Perinatal depression and its associated risk factors during the COVID-19 pandemic in low- and middle-income countries: a systematic review and meta-analysis.

PURPOSE: Perinatal depression significantly impacts maternal and child health, with further complexities arising during the COVID-19 pandemic. This review is the first to comprehensively synthesize evidence on the prevalence of perinatal depression and its associated risk factors in Low- and Middle-Income Countries (LMICs) during the pandemic period. METHODS: The study protocol was registered in PROSPERO (CRD42022326991). This review followed the Joanna Briggs Institute (JBI) guideline for prevalence studies. A comprehensive literature search was conducted in six databases: PubMed, Scopus, Web of Science, PsycInfo, CINAHL, and ProQuest. Pooled prevalence estimates were computed for both prenatal and postnatal depression. Identified risk factors were summarized narratively. RESULTS: A total of 5169 studies were screened, out of which 58 were included in the narrative review and 48 [prenatal (n = 36) and postnatal (n = 17)] were included in the meta-analysis. The pooled depression prevalence for prenatal women was 23% (95% CI: 19-27%), and for the postnatal women was 23% (95% CI: 18-30%). Maternal age, education, perceived fear of COVID-19 infection, week of pregnancy, pregnancy complications, and social and family support were identified as associated risk factors for depression. CONCLUSIONS: Our review demonstrates an increased prevalence of perinatal depression during the COVID-19 pandemic in LMICs. It sheds light on the significant burden faced by pregnant and postnatal women and emphasizes the necessity for targeted interventions during the ongoing and potential future crisis.

Barriers and facilitators to informal healthcare provider engagement in the national tuberculosis elimination program of India: An exploratory study from West Bengal.

India has a high burden of Tuberculosis (TB), accounting for a significant portion of global cases. While efforts are being made to engage the formal private sector in the National TB Elimination Program (NTEP) of India, there remains a significant gap in addressing the engagement of Informal Healthcare Providers (IPs), who serve as the first point of contact for healthcare in many communities. Recognizing the increasing evidence of IPs' importance in TB care, it is crucial to enhance their engagement in the NTEP. Therefore, this study explored various factors influencing the engagement of IPs in the program. A qualitative study was conducted in West Bengal, India, involving 23 IPs and 11 Formal Providers (FPs) from different levels of the formal health system. Thematic analysis of the data was conducted following a six-step approach outlined by Braun and Clarke. Three overarching themes were identified in the analysis, encompassing barriers and facilitators to IPs' engagement in the NTEP. The first theme focused on IPs' position and capacity as care providers, highlighting their role as primary care providers and the trust and acceptance extended by the community. The second theme explored policy and system-level drivers and prohibitors, revealing barriers such as role ambiguity, competing tasks, and quality of care issues. Facilitators such as growing recognition of IPs' importance in the health system, an inclusive incentive system, and willingness to collaborate were also identified. The third theme focused on the relationship between the formal and informal systems, highlighting a need to strengthen the relationship between the two. This study sheds light on factors influencing the engagement of IPs in the NTEP of India. It emphasizes the need for role clarity, knowledge enhancement, and improved relationships between formal and informal systems. By addressing these factors, policymakers and stakeholders can strengthen the engagement of IPs in the NTEP.

A Type II hybrid effectiveness-implementation study of an integrated CHW intervention to address maternal healthcare in rural Nepal.

