Integrated Management of Childhood Illness implementation in Nepal: understanding strategies, context, and outcomes.

BACKGROUND: Health system-delivered evidence-based interventions (EBIs) are important to reducing amenable under-5 mortality (U5M). Implementation research (IR) can reduce knowledge gaps and decrease lags between new knowledge and its implementation in real world settings. IR can also help understand contextual factors and strategies useful to adapting EBIs and their implementation to local settings. Nepal has been a leader in dropping U5M including through adopting EBIs such as integrated management of childhood illness (IMCI). We use IR to identify strategies used in Nepal's adaptation and implementation of IMCI. METHODS: We conducted a mixed methods case study using an implementation research framework developed to understand how Nepal outperformed its peers between 2000-2015 in implementing health system-delivered EBIs known to reduce amenable U5M. We combined review of existing literature and data supplemented by 21 key informant interviews with policymakers and implementers, to understand implementation strategies and contextual factors that affected implementation outcomes. We extracted relevant results from the case study and used explanatory mixed methods to understand how and why Nepal had successes and challenges in adapting and implementing one EBI, IMCI. RESULTS: Strategies chosen and adapted to meet Nepal's specific context included leveraging local research to inform national decision-makers, pilot testing, partner engagement, and building on and integrating with the existing community health system. These cross-cutting strategies benefited from facilitating factors included community health system and structure, culture of data use, and local research capacity. Geography was a critical barrier and while substantial drops in U5M were seen in both the highest and lowest wealth quintiles, with the wealth equity gap decreasing from 73 to 39 per 1,000 live births from 2001 to 2016, substantial geographic inequities remained. CONCLUSIONS: Nepal's story shows that implementation strategies that are available across contexts were key to adopting and adapting IMCI and achieving outcomes including acceptability, effectiveness, and reach. The value of choosing strategies that leverage facilitating factors such as investments in community-based and facility-based approaches as well as addressing barriers such as geography are useful lessons for countries working to accelerate adaptation and implementation of strategies to implement EBIs to continue achieving child health targets.

Exploring determinants of hydrocele surgery coverage related to Lymphatic Filariasis in Nepal: An implementation research study.

BACKGROUND: Hydrocele is a chronic condition in males in which there is an excessive collection of straw-colored fluid, which leads to enlargement of the scrotum. It is a common manifestation of lymphatic filariasis (LF) affecting nearly 25 million men worldwide. Surgery is the recommended treatment for hydrocele and is available free of cost in all government hospitals in Nepal. This research explored patient, provider, and community factors related to accessing hydrocele surgery services by the patients. METHODS: This study employed a qualitative method. The research was conducted in two LF endemic districts, namely Kanchanpur and Dhading, which are reported to have the highest number of hydrocele cases during morbidity mapping conducted in 2016. In addition to five key informant interviews with the LF focal persons (one national and 4 district-level), nine in-depth interviews were conducted with hydrocele patients (5 of whom had undergone surgery and 4 who had not undergone surgery) and with 3 family members, and two focus group discussions with the female community health volunteers. RESULTS: Most of the respondents did not have knowledge of hydrocele as one of the clinical manifestations of LF nor that it is transmitted through a mosquito bite. Although perceived as treatable with surgery, most of the patients interviewed believed in as well as practiced home remedies. Meanwhile, fear of surgery, embarrassment, lack of money, along with no knowledge of the free hydrocele surgery acted as barriers for accessing the surgery. On the other hand, financial support, flexible guidelines enabling the hospital to conduct surgery, decentralization and scaling up of morbidity mapping along with free hydrocele surgery camps in any remaining endemic districts were identified as enablers for accessing surgery. CONCLUSION: Hydrocele surgery coverage could be improved if the program further addresses community awareness. There is a need for more focus on information dissemination about hydrocele and hydrocele surgery.

Self-Reported Changes in Risk Behaviours of Cardiovascular Diseases among School Adolescents in Nepal: Application of an Integrated Experiential Learning Approach.

Cardiovascular diseases (CVDs) account for the largest proportion of all deaths in Nepal (30%). Studies report that CVDs often begin with modifiable lifestyle risk behaviours established during adolescence which manifest later. This study aimed to measure changes in the five mortality-associated CVD risk behaviours (i.e., consumption of tobacco, alcohol, and junk food, physical inactivity, and stress among school adolescents) using an integrative intervention with the experiential learning approach. The study was carried out for 24 weeks (25 credit hours) among 4,225 students from grades 8 to 10 in community schools in seven provinces in Nepal. Pre- and post-intervention in-class self-reported surveys were conducted for assessing change in the students' aggregate risk behaviours. These percent changes were assessed through bivariate analysis. Key-informant interviews of teachers were conducted to assess their perceptions of the effectiveness of the intervention. At 24 weeks, the percentages of students reporting consumption of cigarettes and smokeless tobacco declined by 25% and 28% respectively, consumption of alcohol declined by 29%, consumption of instant noodles by 11%, and consumption of coke by 43%. The proportion of students reporting 'going to school by foot every day' increased by 11%, and those 'exercising until they sweat' increased by 29%. The percentage of students who reported feeling that their 'life has been running as desired' increased by 16%. Key-informant interviews of the teachers revealed that the intervention had contributed to improved motivation, knowledge, and attitude among students towards mitigating the risk behaviours. These interviews also recommended continuation of the intervention. The sample in this study has shown positive changes in school adolescents' self-reported aggregate CVD risk behaviours using the experiential learning approach. However, further research should be conducted to explore the sustainability and scaling of these learning modules through the existing non-communicable disease (NCD) school curriculum activities in Nepal.