Multisectoral community development in Nepal has greater effects on child growth and diet than nutrition education alone.

OBJECTIVE: To compare the impact on child diet and growth of a multisectoral community intervention v. nutrition education and livestock management training alone. DESIGN: Longitudinal community-based randomized trial involving three groups of villages assigned to receive: (i) Full Package community development activities, delivered via women's groups; (ii) livestock training and nutrition education alone (Partial Package); or (iii) no intervention (Control). Household surveys, child growth monitoring, child and household diet quality measures (diet diversity (DD), animal-source food (ASF) consumption) were collected at five visits over 36 months. Mixed-effect linear regression and Poisson models used survey round, treatment group and group-by-round interaction to predict outcomes of interest, adjusted for household- and child-specific characteristics. SETTING: Banke, Nepal. PARTICIPANTS: Households (n 974) with children aged 1-60 months (n 1333). RESULTS: Children in Full Package households had better endline anthropometry (weight-for-age, weight-for-height, mid-upper-arm-circumference Z-scores), DD, and more consumption of ASF, after adjusting for household- and child-specific characteristics. By endline, compared with Partial Package or Control groups, Full Package households demonstrated preferential child feeding practices and had significantly more improvement in household wealth and hygiene habits. CONCLUSIONS: In this longitudinal study, a comprehensive multisectoral intervention was more successful in improving key growth indicators as well as diet quality in young children. Provision of training in livestock management and nutrition education alone had limited effect on these outcomes. Although more time-consuming and costly to administer, incorporating nutrition training with community social capital development was associated with better child growth and nutrition outcomes than isolated training programmes alone.

Diet quality over time is associated with better development in rural Nepali children.

Developmental delays affect between 150 and 200 million children <5 years of age worldwide. Outside of diet supplement studies, relatively little is known about the relationships between diet quality and developmental status in resource-poor settings. We examined associations between different aspects of dietary quality (dietary diversity score [DDS] and animal-source food [ASF] consumption) and child development (assessed using the Ages and Stages Questionnaire-3 [ASQ-3]) among children whose families were enrolled in a community development intervention trial (implemented by Heifer Nepal) in western Nepal. Two sets of analyses were performed: (a) cross-sectional Sample (N = 629) seen at the endline survey and (b) longitudinal sample (N = 269) with complete dietary records (six surveys over 48 months). In both samples, child development was significantly related to household wealth, maternal education, and especially home environmental quality. In the cross-sectional sample, greater consumption of eggs (adjusted odds ratio [aOR] 0.80, p = .04) or dairy products (aOR 0.95, p = .05) over the previous 7 days significantly reduced odds of low total ASQ score, by logistic regression analysis. In the longitudinal sample, only egg consumption and cumulative DDS and ASF scores were associated with significantly reduced odds of low total ASQ score (aORs 0.59-0.89). In adjusted linear regression analysis, both cumulative DDS (ß [CI]: 1.92 [0.4, 3.5]) and ASF scores (2.46 [0.3, 4.7]) were significantly associated with greater continuous total child development. Programmes targeting child development must address home environmental quality as well as long-term diet quality.

Determination of medical abortion success by women and community health volunteers in Nepal using a symptom checklist.

BACKGROUND: We sought to determine if female community health volunteers (FCHVs) and literate women in Nepal can accurately determine success of medical abortion (MA) using a symptom checklist, compared to experienced abortion providers. METHODS: Women undergoing MA, and FCHVs, independently assessed the success of each woman's abortion using an 8-question symptom checklist. Any answers in a red-shaded box indicated that the abortion may not have been successful. Women's/FCHVs' assessments were compared to experienced abortion providers using standard of care. RESULTS: Women's (n = 1153) self-assessment of MA success agreed with abortion providers' determinations 85% of the time (positive predictive value = 90, 95% CI 88, 92); agreement between FCHVs and providers was 82% (positive predictive value = 90, 95% CI 88, 92). Of the 92 women (8%) requiring uterine evacuation with manual vacuum aspiration (n = 84, 7%) or medications (n = 8, 0.7%), 64% self-identified as needing additional care; FCHVs identified 61%. However, both women and FCHVs had difficulty recognizing that an answer in a red-shaded box indicated that the abortion may not have been successful. Of the 453 women with a red-shaded box marked, only 35% of women and 41% of FCHVs identified the need for additional care. CONCLUSION: Use of a checklist to determine MA success is a promising strategy, however further refinement of such a tool, particularly for low-literacy settings, is needed before widespread use.

