has the highest fertility rate in the world, with the highest unmet need for family planning (FP). Yet, there is a lack of knowledge about the determinants for non-utilisation of modern contraceptive methods among women of reproductive age. This systematic review of literature assessed factors affecting the unmet need and reasons for non-utilisation of modern contraceptive methods during the postpartum period in Sub-Saharan African women. METHODS: An online literature search was conducted in several databases: MEDLINE, Cochrane Review, PubMed, Elsevier's Science Direct and Web of Science. The search was completed by hand searching. Data were extracted and summarised using the Arksey and O'Malley methodology. RESULTS: In total, 19 studies were included; one qualitative study, seventeen quantitative, and one used a mixed-methods approach. Studies were conducted in Ethiopia (n = 11), Nigeria (n = 3), Kenya (n = 2), Malawi (n = 2) and Uganda (n = 1). Factors affecting the unmet need for modern contraceptive methods were described at three levels: (a) individual; (b) household; and (c) healthcare facility level. Reasons for non-use of FP included: fear of side effects; husband's disapproval; the absence of menses; abstinence; and low perception of risk of pregnancy. CONCLUSION: Unmet needs in postpartum FP in women from Sub-Saharan Africa were associated with health-system and socio-demographic determinants. We suggest that there is a need to improve the awareness of modern contraceptive methods through effective interventions. Further research is needed for under-studied countries in this continent.

Accessing health services in India: experiences of seasonal migrants returning to Nepal.

BACKGROUND: Migration to India is a common livelihood strategy for poor people in remote Western Nepal. To date, little research has explored the degree and nature of healthcare access among Nepali migrant workers in India. This study explores the experiences of returnee Nepali migrants with regard to accessing healthcare and the perspectives of stakeholders in the government, support organizations, and health providers working with migrant workers in India. METHODS: Six focus group discussions (FGDs) and 12 in-depth interviews with returnee migrants were conducted by trained moderators in six districts in Western Nepal in late 2017. A further 12 stakeholders working in the health and education sector were also interviewed. With the consent of the participants, FGDs and interviews were audio-recorded. They were then transcribed and translated into English and the data were analysed thematically. RESULTS: The interviewed returnee migrants worked in 15 of India's 29 states, most as daily-wage labourers. Most were from among the lowest castes so called-Dalits. Most migrants had had difficulty accessing healthcare services in India. The major barriers to access were the lack of insurance, low wages, not having an Indian identification card tied to individual biometrics so called: Aadhaar card. Other barriers were unsupportive employers, discrimination at healthcare facilities and limited information about the locations of healthcare services. CONCLUSIONS: Nepali migrants experience difficulties in accessing healthcare in India. Partnerships between the Nepali and Indian governments, migrant support organizations and relevant stakeholders such as healthcare providers, government agencies and employers should be strengthened so that this vulnerable population can access the healthcare they are entitled to.

The Impact of Spousal Migration on the Mental Health of Nepali Women: A Cross-Sectional Study.

Spousal separation, lack of companionship, and increased household responsibilities may trigger mental health problems in left-behind female spouses of migrant workers. This study aimed to examine mental ill-health risk in the left-behind female spouses of international migrant workers in Nepal. A cross-sectional survey was carried out in the Nawalparasi district. Study areas were purposively chosen; however, participants were randomly selected. Nepali versions of the 12-item General Health Questionnaire (GHQ), Beck Depression Inventory (BDI), and Connor-Davidson Resilience Scale (CD-RISC) were used. Mental ill-health risk was prevalent in 3.1% of the participants as determined by GHQ. BDI identified mild or moderate depression in 6.5% of the participants with no one having severe depression. In bivariate analysis, a high frequency of communication with the husband was associated with lower mental ill-health risk and depression, as well as increasing resilience. Reduced return intervals of husbands and a high frequency of remittance were also associated with a low GHQ score. In a multiple regression model, adjusting for potential confounding variables, participants who communicated with their husbands at least once a day had a greater mean CD-RISC score (i.e., high resilience against mental ill-health risk) compared to those who did so at least once a week; a mean difference of 3.6 (95% CI 0.4 to 6.9), P = 0.03. To conclude, a low mental ill-health risk was found in the female spouses of migrants.

