Stakeholders' Perspectives on the "Helping Babies Breathe" Program Situation in Nepal Following the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic impacted healthcare systems, including resuscitation training programs such as Helping Babies Breathe (HBB). Nepal, a country with limited healthcare resources, faces challenges in delivering effective HBB training, managing deliveries, and providing neonatal care, particularly in remote areas. AIMS: This study assessed HBB skills and knowledge postpandemic through interviews with key stakeholders in Nepal. It aimed to identify strategies, adaptations, and innovations to address training gaps and scale-up HBB. METHODS: A qualitative approach was used, employing semistructured interviews about HBB program effectiveness, pandemic challenges, stakeholder engagement, and suggestions for improvement. RESULTS: The study encompassed interviews with 23 participants, including HBB trainers, birth attendants, officials, and providers. Thematic analysis employed a systematic approach by deducing themes from study aims and theory. Data underwent iterative coding and refinement to synthesize content yielding following 5 themes: (1) pandemic's impact on HBB training; (2) resource accessibility for training postpandemic; (3) reviving HBB training; (4) impacts on the neonatal workforce; and (5) elements influencing HBB training progress. CONCLUSION: Postpandemic, healthcare workers in Nepal encounter challenges accessing essential resources and delivering HBB training, especially in remote areas. Adequate budgeting and strong commitment from healthcare policy levels are essential to reduce neonatal mortality in the future.

Stunting Among Under 5-Year-Olds in Nepal: Trends and Risk Factors.

INTRODUCTION: The nutritional status in the first 5 years of life has lifelong and inter-generational impacts on individual's potential and development. This study described the trend of stunting and its risk factors in children under 5 years of age between 2001 and 2016 in Nepal. METHODS: The study used datasets from the 2001, 2006, 2011 and 2016 Nepal Demographic Health Surveys to describe the trend of stunting in under 5-year children. Multiple logistic regression analysis was carried out to assess the risk factors for stunting at the time of the four surveys. RESULTS: The nutritional status of under 5-year children improved between 2001 and 2016. Babies born into poorer families had a higher risk of stunting than those born into wealthier families (AOR 1.51, CI 95% 1.23-1.87). Families residing in hill districts had less risk of stunting than those in the Terai plains (AOR 0.75, CI 95% 0.61-0.94). Babies born to uneducated women had a higher risk of stunting than those born to educated women (AOR 1.57, CI 95% 1.28-1.92). DISCUSSION: Stunting among under-5-year children decreased in the years spanning 2001-2016. This study demonstrated multiple factors that can be addressed to decrease the risk of stunting, which has important implications for neurodevelopment later in life. We add literature on risk factors for stunting in under-5-year children.

Quality of Care for Maternal and Newborn Health in Health Facilities in Nepal.

INTRODUCTION: Nepal has pledged to substantially reduce maternal and newborn death by 2030. Improving quality of intrapartum health services will be vital to reduce these deaths. This paper examines quality of delivery and newborn services in health facilities of Nepal. METHODS: Data were sourced from the Nepal Health Facility Survey 2015, which covered a national representative sample of health facilities. The datasets were analysed to assess service readiness, availability and quality of delivery and newborn care in a sample of 992 health facilities. RESULTS: Of the 992 facilities in the sample, 623 provided delivery and newborn care services. Of the 623 facilities offering delivery and newborn care services, 13.3% offered comprehensive emergency obstetric care (CEmONC), 19.6% provided basic emergency obstetric care (BEmONC) and 53.9% provided basic delivery and newborn service. The availability of essential equipment for delivery and newborn care was more than 80% in health facilities. Except for the coverage of vitamin K injection, the coverage of immediate newborn care was more than 85% in all health facilities. The coverage of use of chlorhexidine ointment to all newborns was more than 70% in government hospitals and primary health care centers (PHCCs) and only 32.3% in private hospitals. CONCLUSIONS: These findings show gaps in equipment and drugs, especially in PHCCs and private health facilities. Improving readiness and availability of equipment and drugs in PHCCs and private health facility will help improve the quality of care to further reduce maternal and newborn mortality in Nepal.