Marital status and abortion among young women in Rupandehi, Nepal.

BACKGROUND: Despite liberalization of the Nepal abortion law, young women continue to experience barriers to safe abortion services. We hypothesize that marital status may differentially impact such barriers, given the societal context of Nepal. METHODS: We evaluated differences in reproductive knowledge and attitudes by marital status with a probability-based, cross-sectional survey of young women in Rupandehi district, Nepal. Participants (N = 600) were surveyed in 2012 on demographics, romantic experiences, media habits, reproductive information, and abortion knowledge and attitudes. We used logistic regression to assess differences by marital status, controlling for age. RESULTS: Participants, who comprised never-married (54%) and ever-married women (45%), reported good access to basic reproductive health and abortion information. Social desirability bias might have prevented reporting of premarital romantic and sexual activity given that participants reported more premarital activities for their friends than for themselves. Only 45% knew that abortion was legal, and fewer ever-married women were aware of abortion legality. Never-married women expected more negative responses from having an abortion than ever-married women. CONCLUSIONS: Findings highlight the need for providing sexual and reproductive health care information and services to young women regardless of marital status.

Abortion clients of a public-sector clinic and a non-governmental organization clinic in Nepal.

This paper investigates similarities and differences between abortion clients of a public-sector clinic and a non-governmental organization (NGO) clinic in Nepal. In 2010, a survey of 1,172 women was conducted in two highly-attended abortion clinics in Kathmandu-one public-sector clinic and another operated by an NGO. Data on the sociodemographic characteristics of clients, their fertility preferences, and use of contraceptives were analyzed. Similarities and differences between the two groups of clients were examined by either chi-square or t-test. The clients of the two clinics were similar with respect to age (27.3+/-5.7 years), education (26.5% had no education), and number of living children (1.88+/-1.08). They differed with regard to contraceptive practice, the circumstances resulting in unintended pregnancy, and future fertility preferences. Just over 50% clients of the public and 35% clients of the NGO clinic reported use of contraceptives surrounding the time of unintended pregnancy. The groups also differed in the contraceptive methods used and in reasons for not using any method. The NGO clinic contributed principally to expanding the availability of and access to abortion services.

Gaps in access and school attainments among people with and without disabilities: a case from Nepal.

AIM: Many children with disabilities in low- and middle-income countries do not attend school and one-third are out of school. In order to ensure that education is for all including children with disabilities, research is needed on barriers to schooling to identify targets for intervention. The study will examine the determinants of school achievement among persons with and without disabilities as well as among each type of impairment. METHODS: The study will utilize data from a recent national, representative household survey on living conditions among persons with and without disabilities. The individual level data used in this article comprise 2123 persons with and 2000 persons without disabilities. RESULTS: The results show that an alarmingly high proportion of persons in Nepal have not accessed formal education, with access being significantly lower among persons with disabilities. While the results may be influenced by the assumed relationship between disability and poverty, results from analyzing the cross-sectional data cannot be conclusive on the influence of disability vs. poverty in determining differences in access and school attainments. Increased environmental barriers, higher age, rural location, and increased levels of disability were found to be associated with lower educational achievement. Pronounced differences in access to education were found between impairment types, with individuals with physical impairments achieving the highest level and individuals with multiple impairments, hearing and mental impairments achieving lowest. CONCLUSIONS: It is necessary both to strengthen the entire educational sector and at the same time allocate resources that will ensure that all children are on board and that particular efforts are implemented to cater for those who are easily side-lined.Implications for rehabilitationAn alarmingly high proportion of persons in Nepal have not attended school.Substantially more individuals with than without disabilities have never attended school.Increased environmental barriers, higher age, rural location, and increased levels of disability were found to be associated with lower educational achievement.Pronounced differences in access to education were found between impairment types, with individuals with physical impairments achieving the highest level and individuals with multiple impairments, hearing and mental impairments achieving lowest.It is necessary both to strengthen the entire educational sector in Nepal and at the same time ensure that particular efforts are implemented to cater for those who are easily sidelined.