Skilled care during pregnancy, childbirth, and postpartum is essential to prevent adverse maternal health outcomes, yet utilization of care remains low in many resource-limited countries, including Nepal. Community health workers (CHWs) can mitigate health system challenges and geographical barriers to achieving universal health coverage. Gaps remain, however, in understanding whether evidence-based interventions delivered by CHWs, closely aligned with WHO recommendations, are effective in Nepal's context. We conducted a type II hybrid effectiveness-implementation, mixed-methods study in two rural districts in Nepal to evaluate the effectiveness and the implementation of an evidence-based integrated maternal and child health intervention delivered by CHWs, using a mobile application. The intervention was implemented stepwise over four years (2014-2018), with 65 CHWs enrolling 30,785 families. We performed a mixed-effects Poisson regression to assess institutional birth rate (IBR) pre-and post-intervention. We used the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework to evaluate the implementation during and after the study completion. There was an average 30% increase in IBR post-intervention, adjusting for confounding variables (p<0.0001). Study enrollment showed 35% of families identified as dalit, janjati, or other castes. About 78-89% of postpartum women received at least one CHW-counseled home visit within 60 days of childbirth. Ten (53% of planned) municipalities adopted the intervention during the study period. Implementation fidelity, measured by median counseled home visits, improved with intervention time. The intervention was institutionalized beyond the study period and expanded to four additional hubs, albeit with adjustments in management and supervision. Mechanisms of intervention impact include increased knowledge, timely referrals, and longitudinal CHW interaction. Full-time, supervised, and trained CHWs delivering evidence-based integrated care appears to be effective in improving maternal healthcare in rural Nepal. This study contributes to the growing body of evidence on the role of community health workers in achieving universal health coverage.

Are informal healthcare providers knowledgeable in tuberculosis care? A cross-sectional survey using vignettes in West Bengal, India.

BACKGROUND: India accounts for one-quarter of the world's TB cases. Despite efforts to engage the private sector in India's National TB Elimination Program, informal healthcare providers (IPs), who serve as the first contact for a significant TB patients, remain grossly underutilised. However, considering the substantial evidence establishing IPs' role in patients' care pathway, it is essential to expand the evidence base regarding their knowledge in TB care. METHODS: We conducted a cross-sectional study in the Birbhum district of West Bengal, India. The data were collected using the TB vignette among 331 IPs (165 trained and 166 untrained). The correct case management was defined following India's Technical and Operational Guidelines for TB Control. RESULTS: Overall, IPs demonstrated a suboptimal level of knowledge in TB care. IPs exhibited the lowest knowledge in asking essential history questions (all four: 5.4% and at least two: 21.7%) compared with ordering sputum test (76.1%), making a correct diagnosis (83.3%) and appropriate referrals (100%). Nonetheless, a statistically significant difference in knowledge (in most domains of TB care) was observed between trained and untrained IPs. CONCLUSIONS: This study identifies gaps in IPs' knowledge in TB care. However, the observed significant difference between the trained and untrained groups indicates a positive impact of training in improving IPs' knowledge in TB care.

What are the tuberculosis care practices of informal healthcare providers? A cross-sectional study from Eastern India.

India is the highest TB burden country, accounting for an estimated 26% of the global TB cases. Systematic engagement of the private sector is a cornerstone of India's National Strategic Plan for TB Elimination (2017-25). However, informal healthcare providers (IPs), who are the first point of contact for a large number of TB patients, remain significantly underutilized in the National TB Elimination Program of India. Non-prioritization of IPs has also resulted in a limited understanding of their TB care practices in the community. We, therefore, undertook a descriptive study to document IPs' TB care practices, primarily focusing on their approach to screening, diagnosis, treatment and referral. This cross-sectional study was carried out from February to March 2020 in the Birbhum District of West Bengal, India. Interviews were conducted utilizing the retrospective case study method. A total of 203 IPs participated who reported seeing at least one confirmed TB patient in 6 months prior to the study. In that duration, IPs reported interacting with an average of five suspected TB cases, two of which were later confirmed as having TB. Antibiotic use was found to be common among IPs (highest 69% during the first visit); however, they were prescribed before the patient was suspected or confirmed as having TB. We noted the practice of prolonged treatment among IPs as patients were prescribed medicines until the second follow-up visit. Referral was the preferred TB case management approach among IPs, but delayed referral was observed, with only one-third (34%) of patients being referred to higher health facilities during their first visit. This study presents important findings on IPs' TB care practices, which have consequences for achieving India's national goal of TB elimination.

