Advancing Cultural Competency Toward Sexual and Gender Minorities: Innovation in Maternal and Child Health Pedagogy.

PURPOSE: The purpose of this project was to develop and disseminate an innovative teaching activity to increase cultural competency toward sexual and gender minority (SGM) populations within the maternal and child health (MCH) context. DESCRIPTION: Over 4.5% of the population (16 million people in the US) identify as SGM, and this population is an often-overlooked group within the traditional MCH context. SGM individuals have specific healthcare needs, including reproductive healthcare needs, that are currently left unaddressed. Given these gaps, the future MCH workforce should be prepared with cultural competency skills to address reproductive health inequities from many perspectives, including SGM populations. An innovative SGM activity was developed and disseminated to supplement the MCH and Reproductive Health curricula. ASSESSMENT: The objectives of this SGM Reproductive Health activity were: (1) to understand SGM populations, terminology, culture, and health inequities within an MCH context; (2) enhance cultural competency and the communication skills appropriate for this population; and (3) develop culturally competent resources for practice. The teaching activity includes a lesson plan, lecture with script, recorded lecture, assignment description, and grading rubric, designed for a U.S. based curriculum. The activity was evaluated and modified based on feedback from students, and pilot tested in practice in a graduate-level reproductive health course. CONCLUSION: Future MCH leaders must have the skills to provide culturally competent care to the populations they serve, including SGM populations. Through teaching about SGM populations and cultural competence, educators can equip future MCH leaders with a culturally competent skillset to prepare them to work in cross-cultural situations.

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.

Impact of the first phase of COVID-19 pandemic on childhood routine immunisation services in Nepal: a qualitative study on the perspectives of service providers and users.

BACKGROUND: The COVID-19 pandemic has disproportionately affected all essential healthcare services delivery in low-resource settings. This study aimed to explore the challenges and experiences of providers and users of childhood immunisation services in Nepal during the COVID-19 pandemic. METHODS: Semi-structured qualitative interviews were conducted with childhood immunisation service providers and users (i.e., parents of children) from Kathmandu valley, Nepal. All interviews were conducted through phone or internet-based tools, such as Zoom, WhatsApp, and messenger. All interviews were audio-recorded, transcribed verbatim, and analysed using theme-based content analysis in an Excel spreadsheet. RESULTS: A total of 15 participants (n = 7 service providers and n = 8 service users) participated. Six themes were identified, namely: (1) impact of COVID-19 and lockdown on childhood immunisation services; (2) motivation and resilience for childhood immunisation; (3) Biosafety practices and Personal Protective Equipment (PPE) availability during the COVID-19 pandemic; (4) service adjustments and guidelines during pandemic; (5) availability of vaccines; and (6) immunisation program resilience in view of COVID-19. Service providers mentioned facing disruptions in services and some parents had decided to delay scheduled immunisation. However, most service providers showed determinations to deliver the services with high morale, while most service users reported taking their children for immunisation. Families migrating from urban to rural areas during the pandemic led to service providers having no means to confirm complete immunisation of migrating children. Service providers also experienced lack of adequate guidance to deal with the pandemic and personal protective equipment to protect themselves and service users. CONCLUSION: Despite experiencing disruptions in childhood immunisation service due to the COVID-19 pandemic, service users and providers were determined to vaccinate the children. There is an urgent need for effective preparedness plans to be in place to address the observed barriers and to ensure resilient immunisation services during ongoing and future pandemics.

Health System Preparedness for COVID-19 and Its Impacts on Frontline Health-Care Workers in Nepal: A Qualitative Study Among Frontline Health-Care Workers and Policy-Makers.

