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.

Transforming pharmaceutical education: A needs-based global analysis for policy development.

Background: A needs-based approach is desirable for the transformation of pharmaceutical education, and to link pharmaceutical education with the health needs of populations and national priorities. There are varying levels of data in the literature on the status of pharmaceutical education in all six World Health Organization (WHO) regions, especially in the context of needs identification and evidence-based policy interventions. The framework for this study was the FIP Development Goals. Objectives: The aim of the study was to develop evidence-based policies through a needs-based approach for pharmaceutical education transformation nationally, regionally and globally by addressing the following objectives: 1. Identify global and regional needs in pharmaceutical education, through a regional SWOT analysis and prioritization of FIP development goals; 2. Develop valid and credible regional roadmaps for pharmaceutical education advancement according to the identified prioritized goals and 3. Develop a global call to action as a policy intervention for advancing pharmaceutical education. Methods: This study was conducted between 2020 and 2021 using a mixed methods approach. Surveys of higher education institutions and a series of qualitative interviews were conducted with national professional leadership organizations, with further regional workshops having 284 participants recruited from the International Pharmaceutical Federation (FIP) membership base, spanning all six WHO regions. Results: Eleven out of 21 FIP DGs were identified as priorities for regional roadmaps and FIP DG 1 (Academic capacity) was identified as a priority in four regions. All regions had distinctive results with an area of commonality between them. There were common weaknesses in the adoption of competency-based education and inter-professional education. Conclusions: It is critical for every country and region to develop needs- and evidence-based policies for the transformation of pharmaceutical education, for which FIP DGs provide a systematic framework.

A cluster randomized controlled trial of an electronic decision-support system to enhance antenatal care services in pregnancy at primary healthcare level in Telangana, India: trial protocol.

BACKGROUND: India contributes 15% of the total global maternal mortality burden. An increasing proportion of these deaths are due to Pregnancy Induced Hypertension (PIH), Gestational Diabetes Mellitus (GDM), and anaemia. This study aims to evaluate the effectiveness of a tablet-based electronic decision-support system (EDSS) to enhance routine antenatal care (ANC) and improve the screening and management of PIH, GDM, and anaemia in pregnancy in primary healthcare facilities of Telangana, India. The EDSS will work at two levels of primary health facilities and is customized for three cadres of healthcare providers - Auxiliary Nurse Midwifes (ANMs), staff nurses, and physicians (Medical Officers). METHODS: This will be a cluster randomized controlled trial involving 66 clusters with a total of 1320 women in both the intervention and control arms. Each cluster will include three health facilities-one Primary Health Centre (PHC) and two linked sub-centers (SC). In the facilities under the intervention arm, ANMs, staff nurses, and Medical Officers will use the EDSS while providing ANC for all pregnant women. Facilities in the control arm will continue to provide ANC services using the existing standard of care in Telangana. The primary outcome is ANC quality, measured as provision of a composite of four selected ANC components (measurement of blood pressure, blood glucose, hemoglobin levels, and conducting a urinary dipstick test) by the healthcare providers per visit, observed over two visits. Trained field research staff will collect outcome data via an observation checklist. DISCUSSION: To our knowledge, this is the first trial in India to evaluate an EDSS, targeted to enhance the quality of ANC and improve the screening and management of PIH, GDM, and anaemia, for multiple levels of health facilities and several cadres of healthcare providers. If effective, insights from the trial on the feasibility and cost of implementing the EDSS can inform potential national scale-up. Lessons learned from this trial will also inform recommendations for designing and upscaling similar mHealth interventions in other low and middle-income countries. CLINICALTRIALS: gov, NCT03700034, registered 9 Oct 2018, https://www. CLINICALTRIALS: gov/ct2/show/NCT03700034 CTRI, CTRI/2019/01/016857, registered on 3 Mar 2019, http://www.ctri.nic.in/Clinicaltrials/pdf_generate.php?trialid=28627&EncHid=&modid=&compid=%27,%2728627det%27.

Prioritizing intervention measures to prevent inappropriate self-medication practices using the Analytical Hierarchy Process.