Impact of antimicrobial stewardship program on antimicrobial-resistance and prescribing in nursing homes: a systematic review and meta-analysis.

OBJECTIVES: The success of the antimicrobial stewardship program (ASP) is more often measured in antimicrobial use in the literature; however, there is limited evidence regarding antimicrobial resistance (AMR). This study aims to systematically review the impact of urinary tract infection-targeted ASP on overall AMR, antimicrobial use, and specific to fluoroquinolone (FQ) use in nursing homes (NHs). METHODS: This systematic review and meta-analysis included studies published in EMBASE, PubMed, Scopus, Medline, and Cochrane Central Register of Controlled Trials. Two reviewers independently extracted data in standard forms in "Covidence." The outcome was presented in percent change and rate ratio. Meta-analysis was done using DerSimonian and Laird random-effects model with inverse variance weighting. RESULTS: A total of 216 NHs participated in 16 included studies. Most of the ASP was educational, targeted to nurses and physicians. Four studies reported information about uropathogens resistance, 10 FQ-related, 13 antimicrobials prescribed, and 11 urine cultures. ASP had a positive impact on reducing overall and FQ-related AMR. However, fewer studies representation with varying information did not allow us to generalise. ASP performance was impressive in reducing antimicrobial prescribing (pooled rate ratio = 0.69, 95% CI 0.60-0.81, P ≤ 0.001) and urine culture rate (pooled rate ratio = 0.64, 95% CI 0.61-0.67, P ≤ 0.001) in NHs. CONCLUSION: The findings are encouraging despite the limited studies reported ASP impact on AMR. However, it takes years to see the impact of ASP on AMR. Therefore, future research should allocate a long-term follow-up and at least an outcome related to AMR to generate concrete evidence.

Role of informal healthcare providers in tuberculosis care in low- and middle-income countries: A systematic scoping review.

Achieving targets set in the End TB Strategy is still a distant goal for many Low- and Middle-Income Countries (LMICs). The importance of strengthening public-private partnership by engaging all identified providers in Tuberculosis (TB) care has long been advocated in global TB policies and strategies. However, Informal Healthcare Providers (IPs) are not yet prioritised and engaged in National Tuberculosis Programs (NTPs) globally. There exists a substantial body of evidence that confirms an important contribution of IPs in TB care. A systematic understanding of their role is necessary to ascertain their potential in improving TB care in LMICs. The purpose of this review is to scope the role of IPs in TB care. The scoping review was guided by a framework developed by the Joanna Briggs Institute. An electronic search of literature was conducted in MEDLINE, EMBASE, SCOPUS, Global Health, CINAHL, and Web of Science. Of a total 5234 records identified and retrieved, 92 full-text articles were screened, of which 13 were included in the final review. An increasing trend was observed in publication over time, with most published between 2010-2019. In 60% of the articles, NTPs were mentioned as a collaborator in the study. For detection and diagnosis, IPs were primarily involved in identifying and referring patients. Administering DOT (Directly Observed Treatment) to the patient was the major task assigned to IPs for treatment and support. There is a paucity of evidence on prevention, as only one study involved IPs to perform this role. Traditional health providers were the most commonly featured, but there was not much variation in the role by provider type. All studies reported a positive role of IPs in improving TB care outcomes. This review demonstrates that IPs can be successfully engaged in various roles in TB care with appropriate support and training. Their contribution can support countries to achieve their national and global targets if prioritized in National TB Programs.

Collaborative care model for depression in rural Nepal: a mixed-methods implementation research study.

