Understanding health system resilience in responding to COVID-19 pandemic: experiences and lessons from an evolving context of federalization in Nepal.

INTRODUCTION: The COVID-19 pandemic has tested the resilience capacities of health systems worldwide and highlighted the need to understand the concept, pathways, and elements of resilience in different country contexts. In this study, we assessed the health system response to COVID-19 in Nepal and examined the processes of policy formulation, communication, and implementation at the three tiers of government, including the dynamic interactions between tiers. Nepal was experiencing the early stages of federalization reform when COVID-19 pandemic hit the country, and clarity in roles and capacity to implement functions were the prevailing challenges, especially among the subnational governments. METHODS: We adopted a cross-sectional exploratory design, using mixed methods. We conducted a desk-based review of all policy documents introduced in response to COVID-19 from January to December 2020, and collected qualitative data through 22 key informant interviews at three tiers of government, during January-March 2021. Two municipalities were purposively selected for data collection in Lumbini province. Our analysis is based on a resilience framework that has been developed by our research project, ReBUILD for Resilience, which helps to understand pathways to health system resilience through absorption, adaptation and transformation. RESULTS: In the newly established federal structure, the existing emergency response structure and plans were utilized, which were yet to be tested in the decentralized system. The federal government effectively led the policy formulation process, but with minimal engagement of sub-national governments. Local governments could not demonstrate resilience capacities due to the novelty of the federal system and their consequent lack of experience, confusion on roles, insufficient management capacity and governance structures at local level, which was further aggravated by the limited availability of human, technical and financial resources. CONCLUSIONS: The study findings emphasize the importance of strong and flexible governance structures and strengthened capacity of subnational governments to effectively manage pandemics. The study elaborates on the key areas and pathways that contribute to the resilience capacities of health systems from the experience of Nepal. We draw out lessons that can be applied to other fragile and shock-prone settings.

Exploring community insights on antimicrobial resistance in Nepal: a formative qualitative study.

BACKGROUND: Antimicrobial resistance (AMR) is the process by which microbes evolve mechanisms to survive the medicines designed to destroy them i.e. antimicrobials (AMs). Despite being a natural process, AMR is being hastened by the abuse of AMs. In context of Nepal, there is limited information on drivers of AMR and barriers in addressing it from a community perspective. This study explores the local language and terminology used around AMs in the community, commonly used AMs and reasons for their usage, how these AMs are sourced, and the perceived barriers to addressing AMR via One Health approach. METHODS: A phenomenological study design was utilized with applied qualitative research theoretically framed as pragmatism. Twelve in-depth interviews and informal discussions with a One Health focus, were purposively conducted with wide range of stakeholders and community resident of Kapilvastu municipality of Nepal during April 2022. The acquired data was analyzed manually via a thematic framework approach. The study obtained ethical approval from ethical review board of Nepal Health Research Council and University of Leeds. RESULTS: Nepali and Awadhi languages does not have specific words for AMs or AMR, which is understandable by the community people. Rather, community use full explanatory sentences. People use AMs but have incomplete knowledge about them and they have their own local words for these medicines. The knowledge and usage of AMs across human and animal health is impacted by socio-structural factors, limited Government regulation, inadequate supply of AMs in local government health facilities and the presence of various unregulated health providers that co-exist within the health system. Novel ideas such as the use of visual and smart technology, for instance mobile phones and social media exposure, can enable access to information about AMs and AMR. CONCLUSION: This study shows that terminology that is understandable by the community referring to AMs and AMR in Nepali and Awadhi languages does not exist, but full explanatory sentences and colloquial names are used. Despite regular utilisation, communities have incomplete knowledge regarding AMs. Since, knowledge alone cannot improve behaviour, behavioural interventions are required to address AMR via community engagement to co-produce their own solutions. TRIAL REGISTRATION: Not applicable.

Assessing food-based strategies to address anaemia in pregnancy in rural plains Nepal: a mixed methods study.