The Association of Childhood Pneumonia with Household Air Pollution in Nepal: Evidence from Nepal Demographic Health Surveys.

INTRODUCTION: Childhood pneumonia is a major cause of mortality worldwide while household air pollution (HAP) is a major contributor to childhood pneumonia in low and middle-income countries. This paper presents the prevalence trend of childhood pneumonia in Nepal and assesses its association with household air pollution. METHODS: The study analysed data from the 2006, 2011 and 2016 Nepal Demographic Health Surveys (NDHS). It calculated the prevalence of childhood pneumonia and the factors that cause household air pollution. The association of childhood pneumonia and HAP was assessed using univariate and multi-variate analysis. The population attributable fraction (PAF) of indoor pollution for causing pneumonia was calculated using 2016 NDHS data to assess the burden of pneumonia attributable to HAP factors. RESULTS: The prevalence of childhood pneumonia decreased in Nepal between 2006 and 2016 and was higher among households using polluting cooking fuels. There was a higher risk of childhood pneumonia among children who lived in households with no separate kitchens in 2011 [Adjusted risk ratio (ARR) 1.40, 95% CI 1.01-1.97] and in 2016 (ARR 1.93, 95% CI 1.14-3.28). In 2016, the risk of children contracting pneumonia in households using polluting fuels was double (ARR 1.98, 95% CI 1.01-3.92) that of children from households using clean fuels. Based on the 2016 data, the PAF for pneumonia was calculated as 30.9% for not having a separate kitchen room and 39.8% for using polluting cooking fuel. DISCUSSION FOR PRACTICE: Although the occurrence of childhood pneumonia in Nepal has decreased, the level of its association with HAP remained high.

Trends for Neonatal Deaths in Nepal (2001-2016) to Project Progress Towards the SDG Target in 2030, and Risk Factor Analyses to Focus Action.

INTRODUCTION: Nepal has made considerable progress on improving child survival during the Millennium Development Goal period, however, further progress will require accelerated reduction in neonatal mortality. Neonatal survival is one of the priorities for Sustainable Development Goals 2030. This paper examines the trends, equity gaps and factors associated with neonatal mortality between 2001 and 2016 to assess the likelihood of Every Newborn Action Plan (ENAP) target being reached in Nepal by 2030. METHODS: This study used data from the 2001, 2006, 2011 and 2016 Nepal Demographic and Health Surveys. We examined neonatal mortality rate (NMR) across the socioeconomic strata and the annual rate of reduction (ARR) between 2001 and 2016. We assessed association of socio-demographic, maternal, obstetric and neonatal factors associated with neonatal mortality. Based on the ARR among the wealth quintile between 2001 and 2016, we made projection of NMR to achieve the ENAP target. Using the Lorenz curve, we calculated the inequity distribution among the wealth quintiles between 2001 and 2016. RESULTS: In NDHS of 2001, 2006, 2011 and 2016, a total of 8400, 8600, 13,485 and 13,089 women were interviewed respectively. There were significant disparities between wealth quintiles that widened over the 15 years. The ARR for NMR declined with an average of 4.0% between 2001 and 2016. Multivariate analysis of the 2016 data showed that women who had not been vaccinated against tetanus had the highest risk of neonatal mortality (adjusted odds ratio [AOR] 3.38; 95% confidence interval [CI] 1.20-9.55), followed by women who had no education (AOR 1.87; 95% CI 1.62-2.16). Further factors significantly associated with neonatal mortality were the mother giving birth before the age of 20 (AOR 1.76; CI 95% 1.17-2.59), household air pollution (AOR 1.37; CI 95% 1.59-1.62), belonging to a poorest quintile (AOR 1.37; CI 95% 1.21-1.54), residing in a rural area (AOR 1.28; CI 95% 1.13-1.44), and having no toilet at home (AOR 1.21; CI 95% 1.06-1.40). If the trend of neonatal mortality rate of 2016 continues, it is projected that the poorest family will reach the ENAP target in 2067. CONCLUSIONS: Although neonatal mortality is declining in Nepal, if the current trend continues it will take another 50 years for families in the poorest group to attain the 2030 ENAP target. There are different factors associated with neonatal mortality, reducing the disparities for maternal and neonatal care will reduce mortality among the poorest families.