INTRODUCTION: Despite carrying a disproportionately high burden of depression, patients in low-income countries lack access to effective care. The collaborative care model (CoCM) has robust evidence for clinical effectiveness in improving mental health outcomes. However, evidence from real-world implementation of CoCM is necessary to inform its expansion in low-resource settings. METHODS: We conducted a 2-year mixed-methods study to assess the implementation and clinical impact of CoCM using the WHO Mental Health Gap Action Programme protocols in a primary care clinic in rural Nepal. We used the Capability Opportunity Motivation-Behaviour (COM-B) implementation research framework to adapt and study the intervention. To assess implementation factors, we qualitatively studied the impact on providers' behaviour to screen, diagnose and treat mental illness. To assess clinical impact, we followed a cohort of 201 patients with moderate to severe depression and determined the proportion of patients who had a substantial clinical response (defined as ≥50% decrease from baseline scores of Patient Health Questionnaire (PHQ) to measure depression) by the end of the study period. RESULTS: Providers experienced improved capability (enhanced self-efficacy and knowledge), greater opportunity (via access to counsellors, psychiatrist, medications and diagnostic tests) and increased motivation (developing positive attitudes towards people with mental illness and seeing patients improve) to provide mental healthcare. We observed substantial clinical response in 99 (49%; 95% CI: 42% to 56%) of the 201 cohort patients, with a median seven point (Q1:-9, Q3:-2) decrease in PHQ-9 scores (p<0.0001). CONCLUSION: Using the COM-B framework, we successfully adapted and implemented CoCM in rural Nepal, and found that it enhanced providers' positive perceptions of and engagement in delivering mental healthcare. We observed clinical improvement of depression comparable to controlled trials in high-resource settings. We recommend using implementation research to adapt and evaluate CoCM in other resource-constrained settings to help expand access to high-quality mental healthcare.

Costing Analysis of a Pilot Community Health Worker Program in Rural Nepal.

Community health workers (CHWs) are essential to primary health care systems and are a cost-effective strategy to achieve the Sustainable Development Goals (SDGs). Nepal is strongly committed to universal health coverage and the SDGs. In 2017, the Nepal Ministry of Health and Population partnered with the nongovernmental organization Nyaya Health Nepal to pilot a program aligned with the 2018 World Health Organization guidelines for CHWs. The program includes CHWs who: (1) receive regular financial compensation; (2) meet a minimum education level; (3) are well supervised; (4) are continuously trained; (5) are integrated into local primary health care systems; (6) use mobile health tools; (7) have consistent supply chain; (8) live in the communities they serve; and (9) provide service without point-of-care user fees. The pilot model has previously demonstrated improved institutional birth rate, antenatal care completion, and postpartum contraception utilization. Here, we performed a retrospective costing analysis from July 16, 2017 to July 15, 2018, in a catchment area population of 60,000. The average per capita annual cost is US$3.05 (range: US$1.94 to US$4.70 across 24 villages) of which 74% is personnel cost. Service delivery and administrative costs and per beneficiary costs for all services are also described. To address the current discourse among Nepali policy makers at the local and federal levels, we also present 3 alternative implementation scenarios that policy makers may consider. Given the Government of Nepal's commitment to increase health care spending (US$51.00 per capita) to 7.0% of the 2030 gross domestic product, paired with recent health care systems decentralization leading to expanded fiscal space in municipalities, this CHW program provides a feasible opportunity to make progress toward achieving universal health coverage and the health-related SDGs. This costing analysis offers insights and practical considerations for policy makers and locally elected officials for deploying a CHW cadre as a mechanism to achieve the SDG targets.

Measuring fidelity, feasibility, costs: an implementation evaluation of a cluster-controlled trial of group antenatal care in rural Nepal.

