Health system gaps in cardiovascular disease prevention and management in Nepal.

BACKGROUND: Cardiovascular diseases (CVDs) are the leading cause of deaths and disability in Nepal. Health systems can improve CVD health outcomes even in resource-limited settings by directing efforts to meet critical system gaps. This study aimed to identify Nepal's health systems gaps to prevent and manage CVDs. METHODS: We formed a task force composed of the government and non-government representatives and assessed health system performance across six building blocks: governance, service delivery, human resources, medical products, information system, and financing in terms of equity, access, coverage, efficiency, quality, safety and sustainability. We reviewed 125 national health policies, plans, strategies, guidelines, reports and websites and conducted 52 key informant interviews. We grouped notes from desk review and transcripts' codes into equity, access, coverage, efficiency, quality, safety and sustainability of the health system. RESULTS: National health insurance covers less than 10% of the population; and more than 50% of the health spending is out of pocket. The efficiency of CVDs prevention and management programs in Nepal is affected by the shortage of human resources, weak monitoring and supervision, and inadequate engagement of stakeholders. There are policies and strategies in place to ensure quality of care, however their implementation and supervision is weak. The total budget on health has been increasing over the past five years. However, the funding on CVDs is negligible. CONCLUSION: Governments at the federal, provincial and local levels should prioritize CVDs care and partner with non-government organizations to improve preventive and curative CVDs services.

Advancing diabetes primary care education and knowledge in Nepal: A scoping review and case study discussion.

AIMS: Diabetes mellitus (DM) is a chronic disorder of insulin and glucose metabolism. It affects more than 463 million people worldwide and is expected to reach 700 million by 2045. In the Southeast Asian region, the prevalence of DM has tripled to 115 million due to rapid urbanization, unhealthy diet, sedentary lifestyles, and genetic factors. In Nepal, a developing country, DM affects 8.5% of adults, with an alarming increase in recent years. Lack of diabetes education and limited populational adoption of behavioural changes further hamper care. METHODS: In the present study, we performed a scoping review to determine the status of awareness, attitudes, and knowledge about diabetes in the Nepalese population with a focus on the educational initiatives that have been implemented. We also conducted a two-week international case study discussion among medical students to brainstorm viable intervention strategies. RESULTS: Our findings indicate that limited data is available on the level of education or initiatives to improve knowledge and practice among healthcare professionals and community members. Targeted studies of people with diabetes also present heterogeneous results due to differences in the sample population, geographic location, education, age, and gender. Accordingly, we propose five interrelated education-based strategies that leverage existing networks to expand community outreach and engagement, improve system resilience, and improve health outcomes. CONCLUSIONS: Effective education for healthcare professionals, community, and patients with diabetes is vital in improving diabetes outcomes in Nepal and South Asia. Collaboration, funding, and evaluation are key areas needing reform.

Digital health interventions for suicide prevention among LGBTQ: A narrative review.

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.

Cross-country analysis of national mental health investment case studies in sub-Saharan Africa and Central, South and South-East Asia.

Introduction: Despite the increasing interest in and political commitment to mental health service development in many regions of the world, there remains a very low level of financial commitment and corresponding investment. Assessment of the projected costs and benefits of scaling up the delivery of effective mental health interventions can help to promote, inform and guide greater investment in public mental health. Methods: A series of national mental health investment case studies were carried out (in Bangladesh, Kenya, Nepal, Philippines, Uganda, Uzbekistan and Zimbabwe), using standardized guidance developed by WHO and UNDP and implemented by a multi-disciplinary team. Intervention costs and the monetized value of improved health and production were computed in national currency units and, for comparison, US dollars. Benefit-cost ratios were derived. Findings: Across seven countries, the economic burden of mental health conditions was estimated at between 0.5%-1.0% of Gross Domestic Product. Delivery of an evidence-based package of mental health interventions was estimated to cost US$ 0.40-2.40 per capita per year, depending on the country and its scale-up period. For most conditions and country contexts there was a return of >1 for each dollar or unit of local currency invested (range: 0.0-10.6 to 1) when productivity gains alone are included, and >2 (range: 0.4-30.3 to 1) when the intrinsic economic value of health is also considered. There was considerable variation in benefit-cost ratios between intervention areas, with population-based preventive measures and treatment of common mental, neurological and conditions showing the most attractive returns when all assessed benefits are taken into account. Discussion and Conclusion: Performing a mental health investment case can provide national-level decision makers with new and contextualized information on the outlays and returns that can be expected from renewed local efforts to enhance access to quality mental health services. Economic evidence from seven low- and middle-income countries indicates that the economic burden of mental health conditions is high, the investment costs are low and the potential returns are substantial.

Implementation strategy in collaboration with people with lived experience of mental illness to reduce stigma among primary care providers in Nepal (RESHAPE): protocol for a type 3 hybrid implementation effectiveness cluster randomized controlled trial.

BACKGROUND: There are increasing efforts for the integration of mental health services into primary care settings in low- and middle-income countries. However, commonly used approaches to train primary care providers (PCPs) may not achieve the expected outcomes for improved service delivery, as evidenced by low detection rates of mental illnesses after training. One contributor to this shortcoming is the stigma among PCPs. Implementation strategies for training PCPs that reduce stigma have the potential to improve the quality of services. DESIGN: In Nepal, a type 3 hybrid implementation-effectiveness cluster randomized controlled trial will evaluate the implementation-as-usual training for PCPs compared to an alternative implementation strategy to train PCPs, entitled Reducing Stigma among Healthcare Providers (RESHAPE). In implementation-as-usual, PCPs are trained on the World Health Organization Mental Health Gap Action Program Intervention Guide (mhGAP-IG) with trainings conducted by mental health specialists. In RESHAPE, mhGAP-IG training includes the added component of facilitation by people with lived experience of mental illness (PWLE) and their caregivers using PhotoVoice, as well as aspirational figures. The duration of PCP training is the same in both arms. Co-primary outcomes of the study are stigma among PCPs, as measured with the Social Distance Scale at 6 months post-training, and reach, a domain from the RE-AIM implementation science framework. Reach is operationalized as the accuracy of detection of mental illness in primary care facilities and will be determined by psychiatrists at 3 months after PCPs diagnose the patients. Stigma will be evaluated as a mediator of reach. Cost-effectiveness and other RE-AIM outcomes will be assessed. Twenty-four municipalities, the unit of clustering, will be randomized to either mhGAP-IG implementation-as-usual or RESHAPE arms, with approximately 76 health facilities and 216 PCPs divided equally between arms. An estimated 1100 patients will be enrolled for the evaluation of accurate diagnosis of depression, generalized anxiety disorder, psychosis, or alcohol use disorder. Masking will include PCPs, patients, and psychiatrists. DISCUSSION: This study will advance the knowledge of stigma reduction for training PCPs in partnership with PWLE. This collaborative approach to training has the potential to improve diagnostic competencies. If successful, this implementation strategy could be scaled up throughout low-resource settings to reduce the global treatment gap for mental illness. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04282915 . Date of registration: February 25, 2020.