Drivers of antimicrobial resistance within the communities of Nepal from One Health perspective: a scoping review.

Background: A major driver of antimicrobial resistance (AMR) is the inappropriate use of antimicrobials. At the community level, people are often engaged in behaviors that drive AMR within human, animal, and environmental (One Health) impacts. This scoping review consolidates research to determine (a) the community's knowledge, attitudes, and practices around AMR; (b) existing community-based interventions; and (c) barriers and enablers to addressing AMR in Nepal. Methods: This scoping review follows the Joanna Briggs Institute scoping review methodology. Literature indexed in PubMed, Scopus, CINAHL, Global Index Medicus, HINARI-SUMMON, Embase (Ovid), Global Health (Ovid), CAB Abstracts (Ovid), Web of Science, and Google Scholar between January 2000 and January 2023 were reviewed for inclusion. Articles were included in the review if they considered the issues of AMR at the community level in Nepal; this excluded clinical and laboratory-based studies. A total of 47 studies met these criteria, were extracted, and analyzed to consolidate the key themes. Results: A total of 31 (66%) articles exclusively included human health; five (11%) concentrated only on animal health; no studies solely focused on environmental aspects of AMR; and the remaining studies jointly presented human, animal, and environmental aspects. Findings revealed inadequate knowledge accompanied by inappropriate practice in both the human and animal health sectors. Four community interventions improved knowledge and practices on the appropriate use of antimicrobials among community people. However, various social and economic factors were found as barriers to the appropriate use of antimicrobials in the community. Conclusion: Community engagement and One Health approaches could be key tools to improve awareness of AMR and promote behavioral change related to AM use in communities, as current studies have revealed inadequate knowledge alongside inappropriate practices shared in both human and animal health sectors. Systematic review registration: DOI: 10.17605/OSF.IO/FV326.

Assessing intersectional gender analysis in Nepal's health management information system: a case study on tuberculosis for inclusive health systems.

BACKGROUND: Tuberculosis (TB) remains a major public health problem in Nepal, high in settings marked by prevalent gender and social inequities. Various social stratifiers intersect, either privileging or oppressing individuals based on their characteristics and contexts, thereby increasing risks, vulnerabilities and marganilisation associated with TB. This study aimed to assess the inclusiveness of gender and other social stratifiers in key health related national policies and the Health Management Information System (HMIS) of National Tuberculosis Programme (NTP) by conducting an intersectional analysis of TB cases recorded via HMIS. METHODS: A desk review of key policies and the NTP's HMIS was conducted. Retrospective intersectional analysis utilized two secondary data sources: annual NTP report (2017-2021) and records of 628 TB cases via HMIS 6.5 from two TB centres (2017/18-2018/19). Chi-square test and multi-variate analysis was used to assess the association between social stratifers and types of TB, registration category and treatment outcome. RESULTS: Gender, social inclusion and concept of intersectionality are incorporated into various health policies and strategies but lack effective implementation. NTP has initiated the collection of age, sex, ethnicity and location data since 2014/15 through the HMIS. However, only age and sex disaggregated data are routinely reported, leaving recorded social stratifiers of TB patients static without analysis and dissemination. Furthermore, findings from the intersectional analysis using TB secondary data, showed that male more than 25 years exhibited higher odds [adjusted odds ratio (aOR) = 4.95, 95% confidence interval (CI): 1.60-19.06, P = 0.01)] of successful outcome compared to male TB patients less than 25 years. Similarly, sex was significantly associated with types of TB (P < 0.05) whereas both age (P < 0.05) and sex (P < 0.05) were significantly associated with patient registration category (old/new cases). CONCLUSIONS: The results highlight inadequacy in the availability of social stratifiers in the routine HMIS. This limitation hampers the NTP's ability to conduct intersectional analyses, crucial for unveiling the roles of other social determinants of TB. Such limitation underscores the need for more disaggregated data in routine NTP to better inform policies and plans contributing to the development of a more responsive and equitable TB programme and effectively addressing disparities.

Essential newborn care practices in health facilities of Nepal: Evidence from Nepal Health Facility Survey 2015 and 2021.