Anaemia in pregnancy is a persistent health problem in Nepal and could be reduced through nutrition counselling and strengthened iron folic acid supplementation programmes. We analysed 24-hour diet recall data from 846 pregnant women in rural plains Nepal, using linear programming to identify the potential for optimised food-based strategies to increase iron adequacy. We then conducted qualitative research to analyse how anaemia was defined and recognised, how families used food-based strategies to address anaemia, and the acceptability of optimised food-based strategies. We did 16 interviews of recently pregnant mothers, three focus group discussions with fathers, three focus group discussions with mothers-in-law and four interviews with key informants. Dietary analyses showed optimised diets did not achieve 100 % of recommended iron intakes, but iron intakes could be doubled by increasing intakes of green leaves, egg and meat. Families sought to address anaemia through food-based strategies but were often unable to because of the perceived expense of providing an 'energy-giving' diet. Some foods were avoided because of religious or cultural taboos, or because they were low status and could evoke social consequences if eaten. There is a need for counselling to offer affordable ways for families to optimise iron adequacy. The participation of communities in tailoring advice to ensure cultural relevance and alignment with local norms is necessary to enable its effectiveness.

Contextual factors affecting the implementation of an anemia focused virtual counseling intervention for pregnant women in plains Nepal: a mixed methods process evaluation.

BACKGROUND: Anemia is estimated to cause 115,000 maternal deaths each year. In Nepal, 46% of pregnant women have anemia. As part of an integrated anemia-prevention strategy, family engagement and counseling of pregnant women can increase compliance to iron folic acid tablets, but marginalized women often have lower access to these interventions. We implemented the VALID (Virtual antenatal intervention for improved diet and iron intake) randomized controlled trial to test a family-focused virtual counseling mHealth intervention designed to inclusively increase iron folic acid compliance in rural Nepal; here we report findings from our process evaluation research. METHODS: We conducted semi structured interviews with 20 pregnant women who had received the intervention, eight husbands, seven mothers-in-laws and four health workers. We did four focus groups discussions with intervention implementers, 39 observations of counseling, and used routine monitoring data in our evaluation. We used inductive and deductive analysis of qualitative data, and descriptive statistics of monitoring data. RESULTS: We were able to implement the intervention largely as planned and all participants liked the dialogical counseling approach and use of story-telling to trigger conversation. However, an unreliable and inaccessible mobile network impeded training families about how to use the mobile device, arrange the counseling time, and conduct the counseling. Women were not equally confident using mobile devices, and the need to frequently visit households to troubleshoot negated the virtual nature of the intervention for some. Women's lack of agency restricted both their ability to speak freely and their mobility, which meant that some women were unable to move to areas with better mobile reception. It was difficult for some women to schedule the counseling, as there were competing demands on their time. Family members were difficult to engage because they were often working outside the home; the small screen made it difficult to interact, and some women were uncomfortable speaking in front of family members. CONCLUSIONS: It is important to understand gender norms, mobile access, and mobile literacy before implementing an mHealth intervention. The contextual barriers to implementation meant that we were not able to engage family members as much as we had hoped, and we were not able to minimize in-person contact with families. We recommend a flexible approach to mHealth interventions which can be responsive to local context and the situation of participants. Home visits may be more effective for those women who are most marginalized, lack confidence in using a mobile device, and where internet access is poor.

Scaling up tobacco cessation within TB programmes: findings from a multi-country, mixed-methods implementation study.

BACKGROUND: Brief behavioural support can effectively help tuberculosis (TB) patients quit smoking and improve their outcomes. In collaboration with TB programmes in Bangladesh, Nepal and Pakistan, we evaluated the implementation and scale-up of cessation support using four strategies: (1) brief tobacco cessation intervention, (2) integration of tobacco cessation within routine training, (3) inclusion of tobacco indicators in routine records and (4) embedding research within TB programmes. METHODS: We used mixed methods of observation, interviews, questionnaires and routine data. We aimed to understand the extent and facilitators of vertical scale-up (institutionalization) within 59 health facility learning sites in Pakistan, 18 in Nepal and 15 in Bangladesh, and horizontal scale-up (increased coverage beyond learning sites). We observed training and surveyed all 169 TB health workers who were trained, in order to measure changes in their confidence in delivering cessation support. Routine TB data from the learning sites were analysed to assess intervention delivery and use of TB forms revised to report smoking status and cessation support provided. A purposive sample of TB health workers, managers and policy-makers were interviewed (Bangladesh n = 12; Nepal n = 13; Pakistan n = 19). Costs of scale-up were estimated using activity-based cost analysis. RESULTS: Routine data indicated that health workers in learning sites asked all TB patients about tobacco use and offered them cessation support. Qualitative data showed use of intervention materials, often with adaptation and partial implementation in busy clinics. Short (1-2 hours) training integrated within existing programmes increased mean confidence in delivering cessation support by 17% (95% CI: 14-20%). A focus on health system changes (reporting, training, supervision) facilitated vertical scale-up. Dissemination of materials beyond learning sites and changes to national reporting forms and training indicated a degree of horizontal scale-up. Embedding research within TB health systems was crucial for horizontal scale-up and required the dynamic use of tactics including alliance-building, engagement in the wider policy process, use of insider researchers and a deep understanding of health system actors and processes. CONCLUSIONS: System-level changes within TB programmes may facilitate routine delivery of cessation support to TB patients. These strategies are inexpensive, and with concerted efforts from TB programmes and donors, tobacco cessation can be institutionalized at scale.

