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Background: As the field of global mental health grows, many psychotherapy trainees will work across cultures in low-resource settings in high-income countries or in low- and middle-income countries. Faculty members and mentors may face several challenges in providing supervision for psychologists in low-resource settings. As such, there is a need to develop best practices for psychotherapy supervision in global mental health. Methods: We describe the common challenges and potential strategies in psychotherapy supervision based on our research, clinical, and academic partnerships between academic institutions, a nonprofit organization, and the Nepali government. Results: The strategies and considerations we have found helpful include focusing on therapies with strong behavioral and interpersonal (rather than emotional or cognitive) components and using locally validated therapies or standard manuals that have been endorsed by the WHO for low-resource settings. Other strategies include providing psychotherapy training for local psychiatrists who may be in supervisory roles and gaining competence in navigating different expectations of social structures and family dynamics. Conclusion: Supervisors face many challenges while supporting trainees and early psychologists in global mental health settings. While ensuring local adaptation, key considerations can be developed into best practices to support psychiatrists, supervisors, and trainees based in low- and middle-income countries.
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Adherence to treatment regimens is a common challenge in achieving HIV control, especially among youth. Motivational Interviewing (MI) is an evidence-based intervention to facilitate behavior change (such as adherence to treatment) by focusing on the client's priorities and motivations. Community Health Workers (CHWs), who are well situated to engage clients for care, can use MI but studies have shown that they often lose MI skills. While mHealth tools can support CHWs in delivering evidence-based counseling techniques such as MI, it is important to understand the barriers and facilitators in using such tools. Our parent study includes developing and testing a novel mHealth tool called, Community based mHealth Motivational Interviewing Tool for HIV-positive youth (COMMIT+). In this descriptive qualitative study, we share the results from semi-structured interviews with 12 CHWs who used COMMIT+ to engage youth living with HIV, and 7 of their Community Health Nurse supervisors. Our results demonstrate the barriers and facilitators experienced by CHWs in using a mHealth tool to deliver MI for youth living with HIV in rural Nepal, and highlight that supportive supervision and user-friendly features of the tool can mitigate many of the barriers.
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BACKGROUND: Although long-acting reversible contraception (LARC) is more effective and longer lasting than short-acting methods, uptake remains low among post-abortion clients. Using a stepped-wedge, cluster-randomized trial, we evaluate the impact of a provider-level peer-comparison intervention to encourage choice of LARC in Nepal among post-abortion clients. METHODS: The intervention used prominently displayed monthly posters comparing the health clinic's previous month performance on LARC uptake against peer clinics. To understand how the intervention affected behavior, while ensuring voluntarism and informed choice, we used mystery client visits, in-depth provider interviews, and client exit survey data. The trial examined 17,680 post-abortion clients in 36 clinics in Nepal from July 2016 to January 2017. The primary outcome was the proportion of clients receiving LARCs. Statistical analysis used ordinary least squares (OLS) regression with ANCOVA estimation to assess the intervention's impact on LARC uptake while controlling for client- and clinic-level characteristics. RESULTS: The intervention increased LARC use among post-abortion clients by 6.6% points [95% CI: 0.85 to 12.3, p-value < 0.05], a 29.5% increase in LARC use compared to control clinics. This effect persisted after the formal experiment ended. Analysis of provider and client experiences showed that the behavioral intervention generated significant change in providers' counseling practices, motivated the sharing of best practices. Quality of care indicators either remained stable or improved. CONCLUSION: We find that a provider-level behavioral intervention increases LARC uptake among post-abortion clients. This type of intervention represents a low-cost option to contribute to reducing unmet need for contraception through provider behavior change.