Availability of newborn care practices in health facilities (HFs) plays an important role in improving the survival and well-being of newborns. In this paper, we aimed to assess practice of carrying out different newborn care practices among HFs between 2015 and 2021, and associated factors in Nepal. We analyzed data of 621 and 786 HFs offering delivery and newborn care services from Nepal Health Facility Surveys 2015 and 2021, respectively. We summarized categorical variables with a weighted percent and 95% confidence interval (CI). We estimated weighted unadjusted absolute difference in percentage of different newborn care practices between 2015 and 2021, and its 95% CI using binomial regression model. We applied univariable and multivariable logistic regression analysis to determine the factors associated with the availability of all seven newborn care practices. The percentage of HFs carrying out all seven newborn care practices was 50.5% (95% CI: 44.6, 56.3) in 2015 and 83.7% (95% CI: 79.8, 87.0) in 2021 with an overall difference of 33.3 percent points (95% CI: 26.4, 40.1). The proportion of HFs reporting all seven newborn care practices increased significantly between 2015 and 2021 in each all three ecological regions and in provinces except Madhesh and Gandaki. In 2021, private hospitals had lower odds of carrying out all seven newborn care practices compared to federal/provincial hospitals (AOR = 0.26, 95% CI: 0.11, 0.63). Similarly, in 2021, the odds of HFs carrying out all seven newborn care practices was 2.87 (95% CI: 1.06, 8.31) times higher in Sudurpashchim compared to Koshi province. In 2021, HFs carrying out seven newborn care practices did not differ significantly based on ecological belts, quality assurance activities, external supervision, delivery service-related training, and frequency of HF meetings. In conclusion, there has been significant improvement in proportion of facilities carrying out seven essential newborn care practices between 2015 and 2021. Type of facility and provinces were associated with the HFs carrying out seven newborn care practices in Nepal.

Understanding health system resilience in responding to COVID-19 pandemic: experiences and lessons from an evolving context of federalization in Nepal.

INTRODUCTION: The COVID-19 pandemic has tested the resilience capacities of health systems worldwide and highlighted the need to understand the concept, pathways, and elements of resilience in different country contexts. In this study, we assessed the health system response to COVID-19 in Nepal and examined the processes of policy formulation, communication, and implementation at the three tiers of government, including the dynamic interactions between tiers. Nepal was experiencing the early stages of federalization reform when COVID-19 pandemic hit the country, and clarity in roles and capacity to implement functions were the prevailing challenges, especially among the subnational governments. METHODS: We adopted a cross-sectional exploratory design, using mixed methods. We conducted a desk-based review of all policy documents introduced in response to COVID-19 from January to December 2020, and collected qualitative data through 22 key informant interviews at three tiers of government, during January-March 2021. Two municipalities were purposively selected for data collection in Lumbini province. Our analysis is based on a resilience framework that has been developed by our research project, ReBUILD for Resilience, which helps to understand pathways to health system resilience through absorption, adaptation and transformation. RESULTS: In the newly established federal structure, the existing emergency response structure and plans were utilized, which were yet to be tested in the decentralized system. The federal government effectively led the policy formulation process, but with minimal engagement of sub-national governments. Local governments could not demonstrate resilience capacities due to the novelty of the federal system and their consequent lack of experience, confusion on roles, insufficient management capacity and governance structures at local level, which was further aggravated by the limited availability of human, technical and financial resources. CONCLUSIONS: The study findings emphasize the importance of strong and flexible governance structures and strengthened capacity of subnational governments to effectively manage pandemics. The study elaborates on the key areas and pathways that contribute to the resilience capacities of health systems from the experience of Nepal. We draw out lessons that can be applied to other fragile and shock-prone settings.

Factors associated with uptake of breast and cervical cancer screening among Nepalese women: Evidence from Nepal Demographic and Health Survey 2022.