Addressing anaemia in pregnancy in rural plains Nepal: A qualitative, formative study.

Maternal anaemia prevalence in low-income countries is unacceptably high. Our research explored the individual-, family- and community-level factors affecting antenatal care uptake, iron folic acid (IFA) intake and consumption of micronutrient-rich diets among pregnant women in the plains of Nepal. We discuss how these findings informed the development of a home visit and community mobilisation intervention to reduce anaemia in pregnancy. We used a qualitative methodology informed by the socio-ecological framework, conducting semi-structured interviews with recently pregnant women and key informants, and focus group discussions with mothers-in-law and fathers. We found that harmful gender norms restricted women's access to nutrient-rich food, restricted their mobility and access to antenatal care. These norms also restricted fathers' role to that of the provider, as opposed to the caregiver. Pregnant women, mothers-in-law and fathers lacked awareness about iron-rich foods and how to manage the side effects of IFA. Fathers lacked trust in government health facilities affecting access to care and trust in the efficacy of IFA. Our research informed interventions by (1) informing the development of intervention tools and training; (2) informing the intervention focus to engaging mothers-in-law and men to enable behaviour change; and (3) demonstrating the need to work in synergy across individual, family and community levels to address power and positionality, gender norms, trust in health services and harmful norms. Participatory groups and home visits will enable the development and implementation of feasible and acceptable strategies to address family and contextual issues generating knowledge and an enabling environment for behaviour change.

MANTRA: development and localization of a mobile educational health game targeting low literacy players in low and middle income countries.

BACKGROUND: Mobile technology is increasingly important for delivering public health interventions to remote populations. This research study developed, piloted, and assessed a serious game for mobile devices that teaches geohazard, maternal, and neonatal health messages. This unique mHealth intervention aimed at low-literacy audiences in low resource settings is part of the Maternal and Neonatal Technologies in Rural Areas (MANTRA) project: Increasing maternal and child health resilience before, during, and after disasters using mobile technology in Nepal. METHODS: The serious game was developed through a co-creation process between London and Kathmandu based researchers by email and video-calling, and face-to-face with local stakeholders in Nepal. The process identified core needs, developed appropriate pictograms and mechanics, and tailored the pilot serious game to the local cultural context. Evaluations and feedback from end users took place in rural villages and suburban Kathmandu in Province Three. Field evaluation sessions used mixed methods. Researchers observed game play and held focus group discussions to elicit qualitative feedback and understand engagement, motivation, and usability, and conducted a paired pre- and post-game knowledge assessment. RESULTS: The MANTRA serious game is contextualized to rural Nepal. The game teaches 28 learning objectives in three modules: maternal health, neonatal health, and geohazards, through picture matching with immediate audio and visual feedback. User feedback from focus groups demonstrated high engagement, motivation, and usability of the game. CONCLUSIONS: This MANTRA study is a unique mHealth intervention of a serious game to teach core health and geohazards messages to low-literacy audiences in rural Nepal. Although the mobile game is tailored for this specific context, the developmental process and insights could be transferable to the development of other games-based interventions and contextualized for any part of the world. Successfully targeting this low-literacy and illiterate audience makes the MANTRA development process the first of its kind and a novel research endeavor with potential for widespread impact and adoption following further game development. TRIAL REGISTRATION: This project was approved by the University College London Ethics Committee in London, United Kingdom [10547/001], and the Nepal Health Research Council in Kathmandu, Nepal [Reg. No. 105/2017]. All participants provided informed written consent.

Using qualitative evaluation components to help understand context: case study of a family planning intervention with female community health volunteers (FCHVs) in Nepal.