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Aborto Induzido , Contracepção Reversível de Longo Prazo , Humanos , Nepal , Feminino , Contracepção Reversível de Longo Prazo/estatística & dados numéricos , Adulto , Adulto Jovem , Adolescente , Gravidez , Promoção da Saúde/métodosRESUMO
Background: Suicidal thoughts and behaviors (STBs) are prevalent within the Lesbian, Gay, Bisexual, Transgender, and Queers (LGBTQ) community, often exacerbated by challenges in accessing care and the perceived stigma and discrimination tied to disclosing one's identity. Digital health interventions that offer psychosocial self-help present a promising platform to reach individuals at risk of STBs, especially those who may not engage with conventional health services. This review aimed to assess the role of digital-based intervention in reducing STBs among LGBTQ individuals. Methods: We conducted a systematic literature search from three databases, PsycINFO, PubMed, and CINHAL, from 1st Jan 1990 to 31st December 2023. The review encompassed studies investigating the feasibility, acceptability, and impact of digital interventions on STBs, employing randomized control trials (RCTs), pseudo-RCTs, observational pre-posttest designs, and qualitative studies. Potential bias was evaluated using the McGill Mixed Methods Appraisal Tool (MMAT). Results: Five non-overlapping studies were included, reporting data from 777 participants. The studies featured diverse types of digital interventions, including videos, online writing, and mobile applications. The studies included three RCTs, and two qualitative studies. Across most of these studies, notable enhancements or reductions in the proportion of participants reporting STBs were observed post-intervention, alongside improvements in help-seeking intentions. The findings underscored that the applications used in the studies were engaging, acceptable, and deemed feasible in effectively addressing suicide prevention among the LGBTQ community. Conclusion: Overall, digital interventions were found to be feasible and acceptable in suicide prevention among LGBTQ communities, demonstrating preliminary efficacy in increasing help-seeking behavior when experiencing suicidal thoughts and in reducing STBs. Therefore, advocating for widespread promotion and dissemination of digital health interventions is crucial, particularly in low- and middle-income countries (LMICs) with limited access to health services and heightened barriers to obtaining such services. Further research using fully powered RCT is imperative to assess the efficacy of these interventions.
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BACKGROUND: Men who have sex with men (MSM) are disproportionately burdened by poor mental health. Despite the increasing burden, evidence-based interventions for MSM are largely nonexistent in Nepal. OBJECTIVE: This study explored mental health concerns, contributing factors, barriers to mental health care and support, and preferred interventions to improve access to and use of mental health support services among MSM in Nepal. METHODS: We conducted focus groups with MSM in Kathmandu, Nepal, in January 2023. In total, 28 participants took part in 5 focus group sessions. Participants discussed several topics related to the mental health issues they experienced, factors contributing to these issues, and their suggestions for potential interventions to address existing barriers. The discussions were recorded, transcribed, and analyzed using Dedoose (version 9.0.54; SocioCultural Research Consultants, LLC) software for thematic analysis. RESULTS: Participants reported substantial mental health problems, including anxiety, depression, suicidal ideation, and behaviors. Contributing factors included family rejection, isolation, bullying, stigma, discrimination, and fear of HIV and other sexually transmitted infections. Barriers to accessing services included cost, lack of lesbian, gay, bisexual, transgender, intersex, queer, and asexual (LGBTIQA+)-friendly providers, and the stigma associated with mental health and sexuality. Participants suggested a smartphone app with features such as a mental health screening tool, digital consultation, helpline number, directory of LGBTIQA+-friendly providers, mental health resources, and a discussion forum for peer support as potential solutions. Participants emphasized the importance of privacy and confidentiality to ensure mobile apps are safe and accessible. CONCLUSIONS: The findings of this study have potential transferability to other low-resource settings facing similar challenges. Intervention developers can use these findings to design tailored mobile apps to facilitate mental health care delivery and support for MSM and other marginalized groups.