Disability among Older People: Analysis of Data from Disability Surveys in Six Low- and Middle-Income Countries.

This analysis of surveys from six low- and middle-income countries (LMICs) aimed to (i) estimate the prevalence of disability among older adults and (ii) compare experiences and participation in key life areas among older people with and without disabilities which may show vulnerability during the COVID-19 pandemic. Data were analysed from district-level or national surveys in Cameroon, Guatemala, Haiti, India, Nepal and the Maldives, which across the six databases totalled 3499 participants aged 60 years and above including 691 people with disabilities. Disability was common among adults 60+, ranging from 9.7% (8.0-11.8) in Nepal to 39.2% in India (95% CI 34.1-44.5%). Mobility was the most commonly reported functional difficulty. In each setting, older people with disabilities were significantly less likely to be working and reported greater participation restrictions and environmental barriers in key life areas compared to people in the same age categories without disabilities (p < 0.05). Disability is common in this population, and older people with disabilities may have greater difficulties participating in COVID-19 responses and have high economic vulnerabilities. It is imperative to prioritise the needs of older people with disabilities in the COVID-19 pandemic, including ensuring accessibility of both health services and the community in general.

Interrogating and Reflecting on Disability Prevalence Data Collected Using the Washington Group Tools: Results from Population-Based Surveys in Cameroon, Guatemala, India, Maldives, Nepal, Turkey and Vanuatu.

The Washington Group (WG) tools capture self-reported functional limitations, ranging from 6 domains in the Short Set (SS) to 11 in the Extended Set (ESF). Prevalence estimates can vary considerably on account of differences between modules and the different applications of them. We compare prevalence estimates by WG module, threshold, application and domain to explore these nuances and consider whether alternative combinations of questions may be valuable in reduced sets. We conducted secondary analyses of seven population-based surveys (analyses restricted to adults 18+) in Low- and Middle-Income Countries that used the WG tools. The prevalence estimates using the SS standard threshold (a lot of difficulty or higher in one or more domain) varied between 3.2% (95% Confidence Interval 2.9-3.6) in Vanuatu to 14.1% (12.2-16.2) in Turkey. The prevalence was higher using the ESF than the SS, and much higher (5 to 10-fold) using a wider threshold of "some" or greater difficulty. Two of the SS domains (communication, self-care) identified few additional individuals with functional limitations. An alternative SS replacing these domains with the psychosocial domains of anxiety and depression would identify more participants with functional limitations for the same number of items. The WG tools are valuable for collecting harmonised population data on disability. It is important that the impact on prevalence of use of different modules, thresholds and applications is recognised. An alternative SS may capture a greater proportion of people with functional domains without increasing the number of items.

Physical activity, time use, and food intakes of rural households in Ghana, India, and Nepal.

With more than 820 million undernourished people living in rural areas of low- and middle-income countries (LMICs), ending hunger and ensuring access to food by all is a global priority. In the past few decades, the adoption of technological innovations in the agricultural sector and related crop yield improvements have not led to expected improvements in the nutritional status of rural households in many LMICs. The increased energy expenditure associated with the adoption of productivity-enhancing innovations may provide an important explanation of the disconnect between agricultural productivity enhancements and improved nutritional outcomes. We develop a methodology for generating reliable livelihood energy/calorie expenditure profiles for rural agricultural households using research-grade accelerometer devices. We integrate the data on physical activity and energy expenditure in rural households with data on time-use and food intakes to generate a data set that provides a unique window into rural livelihoods. This can be a valuable resource to analyse agriculture-nutrition impact pathways and improve the welfare of rural and agricultural households.