BACKGROUND: Evaluations of health interventions are increasingly concerned with measuring or accounting for 'context'. How to do this is still subject to debate and testing, and is particularly important in the case of family planning where outcomes will inevitably be influenced by contextual factors as well as any intervention effects. We conducted an evaluation of an intervention where female community health volunteers (FCHVs) in Nepal were trained to provide better interpersonal communication on family planning. We included a context-orientated qualitative component to the evaluation. Here, we discuss the evaluation findings, specifically focusing on what was added by attending to the context. We explore and illustrate important dimensions of context that may also be relevant in future evaluation work. METHODS: The evaluation used a mixed methods approach, with a qualitative component which included in-depth interviews with women of reproductive age, FCHVs, and family planning service providers. We conducted iterative, thematic analysis. RESULTS: The life-history fertility and contraception narratives generated from the in-depth interviews contextualised the intervention, yielding nuanced data on contraceptive choices, needs, and areas for future action. For instance, it highlighted how women generally knew about effective contraceptive methods and were willing to use them: information was not a major barrier. Barriers instead included reports of providers refusing service when women were not in the fifth day of their menstrual cycle when this was unnecessary. Privacy and secrecy were important to some women, and risked being undermined by information sharing between FCHVs and health services. The qualitative component also revealed unanticipated positive effects of our own evaluation strategies: using referral slips seemed to make it easier for women to access contraception. CONCLUSIONS: Life history narratives collected via in-depth interviews helped us understand pathways from intervention to effect from the user point of view without narrowly focusing only on the intervention, highlighting possible areas for action that would otherwise have been missed. By attending to context in a nuanced way in evaluations, we can build a body of evidence that not only informs future interventions within that context, but also builds better knowledge of contextual factors likely to be important elsewhere.

Assessing intersectional gender analysis in Nepal's health management information system: a case study on tuberculosis for inclusive health systems.

BACKGROUND: Tuberculosis (TB) remains a major public health problem in Nepal, high in settings marked by prevalent gender and social inequities. Various social stratifiers intersect, either privileging or oppressing individuals based on their characteristics and contexts, thereby increasing risks, vulnerabilities and marganilisation associated with TB. This study aimed to assess the inclusiveness of gender and other social stratifiers in key health related national policies and the Health Management Information System (HMIS) of National Tuberculosis Programme (NTP) by conducting an intersectional analysis of TB cases recorded via HMIS. METHODS: A desk review of key policies and the NTP's HMIS was conducted. Retrospective intersectional analysis utilized two secondary data sources: annual NTP report (2017-2021) and records of 628 TB cases via HMIS 6.5 from two TB centres (2017/18-2018/19). Chi-square test and multi-variate analysis was used to assess the association between social stratifers and types of TB, registration category and treatment outcome. RESULTS: Gender, social inclusion and concept of intersectionality are incorporated into various health policies and strategies but lack effective implementation. NTP has initiated the collection of age, sex, ethnicity and location data since 2014/15 through the HMIS. However, only age and sex disaggregated data are routinely reported, leaving recorded social stratifiers of TB patients static without analysis and dissemination. Furthermore, findings from the intersectional analysis using TB secondary data, showed that male more than 25 years exhibited higher odds [adjusted odds ratio (aOR) = 4.95, 95% confidence interval (CI): 1.60-19.06, P = 0.01)] of successful outcome compared to male TB patients less than 25 years. Similarly, sex was significantly associated with types of TB (P < 0.05) whereas both age (P < 0.05) and sex (P < 0.05) were significantly associated with patient registration category (old/new cases). CONCLUSIONS: The results highlight inadequacy in the availability of social stratifiers in the routine HMIS. This limitation hampers the NTP's ability to conduct intersectional analyses, crucial for unveiling the roles of other social determinants of TB. Such limitation underscores the need for more disaggregated data in routine NTP to better inform policies and plans contributing to the development of a more responsive and equitable TB programme and effectively addressing disparities.

Drivers of antimicrobial resistance within the communities of Nepal from One Health perspective: a scoping review.