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Infecções por HIV , Minorias Sexuais e de Gênero , Telemedicina , Masculino , Feminino , Humanos , Homossexualidade Masculina/psicologia , Saúde Mental , Nepal/epidemiologia , Infecções por HIV/diagnósticoRESUMO
Skilled care during pregnancy, childbirth, and postpartum is essential to prevent adverse maternal health outcomes, yet utilization of care remains low in many resource-limited countries, including Nepal. Community health workers (CHWs) can mitigate health system challenges and geographical barriers to achieving universal health coverage. Gaps remain, however, in understanding whether evidence-based interventions delivered by CHWs, closely aligned with WHO recommendations, are effective in Nepal's context. We conducted a type II hybrid effectiveness-implementation, mixed-methods study in two rural districts in Nepal to evaluate the effectiveness and the implementation of an evidence-based integrated maternal and child health intervention delivered by CHWs, using a mobile application. The intervention was implemented stepwise over four years (2014-2018), with 65 CHWs enrolling 30,785 families. We performed a mixed-effects Poisson regression to assess institutional birth rate (IBR) pre-and post-intervention. We used the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework to evaluate the implementation during and after the study completion. There was an average 30% increase in IBR post-intervention, adjusting for confounding variables (p<0.0001). Study enrollment showed 35% of families identified as dalit, janjati, or other castes. About 78-89% of postpartum women received at least one CHW-counseled home visit within 60 days of childbirth. Ten (53% of planned) municipalities adopted the intervention during the study period. Implementation fidelity, measured by median counseled home visits, improved with intervention time. The intervention was institutionalized beyond the study period and expanded to four additional hubs, albeit with adjustments in management and supervision. Mechanisms of intervention impact include increased knowledge, timely referrals, and longitudinal CHW interaction. Full-time, supervised, and trained CHWs delivering evidence-based integrated care appears to be effective in improving maternal healthcare in rural Nepal. This study contributes to the growing body of evidence on the role of community health workers in achieving universal health coverage.
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BACKGROUND: Timely tracking of health outcomes is difficult in low- and middle-income countries without comprehensive vital registration systems. Community health workers (CHWs) are increasingly collecting vital events data while delivering routine care in low-resource settings. It is necessary, however, to assess whether routine programmatic data collected by CHWs are sufficiently reliable for timely monitoring and evaluation of health interventions. To study this, we assessed the consistency of vital events data recorded by CHWs using two methodologies-routine data collected while delivering an integrated maternal and child health intervention, and data from a birth history census approach at the same site in rural Nepal. METHODS: We linked individual records from routine programmatic data from June 2017 to May 2018 with those from census data, both collected by CHWs at the same site using a mobile platform. We categorized each vital event over a one-year period as 'recorded by both methods,' 'census alone,' or 'programmatic alone.' We further assessed whether vital events data recorded by both methods were classified consistently. RESULTS: From June 2017 to May 2018, we identified a total of 713 unique births collectively from the census (birth history) and programmatic maternal 'post-delivery' data. Three-fourths of these births (n = 526) were identified by both. There was high consistency in birth location classification among the 526 births identified by both methods. Upon including additional programmatic 'child registry' data, we identified 746 total births, of which 572 births were identified by both census and programmatic methods. Programmatic data (maternal 'post-delivery' and 'child registry' combined) captured more births than census data (723 vs. 595). Both methods consistently classified most infants as 'living,' while infant deaths and stillbirths were largely classified inconsistently or recorded by only one method. Programmatic data identified five infant deaths and five stillbirths not recorded in census data. CONCLUSIONS: Our findings suggest that data collected by CHWs from routinely tracking pregnancies, births, and deaths are promising for timely program monitoring and evaluation. Despite some limitations, programmatic data may be more sensitive in detecting vital events than cross-sectional census surveys asking women to recall these events.