The Association of Women's Empowerment with Stillbirths in Nepal.

INTRODUCTION: Globally, 2.6 million stillbirths occur each year. Empowering women can improve their overall reproductive health and help reduce stillbirths. Women empowerment has been defined as women's ability to make choices in economic decision-making, household and health care decision-making. In this paper, we aimed to evaluate if women's empowerment is associated with stillbirths. METHODS: Data from 2016 Nepal Demographic Health Surveys (NDHS) were analysed to evaluate the association between women's empowerment and stillbirths. Equiplots were generated to assess the distribution of stillbirths by wealth quintile, place of residence and level of maternal education using data from NHDS 1996, 2001, 2006, 2011 and 2016 data. For the association of women empowerment factors and stillbirths, univariate and multivariate analyses were conducted. RESULTS: A total of 88 stillbirths were reported during the survey. Univariate analysis showed age of mother, education of mother, age of husband, wealth index, head of household, decision on healthcare and decision on household purchases had significant association with stillbirths (p < 0.05). In multivariate analysis, only maternal age 35 years and above was significant (aOR 2.42; 1.22-4.80). Education of mother (aOR 1.48; 0.94-2.33), age of husband (aOR 1.54; 0.86-2.76), household head (aOR 1.51; 0.88-2.59), poor wealth index (aOR 1.62; 0.98-2.68), middle wealth index (aOR 1.37; 0.76-2.47), decision making for healthcare (aOR 1.36; 0.84-2.21) and household purchases (aOR 1.01; 0.61-1.66) had no any significant association with stillbirths. CONCLUSIONS: There are various factors linked with stillbirths. It is important to track stillbirths to improve health outcomes of mothers and newborn. Further studies are necessary to analyse women empowerment factors to understand the linkages between empowerment and stillbirths.

Equity and Coverage in the Continuum of Reproductive, Maternal, Newborn and Child Health Services in Nepal-Projecting the Estimates on Death Averted Using the LiST Tool.

INTRODUCTION: The third Sustainable Development Goal, focused on health, includes two targets related to the reduction in maternal, newborn and under-five childhood mortality. We found it imperative to examine the equity and coverage of reproductive, maternal, newborn and child health (RMNCH) interventions from 2001 to 2016 in Nepal; and the death aversion that will take place during the SDG period. METHODS: We used the datasets from the Nepal Demographic Health Surveys (NDHS) 2001, 2006, 2011 and 2016. We calculated the coverage and equity for RMNCH interventions and the composite coverage index (CCI). Based on the Annualized Rate of Change (ARC) in the coverage for selected RMNCH indicators, we projected the trend for the RMNCH interventions by 2030. We used the Lives Saved Tools (LiST) tool to estimate the maternal, newborn, under-five childhood deaths and stillbirths averted. We categorised the interventions into four different patterns based on coverage and inequity gap. RESULTS: Between 2001 and 2016, a significant improvement is seen in the overall RMNCH intervention coverage-CCI increasing from 46 to 75%. The ARC was highest for skilled attendance at birth (11.7%) followed by care seeking for pneumonia (8.2%) between the same period. In 2016, the highest inequity existed for utilization of the skilled birth attendance services (51%), followed by antenatal care (18%). The inequity gap for basic immunization services reduced significantly from 27.4% in 2001 to 5% in 2016. If the current ARC continues, then an additional 3783 maternal deaths, 36,443 neonatal deaths, 66,883 under-five childhood deaths and 24,024 stillbirths is expected to be averted by the year 2030. CONCLUSION: Nepal has experienced an improvement in the coverage and equity in RMNCH interventions. Reducing inequities will improve coverage for skilled birth attendants and antenatal care. The current annual rate of change in RMNCH coverage will further reduce the maternal, neonatal, under-five childhood deaths and stillbirths.

Does the Helping Babies Breathe Programme impact on neonatal resuscitation care practices? Results from systematic review and meta-analysis.