Background: United Nations Sustainable Development Goal 3 outlines the target of reducing premature mortality from non-communicable diseases by one third through prevention and treatment by 2030. In low and middle-income countries (LMICs) like Nepal, a significant number of people do not have accessible and affordable healthcare services available to them, leading to self-medication practices (SMP). Limited numbers of health professionals, ineffective regulation and easy availability of prescription medicines encourage the use of inappropriate SMP, which could result in health risks. Objectives: The objection of the study is to test the application of Analytical Hierarchy Process (AHP) for prioritizing the intervention measures for preventing inappropriate SMP. Methods: The 25 experts were included in the study, out of which only 16 experts passed the consistency test. Data were collected using a structured questionnaire by the application of AHP model for ranking the intervention measures for preventing inappropriate SMP from March 2020 to May 2020. During this process, the purposively selected experts compared seven intervention measures based on three criteria: control use of prescription and non-prescription medicine, knowledge regarding the medicine and its use, and minimizing healthcare cost. Result: The criteria, "control use of prescription and non-prescription medicine" was judged 3.58 times and 1.53 times more important than to "minimize the healthcare cost" and "knowledge regarding the medicine and its use" respectively. "Regulation of prescription and non-prescription dispensing practice" was the most prioritized intervention measure to prevent inappropriate SMP with a priority score of 20.68% followed by the "accessibility of healthcare system" (19.27%) and "awareness program for the consumers" (17.13%). Conclusion: The AHP method can be used in decision-making related to prioritizing the intervention measures to prevent inappropriate SMP. Among the seven intervention measures considered, "regulation of prescription and non-prescription dispensing practice" was the most preferred intervention measure to improve SMP followed by "access to healthcare" and an "awareness program".

Reintroduction of Post-Baccalaureate Doctor of Pharmacy (PharmD, Post-Bac) Program in Nepal: Exploration of the Obstacles and Solutions to Move Forward.

This commentary article highlights the status of clinical pharmacy education in Nepal, explores the challenges and solutions in sustainably reintroducing Post-Baccalaureate Doctor of Pharmacy (PharmD, Post-Bac) in Nepal, as was previously launched by Kathmandu University (KU) Department of Pharmacy in 2010, and suggests a few prospects forward. Clinical pharmacy practice has remained on the sidelines and subordinate to physicians in Nepal. KU launched the PharmD (Post-Bac.) as a postgraduate program to establish the professional identity of clinical pharmacists in the country. However, despite unremitting efforts, the program did not thrive long and held since 2014. This paper aimed to explore challenges that remained at the forefront of the program and provide possible solutions for its reintroduction. The KU produced three batches of PharmD Post-Bac. graduates and now the revival of the program is crucial. Undoubtedly, a well-trained clinical preceptor can bring significant changes in the quality and competency of the PharmD graduates. Advocacy programs to foster the role of clinical pharmacists in the patient care services and revisiting of Bachelor of Pharmacy (BPharm) curriculum to complement the necessity of the PharmD program are needed. The non-sustenance of the PharmD program is emblematic of the dire mosaic that the clinical pharmacists are facing while delivering patient-oriented services in the country. Hence, strategies need to be formulated for the revival and sustainability of the program.

A Cluster-based, Spatial-sampling Method for Assessing Household Healthcare Utilization Patterns in Resource-limited Settings.

BACKGROUND: Implementation of population-based surveys is resource intensive and logistically demanding, especially in areas with rapidly changing demographics and incomplete or no enumeration of the underlying population and their residences. To remove the need for pre-enumeration and to simplify field logistics for the population healthcare utilization survey used for the Surveillance for Enteric Fever in Asia Project in Nepal, we incorporated a geographic information system-based geosurvey and field mapping system into a single-stage cluster sampling approach. METHODS: A survey was administered to ascertain healthcare-seeking behavior in individuals with recent suspected enteric fever. Catchment areas were based on residential addresses of enteric fever patients using study facilities; clusters were randomly selected from digitally created grids using available satellite images and all households within clusters were offered enrollment. A tablet-compatible geosurvey and mapping system that allowed for data-syncing and use in areas without cellular data was created using the ArcGIS suite of software. RESULTS: Between January 2017 and November 2018, we surveyed 25 521 households in Nepal (16 769 in urban Kathmandu and 8752 in periurban Kavrepalanchok), representing 84 202 individuals. Overall, the survey participation rate was 90.9%, with geographic heterogeneity in participation rates within each catchment area. Areas with higher average household wealth had lower participation rates. CONCLUSION: A geographic information system-based geosurvey and field mapping system allowed creation of a virtual household map at the same time as survey administration, enabling a single-stage cluster sampling method to assess healthcare utilization in Nepal for the Surveillance for Enteric Fever in Asia Project . This system removed the need for pre-enumeration of households in sampling areas, simplified logistics and could be replicated in future community surveys.