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Saúde da Criança , Agentes Comunitários de Saúde , Criança , Estudos Transversais , Feminino , Humanos , Lactente , Morte do Lactente , Nepal , Gravidez , Sistema de Registros , NatimortoRESUMO
OBJECTIVES: Little is known about sex workers' experiences of cervical cryotherapy. We sought to understand sex workers' perspectives of 'screen and treat' programmes and their management of the World Health Organization post-treatment guidance to abstain from sex or use condoms consistently for 4 weeks. We explored contraceptive preferences and use of menstrual regulation services. METHODS: We conducted semi-structured interviews with 16 sex workers and six brothel leaders in an urban brothel complex in Bangladesh between October and November 2018. All had undergone cryotherapy. We conducted a thematic analysis using deductive coding, informed by a priori themes, and inductive data-driven coding. RESULTS: Most sex workers could not abstain from sex during the healing period. Consistent condom use was challenging due to economic incentives attached to condomless sex and coercive behaviours of clients. The implications of non-adherence among high-risk groups such as sex workers are not known. Use of short-acting methods of contraception was common, and discontinuation was high due to side effects and other perceived health concerns. The majority of sex workers and brothel leaders had utilized menstrual regulation services. Barriers to accessing timely menstrual regulation and other sexual and reproductive health services included limited mobility, economic costs, and discriminatory attitudes of health care workers. CONCLUSION: Service innovations are required to enable sex workers to abstain or use condoms consistently in the post-cryotherapy healing phase and to address sex workers' broader sexual and reproductive health needs. Further research is required to assess the risk of HIV and other sexually transmitted infection transmission following cryotherapy among high-risk groups.
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Infecções por HIV , Profissionais do Sexo , Infecções Sexualmente Transmissíveis , Neoplasias do Colo do Útero , Bangladesh , Atenção à Saúde , Feminino , Infecções por HIV/prevenção & controle , Humanos , Pesquisa Qualitativa , Trabalho Sexual , Infecções Sexualmente Transmissíveis/prevenção & controle , Neoplasias do Colo do Útero/prevenção & controleRESUMO
INTRODUCTION: Despite carrying a disproportionately high burden of depression, patients in low-income countries lack access to effective care. The collaborative care model (CoCM) has robust evidence for clinical effectiveness in improving mental health outcomes. However, evidence from real-world implementation of CoCM is necessary to inform its expansion in low-resource settings. METHODS: We conducted a 2-year mixed-methods study to assess the implementation and clinical impact of CoCM using the WHO Mental Health Gap Action Programme protocols in a primary care clinic in rural Nepal. We used the Capability Opportunity Motivation-Behaviour (COM-B) implementation research framework to adapt and study the intervention. To assess implementation factors, we qualitatively studied the impact on providers' behaviour to screen, diagnose and treat mental illness. To assess clinical impact, we followed a cohort of 201 patients with moderate to severe depression and determined the proportion of patients who had a substantial clinical response (defined as ≥50% decrease from baseline scores of Patient Health Questionnaire (PHQ) to measure depression) by the end of the study period. RESULTS: Providers experienced improved capability (enhanced self-efficacy and knowledge), greater opportunity (via access to counsellors, psychiatrist, medications and diagnostic tests) and increased motivation (developing positive attitudes towards people with mental illness and seeing patients improve) to provide mental healthcare. We observed substantial clinical response in 99 (49%; 95% CI: 42% to 56%) of the 201 cohort patients, with a median seven point (Q1:-9, Q3:-2) decrease in PHQ-9 scores (p<0.0001). CONCLUSION: Using the COM-B framework, we successfully adapted and implemented CoCM in rural Nepal, and found that it enhanced providers' positive perceptions of and engagement in delivering mental healthcare. We observed clinical improvement of depression comparable to controlled trials in high-resource settings. We recommend using implementation research to adapt and evaluate CoCM in other resource-constrained settings to help expand access to high-quality mental healthcare.
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Transtornos Mentais , Psiquiatria , Depressão/diagnóstico , Depressão/terapia , Humanos , Nepal , População RuralRESUMO
Adolescent girls in low- and middle-income countries continue to face poor sexual and reproductive health (SRH). In Nepal, early marriage and motherhood, gender-based violence, and unmet need for contraception remain pervasive. Adolescent girls in rural areas bear a disproportionate burden of poor reproductive health outcomes, but there are limited context-specific data. This is a qualitative study to identify factors that impact adolescent girls' utilisation of and access to SRH services in a rural district of Nepal. We conducted 21 individual interviews with adolescent girls aged 15-19 years, and three focus group discussions with community health workers. We used an inductive analytic approach to identify emergent and recurrent themes and present the themes using the social ecological model. Individual-level factors that contribute to low uptake of services among adolescent girls include lack of knowledge, self-perceived lack of need, low decision-making autonomy, and shyness. Interpersonal factors that impact access include unsupportive family norms, absence of open communication, and need for permission from family members to access care. At the community level, disparate gender norms, son preference, and judgment by community members affect adolescent SRH. Inadequate sex education, far travel distance to facilities, lack of female healthcare providers and teachers, and inability to access abortion services were identified as organisational and systems barriers. Stigma was a factor cross-cutting several levels. Our findings suggest the need for multi-level strategies to address these factors to improve adolescent girls' SRH.