AIM: This paper examines the change in neonatal resuscitation practices after the implementation of the Helping Babies Breathe (HBB) programme. METHODS: A systematic review was carried out on studies reporting the impact of HBB programmes among the literature found in Medline, POPLINE, LILACS, African Index Medicus, Cochrane, Web of Science and Index Medicus for the Eastern Mediterranean Region database. We selected clinical trials with randomised control, quasi-experimental and cross-sectional designs. We used a data extraction tool to extract information on intervention and outcome reporting. We carried out a meta-analysis of the extracted data on the neonatal resuscitation practices following HBB programme using Review Manager. RESULTS: Four studies that reported on neonatal resuscitation practices before and after the implementation of the HBB programme were identified. The pooled results showed no changes in the use of stimulation (RR-0.54; 95% CI, 0.21-1.42), suctioning (RR-0.48; 95% CI, 0.18-1.27) and bag-and-mask ventilation (RR-0.93; 95% CI, 0.47-1.83) after HBB training. The proportion of babies receiving bag-and-mask ventilation within the Golden Minute of birth increased by more than 2.5 times (RR-2.67; 95% CI, 2.17-3.28). CONCLUSION: The bag-and-mask ventilation within Golden minute has improved following the HBB programme. Implementation of HBB training improves timely initiation of bag-and-mask ventilation within one minute of birth.

Menstrual hygiene management among women and adolescent girls in the aftermath of the earthquake in Nepal.

BACKGROUND: Menstrual hygiene management (MHM) is an essential aspect of hygiene for women and adolescent girls between menarche and menopause. Despite being an important issue concerning women and girls in the menstruating age group MHM is often overlooked in post-disaster responses. Further, there is limited evidence of menstrual hygiene management in humanitarian settings. This study aims to describe the experiences and perceptions of women and adolescent girls on menstrual hygiene management in post-earthquake Nepal. METHODS: A mixed methods study was carried out among the earthquake affected women and adolescent girls in three villages of Sindhupalchowk district of Nepal. Data was collected using a semi-structured questionnaire that captured experiences and perceptions of respondents on menstrual hygiene management in the aftermath of the Nepal earthquake. Quantitative data were triangulated with in-depth interview regarding respondent's personal experiences of menstrual hygiene management. RESULTS: Menstrual hygiene was rated as the sixth highest overall need and perceived as an immediate need by 18.8% of the respondents. There were 42.8% women & girls who menstruated within first week of the earthquake. Reusable sanitary cloth were used by about 66.7% of the respondents before the earthquake and remained a popular method (76.1%) post-earthquake. None of the respondents reported receiving menstrual adsorbents as relief materials in the first month following the earthquake. Disposable pads (77.8%) were preferred by respondents as they were perceived to be clean and convenient to use. Most respondents (73.5%) felt that reusable sanitary pads were a sustainable choice. Women who were in the age group of 15-34 years (OR = 3.14; CI = (1.07-9.20), did not go to school (OR = 9.68; CI = 2.16-43.33), married (OR = 2.99; CI = 1.22-7.31) and previously used reusable sanitary cloth (OR = 5.82; CI = 2.33-14.55) were more likely to use the reusable sanitary cloth. CONCLUSIONS: In the immediate aftermath of the earthquake, women and girls completely depended on the use of locally available resources as adsorbents during menstruation. Immediate relief activities by humanitarian agencies, lacked MHM activities. Understanding the previous practice and using local resources, the reusable sanitary cloth is a way to address the menstrual hygiene needs in the post-disaster situations in Nepal.

The potential of health literacy to address the health related UN sustainable development goal 3 (SDG3) in Nepal: a rapid review.