Typhoid and Paratyphoid Cost of Illness in Nepal: Patient and Health Facility Costs From the Surveillance for Enteric Fever in Asia Project II.

BACKGROUND: Enteric fever is endemic in Nepal and its economic burden is unknown. The objective of this study was to estimate the cost of illness due to enteric fever (typhoid and paratyphoid) at selected sites in Nepal. METHODS: We implemented a study at 2 hospitals in Nepal to estimate the cost per case of enteric fever from the perspectives of patients, caregivers, and healthcare providers. We collected direct medical, nonmedical, and indirect costs per blood culture-confirmed case incurred by patients and their caregivers from illness onset until after enrollment and 6 weeks later. We estimated healthcare provider direct medical economic costs based on quantities and prices of resources used to diagnose and treat enteric fever, and procedure frequencies received at these facilities by enrolled patients. We collected costs in Nepalese rupees and converted them into 2018 US dollars. RESULTS: We collected patient and caregiver cost of illness information for 395 patients, with a median cost of illness per case of $59.99 (IQR, $24.04-$151.23). Median direct medical and nonmedical costs per case represented ~3.5% of annual individual labor income. From the healthcare provider perspective, the average direct medical economic cost per case was $79.80 (range, $71.54 [hospital B], $93.43 [hospital A]). CONCLUSIONS: Enteric fever can impose a considerable economic burden on patients, caregivers, and health facilities in Nepal. These new estimates of enteric fever cost of illness can improve evaluation and modeling of the costs and benefits of enteric fever-prevention measures.

Incidence of hepatotoxicity due to antitubercular medicines and assessment of risk factors.

BACKGROUND: Antitubercular drugs cause derangement of hepatic function revealed by clinical examination and abnormal liver function test results. Potential hepatotoxicity of some of the first-line antitubercular agents remains a problem, especially during the initial period of treatment. OBJECTIVE: To determine the incidence of antitubercular drug-induced hepatotoxicity in a Nepalese urban population and assess the risk factors. METHOD: Fifty patients diagnosed with active tuberculosis infection with normal pretreatment liver function were monitored clinically as well as biochemically in a prospective cohort analysis. RESULTS: Antitubercular drugs were found to be associated with derangement of hepatic function, resulting in elevation of liver enzymes to a variable extent (t = -4.550, p < 0.01 for aspartate aminotransferase [AST]; t = -5.467, p < 0.01 for alanine aminotransferase [ALT] at 95% CI). Thirty-eight percent of patients had 2 times and 30% had >3 times elevation of ALT. Similarly, 40% and 29% of patients showed 2 and >3 times elevation of the AST level, respectively. Four patients (8%) developed drug-induced hepatotoxicity. Jaundice was the presenting symptom in all patients. The time interval for onset of hepatotoxicity after initiation of therapy was 12-60 days (median 28). Antitubercular drug-induced hepatotoxicity was found more often in younger patients (6% vs 2%; p = 0.368, OR 2.75). Female gender was also a higher risk (p = 0.219, OR 4.2). Most patients who had developed hepatitis were diagnosed per sputum-smear positive reactions. Nutritional status, assessed by body mass index and serum albumin level, was the next predisposing factor. CONCLUSIONS: A finding of an 8% incidence of hepatotoxicity is considerably high. Risk factors of hepatotoxicity included female gender, disease extent, and poor nutritional status. Timely detection and temporary withdrawal of the offending agent can completely cure antitubercular drug-induced hepatotoxicity.