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Saúde Reprodutiva , Saúde Sexual , Adolescente , Feminino , Humanos , Mães , Nepal , Gravidez , Comportamento SexualRESUMO
Community health workers (CHWs) are essential to primary health care systems and are a cost-effective strategy to achieve the Sustainable Development Goals (SDGs). Nepal is strongly committed to universal health coverage and the SDGs. In 2017, the Nepal Ministry of Health and Population partnered with the nongovernmental organization Nyaya Health Nepal to pilot a program aligned with the 2018 World Health Organization guidelines for CHWs. The program includes CHWs who: (1) receive regular financial compensation; (2) meet a minimum education level; (3) are well supervised; (4) are continuously trained; (5) are integrated into local primary health care systems; (6) use mobile health tools; (7) have consistent supply chain; (8) live in the communities they serve; and (9) provide service without point-of-care user fees. The pilot model has previously demonstrated improved institutional birth rate, antenatal care completion, and postpartum contraception utilization. Here, we performed a retrospective costing analysis from July 16, 2017 to July 15, 2018, in a catchment area population of 60,000. The average per capita annual cost is US$3.05 (range: US$1.94 to US$4.70 across 24 villages) of which 74% is personnel cost. Service delivery and administrative costs and per beneficiary costs for all services are also described. To address the current discourse among Nepali policy makers at the local and federal levels, we also present 3 alternative implementation scenarios that policy makers may consider. Given the Government of Nepal's commitment to increase health care spending (US$51.00 per capita) to 7.0% of the 2030 gross domestic product, paired with recent health care systems decentralization leading to expanded fiscal space in municipalities, this CHW program provides a feasible opportunity to make progress toward achieving universal health coverage and the health-related SDGs. This costing analysis offers insights and practical considerations for policy makers and locally elected officials for deploying a CHW cadre as a mechanism to achieve the SDG targets.
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Agentes Comunitários de Saúde/economia , Análise Custo-Benefício , Atenção à Saúde/economia , Custos de Cuidados de Saúde , Atenção Primária à Saúde/economia , Serviços de Saúde Rural/economia , População Rural , Feminino , Programas Governamentais/economia , Humanos , Nepal , Organizações , Política , Gravidez , Cuidado Pré-Natal , Parcerias Público-Privadas , Estudos Retrospectivos , Cobertura Universal do Seguro de SaúdeRESUMO
Unmet need for postpartum contraception in rural Nepal remains high and expanding access to sexual and reproductive healthcare is essential to achieving universal healthcare. We evaluated the impact of an integrated intervention that employed community health workers aided by mobile technology to deliver patient-centred, home-based antenatal and postnatal counselling on postpartum modern contraceptive use. This was a pre-post-intervention study in seven village wards in a single municipality in rural Nepal. The primary outcome was modern contraceptive use among recently postpartum women. We performed a multivariable logistic regression to examine contraceptive use among postpartum women pre- and one-year post-intervention. We conducted qualitative interviews to explore the implementation process. There were 445 postpartum women in the pre-intervention group and 508 in the post-intervention group. Modern contraceptive use increased from 29% pre-intervention to 46% post-intervention (p < 0.0001). Adjusting for age, caste, and household expenditure, time since delivery and sex of child in the index pregnancy, postpartum women one-year post-intervention had twice the odds (OR 2.3; CI 1.7, 3.1; p < 0.0001) of using a modern contraceptive method as compared to pre-intervention. Factors at the individual, family, and systems level influenced women's contraceptive decisions. The intervention contributed to increasing contraceptive use through knowledge transfer, demand generation, referrals to healthcare facilities, and follow-up. A community-based, patient-centred contraceptive counselling intervention supported by mobile technology and integrated into longitudinal care delivered by community health workers appears to be an effective strategy for improving uptake of modern contraception among postpartum women in rural Nepal.