Nepali Migrant Workers and the Need for Pre-departure Training on Mental Health: A Qualitative Study.

Every year around 1000 Nepali migrant workers die abroad. Every one in three females and one in ten males commit suicide, reflecting a high mental health risk among Nepali migrant workers. This study aims to identify triggers of mental ill-health among Nepali migrant workers and their perceptions on the need of mental health components in the pre-departure orientation programme. We conducted five focus group discussions (FGD) and seven in-depth interviews with Nepali migrant workers and eight semi-structured interviews with stakeholders working for migrants. Participants were invited at Kathmandu's international airport on return from abroad, at hotels or bus stations near the airport, through organisations working for migrants, and participants' network. All FGD and interviews were conducted in Kathmandu and audio recorded, transcribed and translated into English. Data were analyzed thematically. High expectations from families back home, an unfair treatment at work, poor arrangements of accommodation, loneliness and poor social life abroad were frequently reported factors for poor mental health. Access to mental health services abroad by Nepali migrant was also poor. We found little on mental health in the pre-departure orientation. We need to improve our knowledge of mental health risks to provide better, more focused and more up-to-date pre-departure training to new migrant workers leaving Nepal.

Sudden cardiac death and kidney health related problems among Nepali migrant workers in Malaysia.

This paper reports on a consultation meeting that discussed two emerging health issues of Nepali migrant workers in Malaysia and the ways they can be addressed. Primarily, it focused on the issue of sudden cardiac deaths of Nepali migrant workers in Malaysia. This issue has been raised internationally by both scientific and media in the recent years. Secondly, it discussed kidney health related problem among Nepali migrant workers which has caught the attention of Nepali media recently. The meeting was organized in Kuala Lumpur, Malaysia on 19th April, 2019 where twenty people including health researchers, representatives of migrant related national and international organizations, and Nepali migrant workers participated. The meeting concluded that three types of data collection are needed: (1) good record of deaths, if at possible proper post-mortems; (2) a verbal autopsy tool to help identify underlying causes ; and qualitative research into kidney related problems.

Hormone use among Nepali transgender women: a qualitative study.

OBJECTIVES: There is a dearth of information on transgender individuals in Nepal, particularly studies exploring their use of hormone therapies. The objectives of this study therefore were to explore (1) how hormones are used, (2) types of hormones used and (3) side effects experienced by transgender women after hormone use. This is the first study of its kind in Nepal addressing this important public health issue. SETTING: The study was conducted in four districts of Nepal: Kathmandu, Sunsai, Banke and Kaski. DESIGN AND PARTICIPANTS: This qualitative study comprises eight focus group discussions (FGDs) and nine interviews. FGDs and three face-to-face interviews were held with transgender women aged 18 years and older and six interviews with stakeholders working with and advocating on behalf of this population. The study was conducted between September 2016 and March 2017. RESULTS: Our participants were young. The majority of FGD participants had completed school-level education and 40% had been using hormones for 1 to 3 years. Five overlapping themes were identified: (1) reasons and motivations for hormone use; (2) accessibility and use of hormones; (3) side effects; (4) utilisation of healthcare services and (5) discontinuation of hormone use. CONCLUSION: Hormone use was common in our sample. Most received information on hormone therapy online and through their peer networks. A few study participants sought doctors' prescriptions for hormone therapy, but hormones were more likely to be bought from local private pharmacies or abroad through friends. This kind of self-medication is associated with a range of risks to the physical and mental health of transgender individuals. Incorporating information, education and communication about hormone therapy into existing health promotion interventions targeted to this population may help transgender people to make better informed choices.

The Health of Nepali Migrants in India: A Qualitative Study of Lifestyles and Risks.