BACKGROUND: Access to high-quality antenatal care services has been shown to be beneficial for maternal and child health. In 2016, the WHO published evidence-based recommendations for antenatal care that aim to improve utilization, quality of care, and the patient experience. Prior research in Nepal has shown that a lack of social support, birth planning, and resources are barriers to accessing services in rural communities. The success of CenteringPregnancy and participatory action women's groups suggests that group care models may both improve access to care and the quality of care delivered through women's empowerment and the creation of social networks. We present a group antenatal care model in rural Nepal, designed and implemented by the healthcare delivery organization Nyaya Health Nepal, as well as an assessment of implementation outcomes. METHODS: The study was conducted at Bayalata Hospital in Achham, Nepal, via a public private partnership between the Nepali non-profit, Nyaya Health Nepal, and the Ministry of Health and Population, with financial and technical assistance from the American non-profit, Possible. We implemented group antenatal care as a prospective non-randomized cluster-controlled, type I hybrid effectiveness-implementation study in six village clusters. The implementation approach allows for iterative improvement in design, making changes to improve the quality of the intervention. Assessments of implementation process and model fidelity were undertaken using a mobile checklist completed by nurse supervisors, and observation forms completed by program leadership. We evaluated data quarterly using descriptive statistics to identify trends. Qualitative interviews and team communications were analyzed through immersion crystallization to identify major themes that evolved during the implementation process. RESULTS: A total of 141 group antenatal sessions were run during the study period. This paper reports on implementation results, whereas we analyze and present patient-level effectiveness outcomes in a complementary paper in this journal. There was high process fidelity to the model, with 85.7% (95% CI 77.1-91.5%) of visits completing all process elements, and high content fidelity, with all village clusters meeting the minimum target frequency for 80% of topics. The annual per capita cost for group antenatal care was 0.50 USD. Qualitative analysis revealed the compromise of stable gestation-matched composition of the group members in order to make the intervention feasible. Major adaptations were made in training, documentation, feedback and logistics. CONCLUSION: Group antenatal care provided in collaboration with local government clinics has the potential to provide accessible and high quality antenatal care to women in rural Nepal. The intervention is a feasible and affordable alternative to individual antenatal care. Our experience has shown that adaptation from prior models was important for the program to be successful in the local context within the national healthcare system. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02330887, registered 01/05/2015, retroactively registered.

The power of peers: an effectiveness evaluation of a cluster-controlled trial of group antenatal care in rural Nepal.

BACKGROUND: Reducing the maternal mortality ratio to less than 70 per 100,000 live births globally is one of the Sustainable Development Goals. Approximately 830 women die from pregnancy- or childbirth-related complications every day. Almost 99% of these deaths occur in developing countries. Increasing antenatal care quality and completion, and institutional delivery are key strategies to reduce maternal mortality, however there are many implementation challenges in rural and resource-limited settings. In Nepal, 43% of deliveries do not take place in an institution and 31% of women have insufficient antenatal care. Context-specific and evidence-based strategies are needed to improve antenatal care completion and institutional birth. We present an assessment of effectiveness outcomes for an adaptation of a group antenatal care model delivered by community health workers and midwives in close collaboration with government staff in rural Nepal. METHODS: The study was conducted in Achham, Nepal, via a public private partnership between the Nepali non-profit, Nyaya Health Nepal, and the Ministry of Health and Population, with financial and technical assistance from the American non-profit, Possible. We implemented group antenatal care as a prospective non-randomized, cluster-controlled, type I hybrid effectiveness-implementation study in six village clusters. The implementation approach allowed for iterative improvement in design by making changes to improve the quality of the intervention. We evaluated effectiveness through a difference in difference analysis of institutional birth rates between groups prior to implementation of the intervention and 1 year after implementation. Additionally, we assessed the change in knowledge of key danger signs and the acceptability of the group model compared with individual visits in a nested cohort of women receiving home visit care and home visit care plus group antenatal care. Using a directed content and thematic approach, we analyzed qualitative interviews to identify major themes related to implementation. RESULTS: At baseline, there were 457 recently-delivered women in the six village clusters receiving home visit care and 214 in the seven village clusters receiving home visit care plus group antenatal care. At endline, there were 336 and 201, respectively. The difference in difference analysis did not show a significant change in institutional birth rates nor antenatal care visit completion rates between the groups. There was, however, a significant increase in both institutional birth and antenatal care completion in each group from baseline to endline. We enrolled a nested cohort of 52 participants receiving home visit care and 62 participants receiving home visit care plus group antenatal care. There was high acceptability of the group antenatal care intervention and home visit care, with no significant differences between groups. A significantly higher percentage of women who participated in group antenatal care found their visits to be 'very enjoyable' (83.9% vs 59.6%, p = 0.0056). In the nested cohort, knowledge of key danger signs during pregnancy significantly improved from baseline to endline in the intervention clusters only (2 to 31%, p < 0.001), while knowledge of key danger signs related to labor and childbirth, the postpartum period, and the newborn did not in either intervention or control groups. Qualitative analysis revealed that women found that the groups provided an opportunity for learning and discussion, and the groups were a source of social support and empowerment. They also reported an improvement in services available at their village clinic. Providers noted the importance of the community health workers in identifying pregnant women in the community and linking them to the village clinics. Challenges in birth planning were brought up by both participants and providers. CONCLUSION: While there was no significant change in institutional birth and antenatal care completion at the population level between groups, there was an increase of these outcomes in both groups. This may be secondary to the primary importance of community health worker involvement in both of these groups. Knowledge of key pregnancy danger signs was significantly improved in the home visit plus group antenatal care cohort compared with the home visit care only group. This initial study of Nyaya Health Nepal's adapted group care model demonstrates the potential for impacting women's antenatal care experience and should be studied over a longer period as an intervention embedded within a community health worker program. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02330887 , registered 01/05/2015, retroactively registered.