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Comportamento Contraceptivo/psicologia , Comportamento Contraceptivo/estatística & dados numéricos , Anticoncepção/estatística & dados numéricos , Serviços de Planejamento Familiar/métodos , Conhecimentos, Atitudes e Prática em Saúde , Adolescente , Adulto , Anticoncepção/métodos , Aconselhamento/métodos , Feminino , Humanos , Entrevistas como Assunto , Pessoa de Meia-Idade , Nepal , Período Pós-Parto , Gravidez , População Rural , Adulto JovemRESUMO
BACKGROUND: In Nepal, the burden of noncommunicable, chronic diseases is rapidly rising, and disproportionately affecting low and middle-income countries. Integrated interventions are essential in strengthening primary care systems and addressing the burden of multiple comorbidities. A growing body of literature supports the involvement of frontline providers, namely mid-level practitioners and community health workers, in chronic care management. Important operational questions remain, however, around the digital, training, and supervisory structures to support the implementation of effective, affordable, and equitable chronic care management programs. METHODS: A 12-month, population-level, type 2 hybrid effectiveness-implementation study will be conducted in rural Nepal to evaluate an integrated noncommunicable disease care management intervention within Nepal's new municipal governance structure. The intervention will leverage the government's planned roll-out of the World Health Organization's Package of Essential Noncommunicable Disease Interventions (WHO-PEN) program in four municipalities in Nepal, with a study population of 80,000. The intervention will leverage both the WHO-PEN and its cardiovascular disease-specific technical guidelines (HEARTS), and will include three evidence-based components: noncommunicable disease care provision using mid-level practitioners and community health workers; digital clinical decision support tools to ensure delivery of evidence-based care; and training and digitally supported supervision of mid-level practitioners to provide motivational interviewing for modifiable risk factor optimization, with a focus on medication adherence, and tobacco and alcohol use. The study will evaluate effectiveness using a pre-post design with stepped implementation. The primary outcomes will be disease-specific, "at-goal" metrics of chronic care management; secondary outcomes will include alcohol and tobacco consumption levels. DISCUSSION: This is the first population-level, hybrid effectiveness-implementation study of an integrated chronic care management intervention in Nepal. As low and middle-income countries plan for the Sustainable Development Goals and universal health coverage, the results of this pragmatic study will offer insights into policy and programmatic design for noncommunicable disease care management in the future. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04087369. Registered on 12 September 2019.
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Pessoal Técnico de Saúde , Sistemas de Apoio a Decisões Clínicas , Entrevista Motivacional , Doenças não Transmissíveis/terapia , População Rural , Consumo de Bebidas Alcoólicas , Doença Crônica , Agentes Comunitários de Saúde , Gerenciamento Clínico , Humanos , Ciência da Implementação , Adesão à Medicação , Nepal , Comportamento de Redução do Risco , Abandono do Uso de TabacoRESUMO
BACKGROUND: Although Nepal legalised abortion in 2002, a significant number of women continue to access unsafe abortions. An estimated 60% of all abortions performed in 2014 were unsafe, with unsafe abortion continuing to be a leading contributor to maternal mortality. Despite medical abortion access being solely permitted through government accredited safe abortion services, medical abortion pills are readily available for illegal purchase at pharmacies throughout the country. METHODS: Utilising an Assets Focused Rapid Participatory Appraisal (AFRPA) research methodology, underpinned by a health information pyramid conceptual framework, this qualitative exploratory study collected data from in-depth, open-ended interviews. The study explored the medical abortion and sexual and reproductive health experiences of ten women who accessed medical abortion through an accredited safe abortion service, and ten women who accessed unsafe medical abortion through pharmacies. RESULTS: Thematic content analysis revealed emerging themes relating to decision-making processes in accessing safe or unsafe medical abortion; knowledge of safe abortion services; and SRH information access and post-abortion contraceptive counselling. Findings emphasised the interconnectivity of sexual and reproductive health and rights; reproductive coercion; education; poverty; spousal separation; and women's personal, social and economic empowerment. CONCLUSIONS: While barriers to safe abortion services persist, so will the continued demand for medical abortion provision through pharmacies. Innovated and effective harm reduction implementations combined with access and information expansion strategies offer the potential to increase access to safe medical abortion while decreasing adverse health outcomes for women.