:Background: Most health research on Nepali migrant workers in India is on sexual health, whilst work, lifestyle and health care access issues are under-researched. Methods: The qualitative study was carried out in two cities of Maharashtra State in 2017. Twelve focus group discussions (FGDs) and five in-depth interviews were conducted with Nepali male and female migrant workers. Similarly, eight interviews were conducted with stakeholders, mostly representatives of organisations working for Nepali migrants in India using social capital as a theoretical foundation. Results: Five main themes emerged from the analysis: (i) accommodation; (ii) lifestyle, networking and risk-taking behaviours; (iii) work environment; (iv) support from local organisations; and (v) health service utilisation. Lack of basic amenities in accommodation, work-related hazards such as lack of safety measures at work or safety training, reluctance of employers to organise treatment for work-related accidents, occupational health issues such as long working hours, high workload, no/limited free time, discrimination by co-workers were identified as key problems. Nepali migrants have limited access to health care facilities due to their inability to prove their identity. Health system of India also discriminates as some treatment is restricted to Indian nationals. The strength of this study is the depth it offers, its limitations includes a lack of generalizability, the latter is a generic issue in such qualitative research. Conclusion: This study suggests risks to Nepali migrant workers' health in India range from accommodation to workplace and from their own precarious lifestyle habit to limited access to health care facilities. We must conduct a quantitative study on a larger population to establish the prevalence of the above mentioned issues and risks. Furthermore, the effectiveness of Nepali migrant support organisations in mitigating these risks needs to be researched.

Adolescents left behind by migrant workers: a call for community-based mental health interventions in Nepal.

Over the past two decades, the unique health needs associated with the second decade of life have been recognized, not least the mental health of adolescents. In parallel, the negative health impacts of parental migration on the children and adolescents who are "left behind" in low- and middle-income countries (LMICs) is beginning to be acknowledged. Nepal is a growing supplier of labour migrants - an estimated 3.5 million Nepali individuals are working abroad - resulting in families being separated and thousands of adolescents being left behind. This can increase psychological and emotional stress and feelings of loneliness and abandonment, and reduce self-esteem among left-behind adolescents, which in turn may have a negative impact on their psychosocial health. Globally, mental health and neurodevelopmental disorders are one of the top three causes of disability-adjusted life-years lost among adolescents. The devastating earthquake in Nepal in 2015 brought into sharp focus the lack of prioritization of mental health services and spurred development of the Community mental health care package Nepal, 2074 in 2017. This package, together with the upcoming revised National Mental Health Policy, emphasizes the need to (i) ensure the availability and accessibility of basic mental health and psychosocial support services for all; and (ii) facilitate integration of mental health services into the primary health-care system. Recognizing that mental health and psychosocial support services have been predominantly focused on the adult population only, the package includes a component on childhood and adolescent mental and behavioural disorders. It will be essential for policy-makers to ensure that strategies are in place to ensure that left-behind adolescents, especially those who are not in school, have access to these community-based services. Given the paucity of research on mental health interventions among adolescents in LMICs in general, monitoring and assessment of what works for this special group of young people in Nepal may have broader implications for implementation in other countries where migration has resulted in significant populations of left-behind adolescents.

Identifying the gaps in Nepalese migrant workers' health and well-being: a review of the literature.

BACKGROUND: The health and well-being of migrant workers from low-income countries is often neglected in travel medicine. This article uses Nepal as a case study to highlight key issues affecting this particular group of international travellers. METHODS: This narrative review used a comprehensive systematic literature search to identify relevant studies on Nepal. The included articles were thematically analysed leading to four key themes or risk factors. RESULTS: The search found 18 articles from which we identified 3 key themes related directly to migrant workers: (1) sexual risk taking; (2) occupational health and (3) lifestyles, and a fourth theme related to partners and family of migrant workers who are left behind in Nepal. Of the 18 included articles, 11 articles discussed sexual risk taking and HIV, whilst considerably fewer focused on work-related risk factors and lifestyle factors in migrant workers. CONCLUSIONS: Migrant workers who are generally healthy appear to be similar to tourist travellers in regarding sexual health as a key issue related to being abroad. Risky sexual behaviour increases in individuals separated from their usual sexual partners, away from their own communities and families, leading to the so-called 'situational disinhibition'. Considering the recent media coverage of deaths and injuries among migrant workers in the Middle East, it is interesting to see that their sexual health is more prevalent in the research literature. This article argues that travel medicine should provide more emphasis to the health and well-being of migrant workers as a highly vulnerable group of travellers with additional impact on the health of those left behind.

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.