Designing and implementing an integrated non-communicable disease primary care intervention in rural Nepal.

Low-income and middle-income countries are struggling with a growing epidemic of non-communicable diseases. To achieve the Sustainable Development Goals, their healthcare systems need to be strengthened and redesigned. The Starfield 4Cs of primary care-first-contact access, care coordination, comprehensiveness and continuity-offer practical, high-quality design options for non-communicable disease care in low-income and middle-income countries. We describe an integrated non-communicable disease intervention in rural Nepal using the 4C principles. We present 18 months of retrospective assessment of implementation for patients with type II diabetes, hypertension and chronic obstructive pulmonary disease. We assessed feasibility using facility and community follow-up as proxy measures, and assessed effectiveness using singular 'at-goal' metrics for each condition. The median follow-up for diabetes, hypertension and chronic obstructive pulmonary disease was 6, 6 and 7 facility visits, and 10, 10 and 11 community visits, respectively (0.9 monthly patient touch-points). Loss-to-follow-up rates were 16%, 19% and 22%, respectively. The median time between visits was approximately 2 months for facility visits and 1 month for community visits. 'At-goal' status for patients with chronic obstructive pulmonary disease improved from baseline to endline (p=0.01), but not for diabetes or hypertension. This is the first integrated non-communicable disease intervention, based on the 4C principles, in Nepal. Our experience demonstrates high rates of facility and community follow-up, with comparatively low lost-to-follow-up rates. The mixed effectiveness results suggest that while this intervention may be valuable, it may not be sufficient to impact outcomes. To achieve the Sustainable Development Goals, further implementation research is urgently needed to determine how to optimise non-communicable disease interventions.

Developing and deploying a community healthcare worker-driven, digitally- enabled integrated care system for municipalities in rural Nepal.

Integrating care at the home and facility level is a critical yet neglected function of healthcare delivery systems. There are few examples in practice or in the academic literature of affordable, digitally-enabled integrated care approaches embedded within healthcare delivery systems in low- and middle-income countries. Simultaneous advances in affordable digital technologies and community healthcare workers offer an opportunity to address this challenge. We describe the development of an integrated care system involving community healthcare worker networks that utilize a home-to-facility electronic health record platform for rural municipalities in Nepal. Key aspects of our approach of relevance to a global audience include: community healthcare workers continuously engaging with populations through household visits every three months; community healthcare workers using digital tools during the routine course of clinical care; individual and population-level data generated routinely being utilized for program improvement; and being responsive to privacy, security, and human rights concerns. We discuss implementation, lessons learned, challenges, and opportunities for future directions in integrated care delivery systems.