Are current approaches for measuring access to clean water and sanitation inclusive of people with disabilities? Comparison of individual- and household-level access between people with and without disabilities in the Tanahun district of Nepal.

BACKGROUND: The critical importance of safe and affordable access to water, sanitation and hygiene (WASH) is highlighted in Goal 6 of the Sustainable Development Goals, which seeks to achieve universal and equitable access for all by 2030. However, people with disabilities-who comprise 15% of the global population-frequently face difficulties meeting their WASH needs. Unmet WASH needs amongst people with disabilities may not be captured through current approaches to tracking progress towards Goal 6, which focus on household- rather than individual-level access. OBJECTIVE: To evaluate access to safe water, sanitation and hygiene (WASH), at the individual- and household-level, amongst people with disabilities in the Tanahun district of Nepal. METHODS: A population-based survey of disability was conducted from August-October 2016 to evaluate access to improved water and sanitation facilities between households with members with disabilities (n = 198) and those without (n = 1,265) in the Tanahun district of Nepal. A nested case-control then compared individual-level access between cases aged 15 and above with disabilities (n = 192) and age-sex-location matched controls without disabilities (n = 189), using the newly developed 21-item "Quality of WASH Access" questionnaire. Multivariate regression was used to compare household- and individual-level indicators between people and households with and without disabilities. In-depth interviews with 18 people with disabilities and their caregivers was conducted to assess the acceptability and appropriateness of the "Quality of WASH Access" questionnaire. FINDINGS: There were no significant differences between households with and without members with disabilities in access to an improved sanitation facility or water source. However, at the individual-level, people with disabilities experienced significantly greater difficulties accessing water, sanitation and hygiene compared to people without disabilities (p<0.001 for all three scores). Amongst people with disabilities, water difficulty scores were associated with having a physical impairment and greater disability severity; sanitation difficulty scores were associated with lower socioeconomic status and physical or self-care limitations; and hygiene difficulty scores were positively associated with self-care limitations and lower socioeconomic status, and inversely associated with hearing impairments. Qualitative research found the "Quality of WASH Access" questionnaire was well understood by participants and captured many of the challenges they faced. Additional challenges not covered by the tool included: (1) time spent on WASH, (2) consistency of access, (3) sufficiency of access, and (4) dignity of access. CONCLUSION: People with disabilities face substantial challenges to meeting their WASH needs, particularly in using services autonomously, consistently, hygienically, with dignity and privacy, and without pain or fear of abuse. These challenges are not captured through household-level data, and so individual-level WASH access are needed to monitor progress towards universal WASH access. The Quality of WASH Access questionnaire may provide a useful data collection tool.

Personal involvement of young people in HIV prevention campaign messages: the role of message format, culture, and gender.

To examine young people's reactions to and understanding of HIV prevention messages developed for MTV's global HIV prevention campaign Staying Alive, videotaped campaign materials were shown to focus group discussion (FGD) participants living in urban areas of Brazil, Kenya, Nepal, and Senegal. Responses related to "personal involvement" with the message were identified in the data from these FGDs and were examined in relationship to the emerging message themes, the message format (public service announcements [PSAs] vs. documentary), cultural context (site), and participant gender. Across groups, greater personal involvement (measured by personal connections, emotional reactions, and lessons learned) was found in responses about the documentary format compared to the PSA format. Exceptions were found for specific PSAs that were considered more relevant within specific gender or cultural contexts. Implications of findings for global campaigns were considered.

Exposure to MTV's global HIV prevention campaign in Kathmandu, Nepal; São Paulo, Brazil; and Dakar, Senegal.