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Aborto Induzido/psicologia , Aborto Legal/psicologia , Serviços de Planejamento Familiar/métodos , Serviços de Planejamento Familiar/estatística & dados numéricos , Farmácias/estatística & dados numéricos , Saúde Reprodutiva/normas , Aborto Induzido/estatística & dados numéricos , Aborto Legal/estatística & dados numéricos , Adolescente , Adulto , Feminino , Acessibilidade aos Serviços de Saúde , Humanos , Pessoa de Meia-Idade , Nepal , Gravidez , Pesquisa Qualitativa , Adulto JovemRESUMO
BACKGROUND: Globally, women face many barriers in the attainment of sexual and reproductive health and rights (SRHR). Since 2002, the legalisation of abortion in Nepal has seen significant progress in the expansion of safe abortion and family planning services. METHODS: This qualitative, exploratory study was conducted in 2014 and uses nine in-depth, open-ended interviews with a cross-section of SRHR professionals, to explore their perspectives on abortion in Nepal. The study was underpinned by the Assets Focused Rapid Participatory Appraisal (AFRPA) research methodology and used the health information pyramid conceptual framework. RESULTS: Thematic content analysis revealed emerging themes relating to barriers to access and uptake of skilled safe abortion services and post-abortion family planning. Findings also emphasised current practical and legal components relating to the provision of medical abortion through pharmacies and highlighted issues of sex-selective abortion within the predominantly patriarchal society. CONCLUSION: Effective and ongoing sector-wide monitoring and evaluation of safe abortion services and their staff is essential for women in Nepal to have adequate access to effective and efficient safe abortion services, access to contraception and sexual and reproductive health (SRH) information post-abortion and to ensure adherence to current Safe Abortion Policy. It is critical that the unsafe (less and least safe) provision of medical abortion through pharmacies and sex-selective abortion continues to be investigated and that innovative strategies are formulated to ensure the cultural, reproductive and sexual health and rights of Nepali women are realised.
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Aborto Induzido , Atitude do Pessoal de Saúde , Serviços de Planejamento Familiar , Acessibilidade aos Serviços de Saúde , Medicina Reprodutiva , Segurança , Aborto Induzido/efeitos adversos , Aborto Induzido/legislação & jurisprudência , Anticoncepção/métodos , Feminino , Política de Saúde , Direitos Humanos , Humanos , Entrevistas como Assunto , Nepal , Saúde Reprodutiva , Saúde Sexual , Estigma Social , Fatores SocioeconômicosRESUMO
PROBLEM: The ability of health care providers to work together is essential for favourable outcomes in neonatal resuscitation, but perceptions of such teamwork have rarely been studied in low-income settings. BACKGROUND: Neonatal resuscitation is a proven intervention for reducing neonatal mortality globally, but the long-term effects of clinical training for this skill need further attention. Having an understanding of barriers to teamwork among nurse midwives can contribute to the sustainability of improved clinical practice. AIM: To explore nurse midwives' perceptions of teamwork when caring for newborns in need of resuscitation. METHODS: Nurse midwives from a tertiary-level government hospital in Nepal participated in five focus groups of between 4 and 11 participants each. Qualitative Content Analysis was used for analysis. FINDINGS: One overarching theme emerged: looking for comprehensive guidelines and shared responsibilities in neonatal resuscitation to avoid personal blame and learn from mistakes. Participants discussed the need for protocols relating to neonatal resuscitation and the importance of shared medical responsibility, and the importance of the presence of a strong and transparent leadership. DISCUSSION: The call for clear and comprehensive protocols relating to neonatal resuscitation corresponded with previous research from different contexts. CONCLUSION: Nurse midwives working at a maternity health care facility in Nepal discussed the benefits and challenges of teamwork in neonatal resuscitation. The findings suggest potential benefits can be made from clarifying guidelines and responsibilities in neonatal resuscitation. Furthermore, a structured process to deal with clinical incidents must be considered. Management must be involved in all processes.