An integrated community health worker intervention in rural Nepal: a type 2 hybrid effectiveness-implementation study protocol.

BACKGROUND: Evidence-based medicines, technologies, and protocols exist to prevent many of the annual 300,000 maternal, 2.7 million neonatal, and 9 million child deaths, but they are not being effectively implemented and utilized in rural areas. Nepal, one of South Asia's poorest countries with over 80% of its population living in rural areas, exemplifies this challenge. Community health workers are an important cadre in low-income countries where human resources for health and health care infrastructure are limited. As local women, they are uniquely positioned to understand and successfully navigate barriers to health care access. Recent case studies of large community health worker programs have highlighted the importance of training, both initial and ongoing, and accountability through structured management, salaries, and ongoing monitoring and evaluation. A gap in the evidence regarding whether such community health worker systems can change health outcomes, as well as be sustainably adopted at scale, remains. In this study, we plan to evaluate a community health worker system delivering an evidence-based integrated reproductive, maternal, newborn, and child health intervention as it is scaled up in rural Nepal. METHODS: We will conduct a type 2 hybrid effectiveness-implementation study to test both the effect of an integrated reproductive, maternal, newborn, and child health intervention and the implementation process via a professional community health worker system. The intervention integrates five evidence-based approaches: (1) home-based antenatal care and post-natal care counseling and care coordination; (2) continuous surveillance of all reproductive age women, pregnancies, and children under age 2 years via a mobile application; (3) Community-Based Integrated Management of Newborn and Childhood Illness; (4) group antenatal and postnatal care; and 5) the Balanced Counseling Strategy to post-partum contraception. We will evaluate effectiveness using a pre-post quasi-experimental design with stepped implementation and implementation using the RE-AIM framework. DISCUSSION: This is the first hybrid effectiveness-implementation study of an integrated reproductive, maternal, newborn, and child health intervention in rural Nepal that we are aware of. As Nepal takes steps towards achieving the Sustainable Development Goals, the data from this three-year study will be useful in the detailed planning of a professionalized community health worker cadre delivering evidence-based reproductive, maternal, newborn, and child health interventions to the country's rural population. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03371186 , registered 04 December 2017, retrospectively registered.

Translating mental health diagnostic and symptom terminology to train health workers and engage patients in cross-cultural, non-English speaking populations.

Although there are guidelines for transcultural adaptation and validation of psychometric tools, similar resources do not exist for translation of diagnostic and symptom terminology used by health professionals to communicate with one another, their patients, and the public. The issue of translation is particularly salient when working with underserved, non-English speaking populations in high-income countries and low- and middle-income countries. As clinicians, researchers, and educators working in cross-cultural settings, we present four recommendations to avoid common pitfalls in these settings. We demonstrate the need for: (1) harmonization of terminology among clinicians, educators of health professionals, and health policymakers; (2) distinction in terminology used among health professionals and that used for communication with patients, families, and the lay public; (3) linkage of symptom assessment with functional assessment; and (4) establishment of a culture of evaluating communication and terminology for continued improvement.

Power, potential, and pitfalls in global health academic partnerships: review and reflections on an approach in Nepal.