Injury and Mortality in Young Nepalese Migrant Workers: A Call for Public Health Action.

Approximately 3.5 million Nepalese are working as migrant workers in the Gulf countries, Malaysia, and India. Every year there are more than 1000 deaths and many hundreds cases of injuries among Nepalese workers in these countries excluding India. A postmortem examination of migrant workers is not carried out in most of these countries, and those with work-related injuries are often sent back to home. Uninsured migrant workers also do not have easy access to health care services in host countries due to the high medical and hospital fees. Greater efforts are needed to protect the health and well-being, labor rights, and human rights of migrant workers from Nepal and other South-Asian nations. There is a need to enforce universal labor laws in these countries and to develop accurate records of mortality and morbidity and their causes.

Guide to the design and application of online questionnaire surveys.

Collecting research data through traditional approaches (face-to-face, postal or telephone survey) can be costly and time consuming. The emerging data collection approach based on internet/e-based technologies (e.g. online platforms and email), is a relatively cost effective survey alternative. These novel data collection strategies can collect large amounts of data from participants in a short time frame. Similarly, they also seem to be feasible and effective in collecting data on sensitive issues or with samples they are generally hard to reach, for example, men who have sex with men (MSM) or migrants. As a significant proportion of the population currently in the world are digitally connected, the shift from postal (paper-pencil) or telephone towards online survey use in research is in the interests of researchers in academia as well as in the commercial world. However, compared to designing and executing paper version of the questionnaire, there is limited literature to help a starting researcher with the design and a use of online questionnaires. This short paper highlights issues around: a) methodological aspect of online questionnaire survey; b) online survey planning and management; and c) ethical concerns that may arise while using this option. We believe that this paper will be useful for researchers who want to gain knowledge or apply this approach in their research.

Importance of Health and Social Care Research into Gender and Sexual Minority Populations in Nepal.

Despite progressive legislative developments and increased visibility of sexual and gender minority populations in the general population, mass media often report that this population face a wide range of discrimination and inequalities. LGBT (lesbian, gay, and bisexual, and transgender) populations have not been considered as priority research populations in Nepal. Research in other geographical settings has shown an increased risk of poor mental health, violence, and suicide and higher rates of smoking, as well as alcohol and drugs use among LGBT populations. They are also risk for lifestyle-related illness such as cancer, diabetes, and heart diseases. Currently, in Nepal, there is a lack of understanding of health and well-being, social exclusion, stigma, and discrimination as experienced by these populations. Good-quality public health research can help design and implement targeted interventions to the sexual and gender minority populations of Nepal.

Women's autonomy in household decision-making: a demographic study in Nepal.

BACKGROUND: How socio-demographic factors influence women's autonomy in decision making on health care including purchasing goods and visiting family and relatives are very poorly studied in Nepal. This study aims to explore the links between women's household position and their autonomy in decision making. METHODS: We used Nepal Demographic Health Survey (NDHS) 2006, which provided data on ever married women aged 15-49 years (n = 8257). The data consists of women's four types of household decision making; own health care, making major household purchases, making purchase for daily household needs and visits to her family or relatives. A number of socio-demographic variables were used in multivariable logistic regression to examine the relationship of these variables to all four types of decision making. RESULTS: Women's autonomy in decision making is positively associated with their age, employment and number of living children. Women from rural area and Terai region have less autonomy in decision making in all four types of outcome measure. There is a mixed variation in women's autonomy in the development region across all outcome measures. Western women are more likely to make decision in own health care (1.2-1.6), while they are less likely to purchase daily household needs (0.6-0.9). Women's increased education is positively associated with autonomy in own health care decision making (p < 0.01), however their more schooling (SLC and above) shows non-significance with other outcome measures. Interestingly, rich women are less likely to have autonomy to make decision in own healthcare. CONCLUSIONS: Women from rural area and Terai region needs specific empowerment programme to enable them to be more autonomous in the household decision making. Women's autonomy by education, wealth quintile and development region needs a further social science investigation to observe the variations within each stratum. A more comprehensive strategy can enable women to access community resources, to challenge traditional norms and to access economic resources. This will lead the women to be more autonomous in decision making in the due course.