BACKGROUND: Health literacy has been linked to health outcomes across population groups around the world. Nepal, a low income country, experiences the double burden of highly prevalent communicable as well as non-communicable diseases. The World Health Organization (WHO) has positioned health literacy as a key mechanism to meet the health-related Sustainable Development Goal (SDG3). However, there is little known about the status of health literacy in developing countries such as Nepal. This paper aims to review the potential of health literacy to address SDG3 in Nepal. METHODS: A rapid review was conducted using the knowledge to action evidence summary approach. Articles included in the review were those reporting on barriers to health care engagements in Nepal published in English language between January 2000 and December 2015. RESULTS: Barriers for healthcare engagement included knowledge and education as strong factors, followed by culture, gender roles, quality of service and cost of services. These barriers influence the Nepalese community to access and engage with services, and make and enact healthcare decisions, not only at the individual level but at the family level. These factors are directly linked to health literacy. Health literacy is a pivotal determinant of understanding, accessing and using health information and health services, it is important that the health literacy needs of the people be addressed. CONCLUSION: Locally identified and developed health literacy interventions may provide opportunities for systematic improvements in health to address impediments to healthcare in Nepal. Further research on health literacy and implementation of health literacy interventions may help reduce inequalities and increase the responsiveness of health systems which could potentially facilitate Nepal to meet the sustainable development goals. While there is currently little in place for health literacy to impact on the SDG3, this paper generates insights into health literacy's potential role.

Barriers and facilitators to the recruitment of disabled people to clinical trials: a scoping review.

INTRODUCTION: Underrepresentation of disabled groups in clinical trials results in an inadequate evidence base for their clinical care, which drives health inequalities. This study aims to review and map the potential barriers and facilitators to the recruitment of disabled people in clinical trials to identify knowledge gaps and areas for further extensive research. The review addresses the question: 'What are the barriers and facilitators to recruitment of disabled people to clinical trials?'. METHODS: The Joanna Briggs Institute (JBI) Scoping review guidelines were followed to complete the current scoping review. MEDLINE and EMBASE databases were searched via Ovid. The literature search was guided by a combination of four key concepts from the research question: (1) disabled populations, (2) patient recruitment, (3) barriers and facilitators, and (4) clinical trials. Papers discussing barriers and facilitators of all types were included. Papers that did not have at least one disabled group as their population were excluded. Data on study characteristics and identified barriers and facilitators were extracted. Identified barriers and facilitators were then synthesised according to common themes. RESULTS: The review included 56 eligible papers. The evidence on barriers and facilitators was largely sourced from Short Communications from Researcher Perspectives (N = 22) and Primary Quantitative Research (N = 17). Carer perspectives were rarely represented in articles. The most common disability types for the population of interest in the literature were neurological and psychiatric disabilities. A total of five emergent themes were determined across the barriers and facilitators. These were as follows: risk vs benefit assessment, design and management of recruitment protocol, balancing internal and external validity considerations, consent and ethics, and systemic factors. CONCLUSIONS: Both barriers and facilitators were often highly specific to disability type and context. Assumptions should be minimised, and study design should prioritise principles of co-design and be informed by a data-driven assessment of needs for the study population. Person-centred approaches to consent that empower disabled people to exercise their right to choose should be adopted in inclusive practice. Implementing these recommendations stands to improve inclusive practices in clinical trial research, serving to produce a well-rounded and comprehensive evidence base.

Challenges of Hospital Oxygen Management during the COVID-19 Pandemic in Rural Nepal.

Oxygen support remains essential for treatment of acute and severe manifestations of COVID-19. In Nepal, like many other low-resource settings, medical oxygen availability was inadequate before the pandemic. The mid-2021 wave of COVID-19 transmission starkly exposed the supply-demand imbalance of medical oxygen across the country. Pre-pandemic, more complex cases were typically referred to hospitals with better resources; however, during the pandemic, these hospitals were overrun. Therefore, resource-poor health facilities have been attempting to provide greater levels of care. However, we are faced with numerous challenges to provide a proper oxygen supply in these health settings. At a logistical level, complex geographies, sparse infrastructure, and inadequate electricity supply pose challenges. On a provider level, a shortage of trained staff and equipment necessary to administer and monitor medical oxygen creates additional pressures. Recognizing the end of the pandemic is still a long way off in many parts of the world, it is imperative that scalable, sustainable approaches to provisioning oxygen to those in greatest need are considered at a policy level.

Use of the English Health Literacy Questionnaire (HLQ) with Health Science University Students in Nepal: A Validity Testing Study.