BACKGROUND: Global health academic partnerships are centered around a core tension: they often mirror or reproduce the very cross-national inequities they seek to alleviate. On the one hand, they risk worsening power dynamics that perpetuate health disparities; on the other, they form an essential response to the need for healthcare resources to reach marginalized populations across the globe. OBJECTIVES: This study characterizes the broader landscape of global health academic partnerships, including challenges to developing ethical, equitable, and sustainable models. It then lays out guiding principles of the specific partnership approach, and considers how lessons learned might be applied in other resource-limited settings. METHODS: The experience of a partnership between the Ministry of Health in Nepal, the non-profit healthcare provider Possible, and the Health Equity Action and Leadership Initiative at the University of California, San Francisco School of Medicine was reviewed. The quality and effectiveness of the partnership was assessed using the Tropical Health and Education Trust Principles of Partnership framework. RESULTS: Various strategies can be taken by partnerships to better align the perspectives of patients and public sector providers with those of expatriate physicians. Actions can also be taken to bring greater equity to the wealth and power gaps inherent within global health academic partnerships. CONCLUSIONS: This study provides recommendations gleaned from the analysis, with an aim towards both future refinement of the partnership and broader applications of its lessons and principles. It specifically highlights the importance of targeted engagements with academic medical centers and the need for efficient organizational work-flow practices. It considers how to both prioritize national and host institution goals, and meet the career development needs of global health clinicians.

Partnerships in mental healthcare service delivery in low-resource settings: developing an innovative network in rural Nepal.

BACKGROUND: Mental illnesses are the largest contributors to the global burden of non-communicable diseases. However, there is extremely limited access to high quality, culturally-sensitive, and contextually-appropriate mental healthcare services. This situation persists despite the availability of interventions with proven efficacy to improve patient outcomes. A partnerships network is necessary for successful program adaptation and implementation. PARTNERSHIPS NETWORK: We describe our partnerships network as a case example that addresses challenges in delivering mental healthcare and which can serve as a model for similar settings. Our perspectives are informed from integrating mental healthcare services within a rural public hospital in Nepal. Our approach includes training and supervising generalist health workers by off-site psychiatrists. This is made possible by complementing the strengths and weaknesses of the various groups involved: the public sector, a non-profit organization that provides general healthcare services and one that specializes in mental health, a community advisory board, academic centers in high- and low-income countries, and bicultural professionals from the diaspora community. CONCLUSIONS: We propose a partnerships model to assist implementation of promising programs to expand access to mental healthcare in low- resource settings. We describe the success and limitations of our current partners in a mental health program in rural Nepal.

Recommendations from primary care providers for integrating mental health in a primary care system in rural Nepal.

BACKGROUND: Globally, access to mental healthcare is often lacking in rural, low-resource settings. Mental healthcare services integration in primary care settings is a key intervention to address this gap. A common strategy includes embedding mental healthcare workers on-site, and receiving consultation from an off-site psychiatrist. Primary care provider perspectives are important for successful program implementation. METHODS: We conducted three focus groups with all 24 primary care providers at a district-level hospital in rural Nepal. We asked participants about their concerns and recommendations for an integrated mental healthcare delivery program. They were also asked about current practices in seeking referral for patients with mental illness. We collected data using structured notes and analyzed the data by template coding to develop themes around concerns and recommendations for an integrated program. RESULTS: Participants noted that the current referral system included sending patients to the nearest psychiatrist who is 14 h away. Participants did not think this was effective, and stated that integrating mental health into the existing primary care setting would be ideal. Their major concerns about a proposed program included workplace hierarchies between mental healthcare workers and other clinicians, impact of staff turnover on patients, reliability of an off-site consultant psychiatrist, and ability of on-site primary care providers to screen patients and follow recommendations from an off-site psychiatrist. Their suggestions included training a few existing primary care providers as dedicated mental healthcare workers, recruiting both senior and junior mental healthcare workers to ensure retention, recruiting academic psychiatrists for reliability, and training all primary care providers to appropriately screen for mental illness and follow recommendations from the psychiatrist. CONCLUSIONS: Primary care providers in rural Nepal reported the failure of the current system of referral, which includes sending patients to a distant city. They welcomed integrating mental healthcare into the primary care system, and reported several concerns and recommendations to increase the likelihood of successful implementation of such a program.