Background: A major driver of antimicrobial resistance (AMR) is the inappropriate use of antimicrobials. At the community level, people are often engaged in behaviors that drive AMR within human, animal, and environmental (One Health) impacts. This scoping review consolidates research to determine (a) the community's knowledge, attitudes, and practices around AMR; (b) existing community-based interventions; and (c) barriers and enablers to addressing AMR in Nepal. Methods: This scoping review follows the Joanna Briggs Institute scoping review methodology. Literature indexed in PubMed, Scopus, CINAHL, Global Index Medicus, HINARI-SUMMON, Embase (Ovid), Global Health (Ovid), CAB Abstracts (Ovid), Web of Science, and Google Scholar between January 2000 and January 2023 were reviewed for inclusion. Articles were included in the review if they considered the issues of AMR at the community level in Nepal; this excluded clinical and laboratory-based studies. A total of 47 studies met these criteria, were extracted, and analyzed to consolidate the key themes. Results: A total of 31 (66%) articles exclusively included human health; five (11%) concentrated only on animal health; no studies solely focused on environmental aspects of AMR; and the remaining studies jointly presented human, animal, and environmental aspects. Findings revealed inadequate knowledge accompanied by inappropriate practice in both the human and animal health sectors. Four community interventions improved knowledge and practices on the appropriate use of antimicrobials among community people. However, various social and economic factors were found as barriers to the appropriate use of antimicrobials in the community. Conclusion: Community engagement and One Health approaches could be key tools to improve awareness of AMR and promote behavioral change related to AM use in communities, as current studies have revealed inadequate knowledge alongside inappropriate practices shared in both human and animal health sectors. Systematic review registration: DOI: 10.17605/OSF.IO/FV326.

Factors influencing the implementation of integrated screening for HIV, syphilis, and hepatitis B for pregnant women in Nepal: A qualitative study.

In Nepal, national guidelines recommend free HIV and syphilis screening for pregnant women at their first antenatal visit, using an opt-out approach. However, screening uptake is low and the guidelines do not include hepatitis B screening. It is essential to understand the factors influencing the implementation of integrated screening for HIV, syphilis, and hepatitis B, as recommended by WHO, to improve uptake and prevent vertical transmission. This study explored the knowledge, attitudes, and perceptions of pregnant women, their families, healthcare providers and policymakers on integrated prenatal screening. We conducted 12 in-depth interviews with pregnant women, 10 with their husbands and 4 with mothers-in-law in Kapilvastu and Kathmandu. In addition, we interviewed 7 health workers and 4 decision-makers. These interviews were sufficient to reach saturation. Data were analysed using a thematic content analysis. A combination of the social-ecological model and the WHO building blocks provided a theoretical framework for interpreting data. The analysis showed that antenatal screening in Nepal involved many stakeholders and was influenced by various factors. Implementation issues were found in the building blocks service delivery, health workforce and medical products. Husbands and in-laws play an important role in the acceptance of screening by pregnant women, especially in rural areas. High levels of stigma and discrimination against people with sexually transmitted diseases were reported, and knowledge of hepatitis B and syphilis was low. Access and uptake of screening could be improved through rapid testing, by strengthening the health system and by integrating hepatitis B screening through an opt-out approach like that for HIV and syphilis. Effective community involvement through awareness campaigns and investment in lower-level health facilities is essential to improve screening rates. This study provides information for decision-makers about challenges in implementing integrated screening to guide the design of targeted interventions to reduce vertical transmission.

Understanding gender and its intersection with social stratifiers on prevention and care seeking behavior of lymphatic filariasis in Nepal.

BACKGROUND: Lymphatic filariasis (LF) is a debilitating and painful neglected tropical disease and is one of the leading causes of permanent disability. In many countries, the intersection of gender with various social stratifiers has influenced exposure to LF and ultimately impacting the disease burden and its elimination. This study aimed to explore the influence of gender and its intersection with other social stratifiers for the prevention and care seeking behavior of LF in Nepal. METHODS: This study employed qualitative research methods: in-depth interviews (IDIs) and focus group discussions (FGDs) for data collection in Bardiya, Nepal. A total of 22 IDIs (11 male, 11 female) and 2 FGDs (1 male and 1 female) were conducted with the community people between January and March 2020. The participants were purposively selected to represent different social stratifiers including age, sex, ethnicity, occupation. The data collected were analyzed using a thematic framework approach with use of intersectional gender analysis matrix. RESULTS: The study findings revealed that men spend more time outside their household compared to women while fulfilling their roles and responsibilities, largely determined by societal expectations and gender norms. This resulted in limited access to preventive health services for men, as they often missed annual mass drug administration programme in their community and limited access to preventive methods. Further traditional occupation, specific to particular ethnicity, influenced the vulnerability to LF for certain ethnic groups. The ability to prevent exposure varied among individuals. Although women made decisions regarding the use of protective methods, it was influenced by patriarchal and gender norms. They often felt a responsibility to take care and priorities males and other family members when resources are limited. The intersectionality of gender with other social stratifiers such as marital status, ethnicity, and geographical areas influenced individual's ability to access information related to LF and care seeking. CONCLUSIONS: Overall, the findings emphasized how access to resources, division of work, norms and values and decision-making power alone and its interaction with various social stratifiers shaped peoples' vulnerability to disease, ability to prevent exposure and response to illness.