BACKGROUND: Rapidly growing coronavirus disease 2019 (COVID-19) pandemic has brought unprecedented challenges to the health system in Nepal. The main objective of this study was to explore the health system preparedness for COVID-19 and its impacts on frontline health-care workers in Nepal. METHODS: Semi-structured interviews were conducted among 32 health-care workers who were involved in clinical care of COVID-19 patients and four policy-makers who were responsible for COVID-19 control and management at central and provincial level. Interviews were conducted through telephone or Internet-based tools such as Zoom and Skype. All interviews were audio-recorded, transcribed into English, and coded using inductive and deductive approaches. RESULTS: Both health-care workers and policy-makers reported failure to initiate pre-emptive control measures at the early stages of the outbreak as the pivot in pandemic control. Although several measures were rolled out when cases started to appear, the overall health system preparedness was low. The poor governance, and coordination between three tiers of government was compounded by the inadequate personal protective equipment for health-care workers, insufficient isolation beds for patients, and poor engagement of the private sector. Frontline health-care workers experienced various degrees of stigma because of their profession and yet were able to maintain their motivation to continue serving patients. CONCLUSION: Preparedness for COVID-19 was affected by the poor coordination between three tiers of governance. Specifically, the lack of human resources, inadequate logistic chain management and laboratory facilities for testing COVID-19 appeared to have jeopardized the health system preparedness and escalated the pandemic in Nepal. Despite the poor preparedness, and health and safety concerns, health-care workers maintained their motivation. There is an urgent need for an effective coordination mechanism between various tiers of health structure (including private sector) in addition to incentivizing the health-care workers for the current and future pandemics.

Prevalence of Cesarean Section and Its Indications in A Tertiary Care Hospital.

INTRODUCTION: Cesarean section is a surgical procedure performed to deliver fetus through abdominal route. Increasing rate of cesarean section worldwide is an alarming concern for public health and obstetricians due to increase in financial burden and risk to health of the mother in comparison to vaginal delivery. The aim of the study was to find the prevalence of cesarean section and its most common indication in a tertiary care hospital. METHODS: This descriptive cross-sectional study was done in a tertiary care hospital, from July 2016 to June 2018 after taking ethical clearance from institutional review board registration number 38970/062/063. Convenience sampling was done. Data was collected and entry was done in microsoft excel, point estimate at 95% CI was calculated along with frequency and proportion for binary data. RESULTS: Out of total deliveries conducted, 862 (36.8%) were CS deliveries, 1477 (63.1%) were vaginal deliveries, and 12 (0.51%) were instrumental deliveries. Prevalence of CS is 862 (36.8%) at 95% CI (34.82%-38.78%). Mean age±S.D of delivering mother was found to be 26.1±0.25 years. Primi cesarean section was more than repeat cesarean section. Most common indication of cesarean section was fetal distress 243 (28%) followed by previous cesarean section 165 (18%), non-progress of labour 106 (12%), oligohydramnios 59 (7%), malpresentation 59 (7%), cephalo pelvic disorders 52 (6.5%), and hypertensive disorder in pregnancy 33 (4%). CONCLUSIONS: Prevalence of cesarean section in a tertiary care hospital is high compared to WHO data. The most common indication of cesarean section are fetal distress and previous cesarean section.

A profile of ectopic pregnancy at nepal medical college teaching hospital.

A retrospective study of ectopic pregnancy at Nepal Medical College Teaching Hospital between January 2001 to June 2006 was carried out to determine incidence, demographic features, clinical presentation, duration at presentation and treatment, and the management protocol. A total of 36 cases of ectopic pregnancy were treated giving the incidence of ectopic pregnancy of 10.2/1000 deliveries and 7.3 /1000 pregnancies. The mean age is 30.1 years (range 23-45 years) and the mean parity is 1.2 with nulliparous at 49%. The mean gestational age is 6.9 weeks (range 5-11 weeks). Among the ethnicity, Mongolians constituted at 54.6%. The commonest risk factors present were infertility (33.3%), previous ectopic pregnancy (16.7%), pelvic inflammatory disease (13.9%) and tubal surgery (13.9%). The commonest symptoms at presentation are abdominal pain (94.4%), amenorrhea (72.2%) and abnormal vaginal bleeding (58.3%); and commonest signs were abdominal tenderness (91.7%), adnexal tenderness (72.2%) and cervical excitation (50.0%). The mean time from symptom to treatment was 176.58 hours and mean time from admission to treatment was 12.88 hours. Ectopic pregnancy was correctly diagnosed clinically in 85.0% patients including 42.5% (12/36) of ruptured ectopic pregnancy. Abdominal ultrasound and urinary â-hCG tests (ELISA test) were additional diagnostic tools. Sixty one percent (22/36) presented in subacute condition. Two cases (5.6%) were presented late causing diagnostic problem and more morbidity like anaemia, blood transfusion, adhesion needing major operations. Salpingectomy is the mainstay of treatment. Only one case has conservative surgery. Late presentation and ruptured ectopic pregnancy is associated with increased morbidity and mortality. High index of suspicion and early recourse to laparotomy save the life from this obstetric disaster.