Research evidence shows that health literacy development is a key factor influencing non-communicable diseases care and patient outcomes. Healthcare professionals with strong health literacy skills are essential for providing quality care. We aimed to report the validation testing of the Health Literacy Questionnaire (HLQ) among health professional students in Nepal. A cross-sectional study was conducted with 419 health sciences students using the HLQ in Nepal. Validation testing and reporting were conducted using five sources outlined by 'the 2014 Standards for Educational and Psychological Testing'. The average difficulty was lowest (17.4%) for Scale 4. Social support for health, and highest (51.9%) for Scale 6. Ability to actively engage with healthcare providers. One factor Confirmatory Factor Analysis (CFA) model showed a good fit for Scale 2, Scale 7 and Scale 9 and a reasonable fit for Scale 3 and Scale 4. The restricted nine-factor CFA model showed a satisfactory level of fit. The use of HLQ is seen to be meaningful in Nepal and warrants translation into native Nepali and other dominant local languages with careful consideration of cultural appropriateness using cognitive interviews.

Disruptions to routine childhood vaccinations in low- and middle-income countries during the COVID-19 pandemic: A systematic review.

Background: The COVID-19 pandemic has disrupted routine childhood vaccinations worldwide with low- and middle-income countries (LMICs) most affected. This study aims to quantify levels of disruption to routine vaccinations in LMICs. Methods: A systematic review (PROSPERO CRD42021286386) was conducted of MEDLINE, Embase, Global Health, CINAHL, Scopus and MedRxiv, on the 11th of February 2022. Primary research studies published from January 2020 onwards were included if they reported levels of routine pediatrics vaccinations before and after March 2020. Study appraisal was performed using NHLBI tool for cross-sectional studies. Levels of disruption were summarized using medians and interquartile ranges. Results: A total of 39 cross-sectional studies were identified. These showed an overall relative median decline of -10.8% [interquartile range (IQR) -27.6%, -1.4%] across all vaccines. Upper-middle-income countries (upper-MICs) (-14.3%; IQR -24.3%, -2.4%) and lower-MICs (-18.0%; IQR -48.6%, -4.1%) showed greater declines than low-income countries (-3.1%; IQR -12.8%, 2.9%), as did vaccines administered at birth (-11.8%; IQR -27.7%, -3.5%) compared to those given after birth (-8.0%; IQR -28.6%, -0.4%). Declines during the first 3 months of the pandemic (-8.1%; IQR -35.1%, -1.4%) were greater than during the remainder of 2020 (-3.9%; IQR -13.0%, 11.4%) compared to baseline. Conclusion: There has been a decline in routine pediatric vaccination, greatest in MICs and for vaccines administered at birth. Nations must prioritize catch-up programs alongside public health messaging to encourage vaccine uptake. Systematic review registration: Identifier: CRD42021286386.

Medical students' attitude towards cultural diversity: a cross-sectional study at a health sciences university in eastern Nepal.

OBJECTIVES: To assess the attitude of medical students towards cultural diversity aiming to elucidate our current status in understanding cultural awareness and sensitivity. DESIGN, SETTING AND PARTICIPANTS: A web-based cross-sectional study was carried out among 601 undergraduate health science students (medical and dental courses) at a health sciences university in eastern Nepal via various modes of social-media platforms like WhatsApp, Messenger, Gmail, etc. OUTCOME MEASURES: Medical students' attitude towards cultural diversity and its association with the sociodemographic profile of the students. RESULTS: A total of 601 students participated in the study, out of which, 64.2% were men with a sex ratio of 1.8:1 and a mean age of 22.3±1.9 years. More than two-thirds (77.2%) of the students had an excellent to good attitude towards cultural diversity. The proportion of students reporting 'excellent' attitude towards cultural diversity was higher among male students compared with female students (37.8% vs 20.5%) and students aged >22 years compared with younger students (37.1% vs 26.7%). Gender (p<0.001) and age (p=0.009) were significantly associated with the attitude towards cultural diversity. CONCLUSIONS: Medical students, in general, are aware of the impacts of a cross-cultural society on the delivery of quality healthcare and also about the need to be aware of prejudices doctors may have towards certain cultures. Majority suggest the inclusion of concepts of multicultural awareness and sensitivity in the medical curriculum itself.