Exploring the potential for children to act on antimicrobial resistance in Nepal: Valuable insights from secondary analysis of qualitative data.

This study explores the perceived roles of children in antimicrobial resistance (AMR) in two sites across Nepal. AMR is a global challenge and underpinned by many complex behavioural drivers including how antimicrobial medicines are sourced and used. Because of this social dynamic, several research groups are using community engagement (CE) approaches to understand AMR at community level. However, most data negate the importance of children in behaviours linked to, and potentially driving AMR. In this study, authors apply secondary analysis methods to 10 transcripts representing the views of 23 adults engaged in an AMR-focused film-making project. By focusing on participants' reference to children, we reveal that antimicrobial usage and adherence to health providers' messages can be influenced by the age of the patient. Secondly that children are involved in some of the behaviours which are known to drive antimicrobial resistance such as purchasing over-the-counter antibiotic drugs. Finally, community members discuss that, with careful creation of resources, AMR could be meaningfully presented in educational settings with a view to children acting as agents of change around AMR-driving behaviours. Findings suggest that age-inclusive community engagement projects could be effective in tackling AMR at community level in Nepal and other low resource settings.

Health worker perspectives on access to antenatal care in rural plains Nepal during the COVID-19 pandemic.

The COVID-19 pandemic affected access to antenatal care in low and middle-income countries where anaemia in pregnancy is prevalent. We analyse how health workers provided antenatal care and the factors affecting access to antenatal care during the COVID-19 pandemic in Kapilvastu district in the western plains of Nepal. We used qualitative and quantitative methodologies, conducting eight semi-structured interviews with health workers who provided antenatal care during the pandemic, and a questionnaire containing open and closed questions with 52 female community health volunteers. Antenatal care was severely disrupted during the pandemic. Health workers had to find ways to provide care with insufficient personal protective equipment and guidance whilst facing extreme levels of stigmatisation which prevented them from providing outreach services. Pregnant women were fearful or unable to visit health institutions during the pandemic because of COVID-19 control measures. Pre-pandemic and during the pandemic health workers tried to contact pregnant and postpartum women and families over the phone, but this was challenging because of limited access to phones, and required pregnant women to make at least one antenatal care visit to give their phone number. The pandemic prevented new pregnancies from being registered, and therefore the possibilities to provide services over the phone for these pregnancies were limited. To reach the most marginalised during a pandemic or other health emergency, health volunteers and households need to exchange phone numbers, enabling proactive monitoring and care-seeking. Strengthening procurement and coordination between the municipal, provincial, and federal levels of government is needed to ensure adequacy of antenatal supplies, such as iron folic acid tablets, in health emergencies. Community engagement is important to ensure women and families are aware of the need to access antenatal care and iron folic acid, and to address stigmatisation of health workers.

Co-designing community-based interventions to tackle antimicrobial resistance (AMR): what to include and why.

Antimicrobial resistance (AMR) is a social and biological problem. Although resistance to antimicrobials is a natural phenomenon, many human behaviors are increasing the pressure on microbes to develop resistance which is resulting in many commonly used treatments becoming ineffective. These behaviors include unregulated use of antimicrobial medicines, pesticides and agricultural chemicals, the disposal of heavy metals and other pollutants into the environment, and human-induced climatic change. Addressing AMR thus calls for changes in the behaviors which drive resistance. Community engagement for antimicrobial resistance (CE4AMR) is an international and interdisciplinary network focused on tackling behavioural drivers of AMR at community level. Since 2019 this network has worked within Low-Middle Income Countries (LMICs), predominantly within Southeast Asia, to tackle behavioral drivers of AMR can be mitigated through bottom-up solutions championed by local people. This commentary presents seven Key Concepts identified from across the CE4AMR portfolio as integral to tackling AMR. We suggest it be used to guide future interventions aimed at addressing AMR via social, participatory, and behavior-change approaches.

Addressing antimicrobial resistance through community engagement: a framework for developing contextually relevant and impactful behaviour change interventions.