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Atitude do Pessoal de Saúde , Tocologia/métodos , Enfermeiros Obstétricos/educação , Enfermeiros Obstétricos/psicologia , Equipe de Enfermagem/métodos , Ressuscitação/educação , Ressuscitação/métodos , Adulto , Feminino , Grupos Focais , Maternidades , Humanos , Recém-Nascido , Nepal , GravidezRESUMO
Introduction Long-acting reversible contraceptives (LARCs) reduce rates of unintended pregnancies and repeat abortion. Uptake and continuation rates of LARCs are very low in Nepal, despite free provision from most health facilities. We sought to establish the effectiveness of a new approach to LARC promotion in Nepal. Methods We examined change in contraceptive method mix in Nepal using service data resulting from introduction of a balanced counseling (BC) approach to family planning (FP). All staff located at nine randomly selected FP sites were trained and began applying BC in April and May 2014. Women who accepted LARCs from a participating facility were re-contacted at 1, 3, 6 and 12 months. We estimated the LARC continuation rate and assessed determinants of continuation using descriptive analysis, Kaplan-Meier survival curves and univariate and multivariate Cox proportional hazard analysis. Results A total of 5744 women received BC between April and July 2014. 1580 women (27.5 %) took up LARCs, raising its contribution to contraceptive method mix at [organization] to 40 %, significantly higher than the 15 % recorded in 2013. 913 women were followed-up, and the LARC continuation rate at 12 months was 82 %. Women's reported satisfaction with LARC [AHR 0.23; 95 % CI 0.14-0.39, p = 0.000] was the single strongest determinant of LARC continuation after adjusting for all background characteristics. Discussion The findings suggest BC is an effective approach for increasing LARC uptake in Nepal. The rate of LARC continuation and its determinants are important inputs to strategies for improved delivery of FP services.
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Comportamento de Escolha , Anticoncepção/métodos , Aconselhamento , Serviços de Planejamento Familiar , Contracepção Reversível de Longo Prazo , Adolescente , Adulto , Estudos de Coortes , Anticoncepcionais Femininos/uso terapêutico , Feminino , Humanos , Nepal , Gravidez , Gravidez não Planejada , Adulto JovemRESUMO
Despite the provision of free and subsidized family planning services and clients' demonstrated intentions to delay pregnancies, family planning uptake among women who receive abortion and postabortion services at Sunaulo Parivar Nepal (SPN), one of Nepal's largest non-governmental sexual and reproductive health (SRH) providers, remains low. Through meetings, interviews, and observations with SPN's stakeholders, service providers, and clients at its 36 SRH centers, we developed hypotheses about client- and provider-side barriers that may inhibit postabortion family planning (PAFP) uptake. On the provider side, we found that the lack of benchmarks (such as the performance of other facilities) against which providers could compare their own performance and the lack of feedback on the performance were important barriers to PAFP uptake. We designed several variants of three interventions to address these barriers. Through conversations with team members at SPN's centralized support office and service providers at SPN centers, we prioritized a peer-comparison tool that allows providers at one center to compare their performance with that of other similar centers. We used feedback from the community of providers on the tools' usability and features to select a variant of the tool that also leverages and reinforces providers' strong intrinsic motivation to provide quality PAFP services. In this paper, we detail the process of identifying barriers and creating an intervention to overcome those barriers. The intervention's effectiveness will be tested with a center-level, stepped-wedge randomized control trial in which SPN's 36 centers will be randomly assigned to receive the intervention at 1-month intervals over a 6-month period. Existing medical record data will be used to monitor family planning uptake.