In 2002 MTV aired a global media campaign, "Staying Alive," to promote HIV prevention among 16- to 25-year-olds. Skeptics believed that a global MTV campaign would reach only a small group of elite young people. MTV increased access to its campaign, however, by making all materials "rights free" to third-party (non-MTV) broadcasters. Over 789 million households in over 166 countries had access to some or all of the campaign. To understand the level of actual exposure and the types of young people exposed, data were analyzed from population-based household surveys in three diverse urban areas where a campaign evaluation was conducted: Kathmandu, Nepal; São Paulo, Brazil and Dakar, Senegal. Exposure rates ranged from 12% in Kathmandu, 23% in São Paulo, and 82% in Dakar, reaching an estimated 32,000, 400,000, 220,000 16- to 25-year-olds in each city, respectively. A number of personal, social and economic characteristics found to predict campaign exposure were identified in each site; in general, these were related to economic status and use of "new" media technologies. Though this skew toward more exposure by those with greater resources existed, we found that the campaign audience was in no way composed only of "elite" young people. (For example, although more of those exposed to the campaign had used the Internet compared with those not exposed, this was not the majority of those exposed in most countries.) The possibility of reaching millions of young people through global networks with minimal marginal costs after production, creates a new paradigm for reaching an important segment of young people.

MTV's "Staying Alive" global campaign promoted interpersonal communication about HIV and positive beliefs about HIV prevention.

In 2002 MTV launched a global multicomponent HIV prevention campaign, "Staying Alive," reaching over 166 countries worldwide. An evaluation of this campaign focused on three diverse sites: Kathmandu, Nepal; São Paulo, Brazil; and Dakar, Senegal. Data were collected before and after campaign implementation through population-based household surveys. Using linear regression techniques, our evaluation examined the effects of campaign exposure on interpersonal communication about HIV and the effects of campaign exposure and interpersonal communication on beliefs about HIV prevention. We found a consistent positive effect of exposure on interpersonal communication across all sites, though there were differences among sites with regard to whom the respondent talked about HIV. We also found a consistent positive effect of exposure on HIV prevention beliefs across sites when interpersonal communication was simultaneously entered into the model. Finally, in two sites we found a relationship between interpersonal communication and HIV prevention beliefs, controlling for exposure, though again, the effects differed by the type of person the communication was with. These similar findings in three diverse sites provide ecological validity of the findings that "Staying Alive" promoted interpersonal communication and influenced young people's beliefs about HIV prevention in a positive way, evidence for the potential of a global media campaign to have an impact on social norms.

Determination of medical abortion eligibility by women and community health volunteers in Nepal: A toolkit evaluation.

OBJECTIVE: To determine if pregnant, literate women and female community health volunteers (FCHVs) in Nepal can accurately determine a woman's eligibility for medical abortion (MA) using a toolkit, compared to comprehensive abortion care (CAC) trained providers. STUDY DESIGN: We conducted a prospective diagnostic accuracy study in which women presenting for first trimester abortion, and FCHVs, independently assessed each woman's eligibility for MA using a modified gestational dating wheel to determine gestational age and a nine-point checklist of MA contraindications or cautions. Ability to determine MA eligibility was compared to experienced CAC-providers using Nepali standard of care. RESULTS: Both women (n = 3131) and FCHVs (n = 165) accurately interpreted the wheel 96% of the time, and the eligibility checklist 72% and 95% of the time, respectively. Of the 649 women who reported potential contraindications or cautions on the checklist, 88% misidentified as eligible. Positive predictive value (PPV) of women's assessment of eligibility based on gestational age was 93% (95% CI 92, 94) compared to CAC-providers' (n = 47); PPV of the medical contraindications checklist and overall (90% [95% CI 88, 91] and 93% [95% CI 92, 94] respectively) must be interpreted with caution given women's difficulty using the checklist. PPV of FCHVs' determinations were 93% (95% CI 92, 94), 90% (95% CI 89,91), and 93% (95% CI 91, 94) respectively. CONCLUSION: Although a promising strategy to assist women and FCHVs to assess MA eligibility, further refinement of the eligibility tools, particularly the checklist, is needed before their widespread use.

Measuring Nutrition Governance: An Analysis of Commitment, Capability, and Collaboration in Nepal.