Background: Community engagement (CE) interventions often explore and promote behaviour change around a specific challenge. Suggestions for behaviour change should be co-produced in partnership with the community. To facilitate this, it is essential that the intervention includes key content that unpacks the challenge of interest via multiple sources of knowledge. However, where community lived experience and academic evidence appear misaligned, tensions can appear within the co-production dynamic of CE. This is specifically so within the context of antimicrobial resistance (AMR) where ideal behaviours are often superseded by what is practical or possible in a particular community context. Methods: Here we describe a framework for the equitable development of contextually appropriate, clearly evidenced behavioural objectives for CE interventions. This framework explores different sources of knowledge on AMR, including the potentially competing views of different stakeholders. Findings: The framework allows key content on AMR to be selected based upon academic evidence, contextual appropriateness and fit to the chosen CE approach. A case study of the framework in action exemplifies how the framework is applicable to a range of contexts, CE approaches and One Health topics beyond just AMR. Conclusions: Within CE interventions, academic evidence is crucial to develop well-informed key content. However, this formative work should also involve community members, ensuring that their contextual knowledge is valued. The type of CE approach also needs careful consideration because methodological constraints may limit the breadth and depth of information that can be delivered within an intervention, and thus the scope of key content.

Study protocol for a randomised controlled trial of a virtual antenatal intervention for improved diet and iron intake in Kapilvastu district, Nepal: VALID.

INTRODUCTION: Despite evidence that iron and folic acid (IFA) supplements can improve anaemia in pregnant women, uptake in Nepal is suboptimal. We hypothesised that providing virtual counselling twice in mid-pregnancy, would increase compliance to IFA tablets during the COVID-19 pandemic compared with antenatal care (ANC alone. METHODS AND ANALYSIS: This non-blinded individually randomised controlled trial in the plains of Nepal has two study arms: (1) control: routine ANC; and (2) 'Virtual' antenatal counselling plus routine ANC. Pregnant women are eligible to enrol if they are married, aged 13-49 years, able to respond to questions, 12-28 weeks' gestation, and plan to reside in Nepal for the next 5 weeks. The intervention comprises two virtual counselling sessions facilitated by auxiliary nurse midwives at least 2 weeks apart in mid-pregnancy. Virtual counselling uses a dialogical problem-solving approach with pregnant women and their families. We randomised 150 pregnant women to each arm, stratifying by primigravida/multigravida and IFA consumption at baseline, providing 80% power to detect a 15% absolute difference in primary outcome assuming 67% prevalence in control arm and 10% loss-to-follow-up. Outcomes are measured 49-70 days after enrolment, or up to delivery otherwise. PRIMARY OUTCOME: consumption of IFA on at least 80% of the previous 14 days. SECONDARY OUTCOMES: dietary diversity, consumption of intervention-promoted foods, practicing ways to enhance bioavailability and knowledge of iron-rich foods. Our mixed-methods process evaluation explores acceptability, fidelity, feasibility, coverage (equity and reach), sustainability and pathways to impact. We estimate costs and cost-effectiveness of the intervention from a provider perspective. Primary analysis is by intention-to-treat, using logistic regression. ETHICS AND DISSEMINATION: We obtained ethical approval from Nepal Health Research Council (570/2021) and UCL ethics committee (14301/001). We will disseminate findings in peer-reviewed journal articles and by engaging policymakers in Nepal. TRIAL REGISTRATION NUMBER: ISRCTN17842200.

Gender and Antimicrobial Resistance: What Can We Learn From Applying a Gendered Lens to Data Analysis Using a Participatory Arts Case Study?

Antimicrobial resistance (AMR), the natural process by which bacteria become resistant to the medicines used to kill them, is becoming one of the greatest threats to health globally. AMR is accelerating at alarming rates due to behaviors across human, animal, and environmental health sectors as well as governance and policy shortfalls across each sector. Antimicrobial resistant infections occur through the same channels as other infectious diseases and are most common in countries/areas where there is limited access to improved sanitation facilities, reliable healthcare and health education. At the community level, much remains to be understood about the drivers of antimicrobial resistance and how to generate community-led, acceptable solutions. Gender can influence every part of an individual's health experiences; access to knowledge, healthcare facilities, financial resources and paid employment are all heavily gendered and influence behaviors relating to the procurement of antimicrobial and antibiotic agents. This analysis uses data gathered during a participatory video study designed to work with two communities in Nepal to understand drivers of antibiotic mis and over use from the perspective of the communities themselves. Findings reveal that gender impacts upon many aspects of AMR-driving behaviors within this community and stimulate essential discussion as to the importance of gender in future AMR research. This paper places a spotlight on gender in the wider AMR conversation, an area that is currently neglected, and improve our collective knowledge on the drivers of AMR from a gendered perspective.

Engaging Female Community Health Volunteers (FCHVs) for cardiovascular diseases risk screening in Nepal.