Compliance with the smoke-free public places legislation in Nepal: A cross-sectional study from Biratnagar Metropolitan City.

BACKGROUND: Smoke-free legislation banning tobacco smoking in public places was implemented across Nepal in 2014 with the ambition to reduce the impact of second-hand smoking. As part of a comprehensive policy package on tobacco control, the implementation of the legislation has seen a marked reduction in tobacco consumption. Yet there remains uncertainty about the level of compliance with smoke-free public places. OBJECTIVES: This study assesses the compliance with smoke-free laws in public places and the factors associated with active smoking in public places in Biratnagar Metropolitan City, Nepal. METHODS: A cross-sectional study was conducted in the Biratnagar metropolitan city in Province 1 of Nepal from July to December 2019. A total of 725 public places within the metropolitan city were surveyed using a structured survey tool. Active smoking was the primary outcome of the study which was defined as smoking by any person during the data collection time at the designated public place. RESULTS: The overall compliance with smoke-free legislation was 56.4%. The highest compliance (75.0%) was observed in Government office buildings. The lowest compliance was observed in eateries, entertainment, and shopping venues (26.3%). There was a statistically significant association between active smoking and the presence of 'no smoking' notices appended at the entrance and the odds of active smoking in eateries, entertainment, hospitality, shopping venues, transportations and transits was higher compared to education and health care institutions. None of the 'no smoking' notices displayed fully adhered to the contents as prescribed by the law. CONCLUSION: As more than half of the public places complied with the requirements of the legislation, there was satisfactory overall compliance with the smoke-free public places law in this study. The public venues (eateries, shopping venues and transportations) that are more frequently visited and have a high turnover of the public have lower compliance with the legislation. The content of the message in the 'no smoking' notices needs close attention to adhere to the legal requirements.

Impact of stimulation among non-crying neonates with intact cord versus clamped cord on birth outcomes: observation study.

Background: Stimulation of non-crying neonates after birth can help transition to spontaneous breathing. In this study, we aim to assess the impact of intact versus clamped umbilical cord on spontaneous breathing after stimulation of non-crying neonates. Methods: This is an observational study among non-crying neonates (n=3073) born in hospitals of Nepal. Non-crying neonates born vaginally at gestational age ≥34 weeks were observed for their response to stimulation with the cord intact or clamped. Obstetric characteristics of the neonates were analysed. Association of spontaneous breathing with cord management was assessed using logistic regression. Results: Among non-crying neonates, 2563 received stimulation. Of these, a higher proportion of the neonates were breathing in the group with cord intact as compared with the group cord clamped (81.1% vs 68.9%, p<0.0001). The use of bag-and-mask ventilation was lower among those who were stimulated with the cord intact than those who were stimulated with cord clamped (18.0% vs 32.4%, p<0.0001). The proportion of neonates with Apgar Score ≤3 at 1 min was lower with the cord intact than with cord clamped (7.6% vs 11.5%, p=0.001). In multivariate analysis, neonates with intact cord had 84% increased odds of spontaneous breathing (adjusted OR, 1.84; 95% CI: 1.48 to 2.29) compared with those with cord clamped. Conclusions: Stimulation of non-crying neonates with intact cord was associated with more spontaneous breathing than among infants who were stimulated with cord clamped. Intact cord stimulation may help establish spontaneous breathing in apnoeic neonates, but residual confounding variables may be contributing to the findings. This study provides evidence for further controlled research to evaluate the effect of initial steps of resuscitation with cord intact.

Perceptions of family planning services and its key barriers among adolescents and young people in Eastern Nepal: A qualitative study.