BACKGROUND: Global commitments to nutrition have supported calls for better evidence to support effective investments at national level. However, too little attention has so far been paid to the role of governance in achieving impacts. OBJECTIVE: This article explores the ways by which the commitment and capabilities of policy implementers affect collaborative efforts for achieving nutrition goals. METHODS: Over 1370 structured interviews were held with government and nongovernment officials over 3 years in 21 districts. Coded responses supported quantitative analysis of stakeholders' knowledge, attitudes, and practices regarding policy implementation. RESULTS: Stakeholder commitment was already high in 2013 when a new national policy was adopted, but capabilities were weak. Only one-third of interviewed respondents had any nutrition training. Rollout of training focusing on districts targeted for early implementation of multisector programming. This raised levels of nutrition training among interviewed respondents to 57% in 2015, which raised demand for technical information to support actions. Better understanding of the complexity of cross-sector work led to calls for higher budgets and more effective cross-sectoral collaboration. CONCLUSION: Nepal offers an example of effective efforts to improve nutrition governance across sectors at all levels of administration. The promotion of awareness, capacity, and new ways of working shows promise. Trainings, information sharing, and management support led to growing willingness among civil servants to engage across sectors. Structured surveys offer a viable way to track change across institutions and sectors.

Risk factors for repeat abortion in Nepal.

OBJECTIVE: To examine the incidence of and risk factors for repeat abortion in Nepal. METHODS: Data were analyzed from a survey of 1172 women who had surgical abortions between December 2009 and March 2010 in 2 clinics in Kathmandu, Nepal. Bivariate and multivariate logistic regressions were performed to estimate odds ratios for the risk factors. RESULTS: Among the respondents, 32.3% (95% confidence interval, 29.6-34.9) had repeat abortions. This incidence rose sharply with age and parity, and was higher among those with no intention of having a future child, those attaining primary or secondary level education, and those attending the non-governmental sector clinic. Women with repeat abortion were similar to those with 1 abortion in terms of contraceptive practice. Among women not using contraceptives at the time of the unintended pregnancy, the 3 most commonly cited reasons were ill health, non-compliance with the method intended for use, and dislike of the method. Women with repeat abortion showed a pattern of contraceptive acceptance immediately after the procedure similar to that of women who had 1 abortion. CONCLUSION: Repeat abortion is emerging as a major public health issue in Nepal, with implications for counseling and provision of abortion, and for family planning services.

Factors in health initiative success: learning from Nepal's newborn survival initiative.

What shapes the level of political priority for alleviation of significant health problems in low-income countries? We investigate this question in the context of the significantly increasing political priority for newborn survival in Nepal since 2000. We use a process-tracing methodology to investigate causes of this shift, drawing on twenty-nine interviews with individuals close to newborn health policymaking in Nepal and extensive document analysis. Shifts in the political context (commitments to the child health MDG), the strength of concerned actors (emergence of collective action, leadership, resources) and the power of ideas (problem status, existence of contextually relevant solutions, agreement on these points) surrounding the issue have been instrumental in elevating priority for newborn survival, if not institutionalizing that priority to ensure long-term support. The findings highlight the significance of political fragmentation in war-torn areas for impeding priority generation. Additionally, theories of social construction provide important insights to the roles of ideas in shaping health initiative success.

Does MTV reach an appropriate audience for HIV prevention messages? Evidence from MTV viewership data in Nepal and Brazil.

In response to the growing numbers of young people affected by HIV around the world, MTV (Music TV), the world's largest television network, has aired a global HIV prevention campaign since 1999, expanding it into a multicomponent campaign in 2002. Questions have been raised, however, about whether MTV is an appropriate channel for these messages, given its provocative content and its reach to those at the upper end of the socioeconomic scale. To address questions about who MTV reaches, viewership data were analyzed from baseline surveys conducted as part of an evaluation of the 2002 HIV prevention campaign. The two sites included in this analysis were Kathmandu, Nepal, and São Paulo, Brazil-each with very different cultures and media environments. We found that, in general, heavier viewers of MTV are younger, better educated, and more dependent on their parents, and they have more access to satellite television and the Internet. MTV viewing was associated with positive attitudes toward HIV prevention behaviors (except for abstinence until marriage) but not with premarital sexual activity.