INTRODUCTION: Non-Communicable Diseases (NCDs) have become the leading public health problems worldwide and the cardiovascular diseases (CVDs) is one of the major NCDs. Female Community Health Volunteers (FCHVs) in Nepal are the key drivers to implementing frontline health services. We explored the potential for engaging FCHVs for CVD risk screening at the community level in Nepal. METHODS: We used multiple approaches (quantitative and qualitative) for data collection. The trained FCHVs administered CVD risk screening questionnaire among 491 adults in rural and urban areas and calculated the CVD risk scores. To maintain consistency and quality, a registered medical doctor also, using the same risk scoring chart, independently calculated the CVD risk scores. Kappa statistics and concordance coefficient were used to compare these two sets of risk screening results. Sensitivity and specificity analyses were conducted. Two focus group discussions among the FCHVs were conducted to determine their experiences with CVD risk screening and willingness to engage with CVD prevention and control efforts. RESULTS: The mean level of agreement between two sets of risk screening results was 94.5% (Kappa = 0.77, P<0.05). Sensitivity of FCHV screening was 90.3% (95% CI: 0.801-0.964); and the specificity was 97% (95% CI: 0.948, 0.984). FCHVs who participated in the FGDs expressed a strong enthusiasm and readiness to using the CVD risk screening tools. Despite their busy workload, all FCHVs showed high level of motivation and willingness in using CVD risk screening tools and contribute to the prevention and control efforts of NCDs. The FCHVs recommended needs for providing additional training and capacity building opportunities. CONCLUSION: We conclude that there is a potential for engaging FCHVs to use simple CVD risk screening tools at the community level. The findings are promising, however, further studies engaging larger number of FCHVs and larger population would warrant feasibility of such tools within the existing healthcare systems in Nepal.

Comprehensive Anaemia Programme and Personalized Therapies (CAPPT): protocol for a cluster-randomised controlled trial testing the effect women's groups, home counselling and iron supplementation on haemoglobin in pregnancy in southern Nepal.

BACKGROUND: Anaemia in pregnancy remains prevalent in Nepal and causes severe adverse health outcomes. METHODS: This non-blinded cluster-randomised controlled trial in the plains of Nepal has two study arms: (1) Control: routine antenatal care (ANC); (2) Home visiting, iron supplementation, Participatory Learning and Action (PLA) groups, plus routine ANC. Participants, including women in 54 non-contiguous clusters (mean 2582; range 1299-4865 population) in Southern Kapilbastu district, are eligible if they consent to menstrual monitoring, are resident, married, aged 13-49 years and able to respond to questions. After 1-2 missed menses and a positive pregnancy test, consenting women < 20 weeks' gestation, who plan to reside locally for most of the pregnancy, enrol into trial follow-up. Interventions comprise two home-counselling visits (at 12-21 and 22-26 weeks' gestation) with iron folic acid (IFA) supplement dosage tailored to women's haemoglobin concentration, plus monthly PLA women's group meetings using a dialogical problem-solving approach to engage pregnant women and their families. Home visits and PLA meetings will be facilitated by auxiliary nurse midwives. The hypothesis is as follows: Haemoglobin of women at 30 ± 2 weeks' gestation is ≥ 0.4 g/dL higher in the intervention arm than in the control. A sample of 842 women (421 per arm, average 15.6 per cluster) will provide 88% power, assuming SD 1.2, ICC 0.09 and CV of cluster size 0.27. Outcomes are captured at 30 ± 2 weeks gestation. Primary outcome is haemoglobin concentration (g/dL). Secondary outcomes are as follows: anaemia prevalence (%), mid-upper arm circumference (cm), mean probability of micronutrient adequacy (MPA) and number of ANC visits at a health facility. Indicators to assess pathways to impact include number of IFA tablets consumed during pregnancy, intake of energy (kcal/day) and dietary iron (mg/day), a score of bioavailability-enhancing behaviours and recall of one nutrition knowledge indicator. Costs and cost-effectiveness of the intervention will be estimated from a provider perspective. Using constrained randomisation, we allocated clusters to study arms, ensuring similarity with respect to cluster size, ethnicity, religion and distance to a health facility. Analysis is by intention-to-treat at the individual level, using mixed-effects regression. DISCUSSION: Findings will inform Nepal government policy on approaches to increase adherence to IFA, improve diets and reduce anaemia in pregnancy. TRIAL REGISTRATION: ISRCTN 12272130 .