INTRODUCTION: Family planning methods are used to promote safer sexual practices, reduce unintended pregnancies and unsafe abortion, and control population. Young people aged 15-24 years belong to a key reproductive age group. However, little is known about their engagement with the family planning services in Nepal. Our study aimed to identify the perceptions of and barriers to the use of family planning among youth in Nepal. METHODS: A qualitative explorative study was done among adolescents and young people aged 15-24 years from the Hattimuda village in eastern Nepal. Six focus group discussions and 25 in-depth interviews were conducted with both male and female participants in the community using a maximum variation sampling method. Data were analyzed using a thematic framework approach. RESULTS: Many individuals were aware that family planning measures postpone pregnancy. However, some young participants were not fully aware of the available family planning services. Some married couples who preferred 'birth spacing' received negative judgments from their family members for not starting a family. The perceived barriers to the use of family planning included lack of knowledge about family planning use, fear of side effects of modern family planning methods, lack of access/affordability due to familial and religious beliefs/myths/misconceptions. On an individual level, some couples' timid nature also negatively influenced the uptake of family planning measures. CONCLUSION: Women predominantly take the responsibility for using family planning measures in male-dominated decision-making societies. Moreover, young men feel that the current family planning programs have very little space for men to engage even if they were willing to participate. Communication in the community and in between the couples seem to be influenced by the presence of strong societal and cultural norms and practices. These practices seem to affect family planning related teaching at schools as well. This research shows that both young men and women are keen on getting involved with initiatives and campaigns for supporting local governments in strengthening the family planning programs in Nepal.

Analysis of maternal and newborn training curricula and approaches to inform future trainings for routine care, basic and comprehensive emergency obstetric and newborn care in the low- and middle-income countries: Lessons from Ethiopia and Nepal.

Program managers routinely design and implement specialised maternal and newborn health trainings for health workers in low- and middle-income countries to provide better-coordinated care across the continuum of care. However, in these countries details on the availability of different training packages, skills covered in those training packages and the gaps in their implementation are patchy. This paper presents an assessment of maternal and newborn health training packages to describe differences in training contents and implementation approaches used for a range of training packages in Ethiopia and Nepal. We conducted a mixed-methods study. The quantitative assessment was conducted using a comprehensive assessment questionnaire based on validated WHO guidelines and developed jointly with global maternal and newborn health experts. The qualitative assessment was conducted through key informant interviews with national stakeholders involved in implementing these training packages and working with the Ministries of Health in both countries. Our quantitative analysis revealed several key gaps in the technical content of maternal and newborn health training packages in both countries. Our qualitative results from key informant interviews provided additional insights by highlighting several issues with trainings related to quality, skill retention, logistics, and management. Taken together, our findings suggest four key areas of improvement: first, training materials should be updated based on the content gaps identified and should be aligned with each other. Second, trainings should address actual health worker performance gaps using a variety of innovative approaches such as blended and self-directed learning. Third, post-training supervision and ongoing mentoring need to be strengthened. Lastly, functional training information systems are required to support planning efforts in both countries.

Whose voices should shape global health education? Curriculum codesign and codelivery by people with direct expertise and lived experience.

There are contrasting opinions of what global health (GH) curricula should contain and limited discussion on whose voices should shape it. In GH education, those with first-hand expertise of living and working in the contexts discussed in GH classrooms are often absent when designing curricula. To address this, we developed a new model of curriculum codesign called Virtual Roundtable for Collaborative Education Design (ViRCoED). This paper describes the rationale and outputs of the ViRCoED approach in designing a new section of the Global Health Bachelor of Science (BSc) curriculum at Imperial College London, with a focus on healthcare in the Syrian conflict. The team, importantly, involved partners with lived and/or professional experience of the conflict as well as alumni of the course and educators in all stages of design and delivery through to marking and project evaluation. The project experimented with disrupting power dynamics and extending ownership of the curriculum beyond traditional faculty by codesigning and codelivering module contents together with colleagues with direct expertise and experience of the Syrian context. An authentic approach was applied to assessment design using real-time syndromic healthcare data from the Aleppo and Idlib Governorates. We discuss the challenges involved in our collaborative partnership and describe how it may have enhanced the validity of our curriculum with students engaging in a richer representation of key health issues in the conflict. We observed an enhanced self-reflexivity in the students' approach to quantitative data and its complex interpretation. The dialogic nature of this collaborative design was also a formative process for partners and an opportunity for GH educators to reflect on their own positionality. The project aims to challenge current standards and structures in GH curriculum development and gesture towards a GH education sector eventually led by those with lived experience and expertise to significantly enhance the validity of GH education.