Breast cancer screening (BCS) and cervical cancer screening (CCS) are integral parts of initiatives to reduce the burden associated with these diseases. In this context, we aimed to determine factors associated with BCS and CCS uptake among Nepalese women aged 30 to 49 years using data from the Nepal Demographic Health Survey (NDHS) 2022. We performed a weighted analysis to account complex survey design of the NDHS 2022. We employed univariable and multivariable logistic regression to determine factors associated with the uptake of BCS and CCS and results were presented as crude odds ratio and adjusted odds ratio (AOR) along with 95% confidence interval (CI). The uptake of BCS and CCS among Nepalese women aged 30 to 49 years were 6.5% and 11.4% respectively. Women from Terai compared to mountain region (AOR = 0.54, 95%CI: 0.31, 0.93) and those engaged in agriculture compared to non-working (AOR = 0.59, 95%CI: 0.42, 0.82) women had lower odds of BCS uptake. Conversely, Dalit women compared to Brahmin/Chhetri (AOR = 2.08, 95%CI: 1.37, 3.16), and women with basic (AOR = 1.49, 95%CI: 1.04, 2.13), secondary (AOR = 1.96, 95%CI: 1.33, 2.88), and higher education (AOR = 2.80, 95% CI: 1.51, 5.19) compared to those with no education had higher odds of BCS uptake. Women from rural areas (AOR = 0.76, 95%CI: 0.61, 0.96), and those living in Bagmati (AOR = 2.16, 95% CI: 1.44, 3.23) and Gandaki (AOR = 2.09, 95%CI: 1.40, 3.14) provinces had higher odds of CCS uptake compared to their urban counterparts and those living in Koshi province, respectively. The odds of CCS increased with age (AOR = 1.06, 95%CI: 1.04, 1.08). Women with secondary education (AOR = 1.47, 95%CI: 1.06, 2.04) had higher odds of CCS uptake compared to those without education. Similarly, married women (AOR = 8.24, 95%CI: 1.03, 66.21), and those with health insurance (AOR = 1.41, 95%CI: 1.08, 1.83) had higher odds of CCS. In conclusion, the uptake of both BCS and CCS was relatively poor among Nepalese women indicating a need for targeted and tailored intervention to increase BCS and CCS uptake.

Association between media exposure and maternal health service use in Nepal: A further analysis of Nepal Demographic and Health Survey-2022.

BACKGROUND: Nepal has made incremental progress in improving coverage of maternal health services leading to improved health outcomes. Government and other health sector stakeholders have consistently considered dissemination of educational messages on maternal health through mass media. However, in Nepal's context, the media's influence on the uptake of maternal health services is less known. This study examines the links between media exposure and maternal health service use in Nepal. METHOD: Our analysis is based on the nationally representative Nepal Demographic and Health Survey (NDHS) 2022 data. We analyzed data from 1933 women aged 15-49 who had given birth in the two years preceding the survey. Weight analysis was performed to account for complex survey design. We presented categorical variables as frequency, percentage, and corresponding 95% Confidence Interval (CI). Univariable and multivariable logistic regression assessed the association between media exposure and maternal health service use, and the results are presented as crude (COR) and adjusted odds ratios (AOR) along with 95% CI. RESULTS: Women exposed to internet use had 1.59 times [AOR = 1.59, 95% CI = 1.16, 2.19], and those exposed to radio and television health programs had 1.73 times [AOR = 1.73, 95% CI = 1.17, 2.56] higher odds of having four or more Antenatal Care (ANC) visits. Similarly, women exposed to mass media had 1.32 times [AOR = 1.32, 95% CI = 1.00, 1.74] and those exposed to health programs had 1.50 times [AOR = 1.50, 95% CI = 1.02, 2.21] higher odds of having an institutional delivery. However, mass media exposure, internet use, and health program exposure were not significantly associated with increased postnatal care of mother and newborn. CONCLUSION: Exposure to health programs and internet use are positively associated with four or more ANC visits. Exposure to mass media and health programs are positively associated with increased institutional delivery. Our findings imply that well-designed campaigns and awareness programs delivered through mass media platforms play a vital role in enhancing the uptake of maternal health services.

Exploring community insights on antimicrobial resistance in Nepal: a formative qualitative study.

BACKGROUND: Antimicrobial resistance (AMR) is the process by which microbes evolve mechanisms to survive the medicines designed to destroy them i.e. antimicrobials (AMs). Despite being a natural process, AMR is being hastened by the abuse of AMs. In context of Nepal, there is limited information on drivers of AMR and barriers in addressing it from a community perspective. This study explores the local language and terminology used around AMs in the community, commonly used AMs and reasons for their usage, how these AMs are sourced, and the perceived barriers to addressing AMR via One Health approach. METHODS: A phenomenological study design was utilized with applied qualitative research theoretically framed as pragmatism. Twelve in-depth interviews and informal discussions with a One Health focus, were purposively conducted with wide range of stakeholders and community resident of Kapilvastu municipality of Nepal during April 2022. The acquired data was analyzed manually via a thematic framework approach. The study obtained ethical approval from ethical review board of Nepal Health Research Council and University of Leeds. RESULTS: Nepali and Awadhi languages does not have specific words for AMs or AMR, which is understandable by the community people. Rather, community use full explanatory sentences. People use AMs but have incomplete knowledge about them and they have their own local words for these medicines. The knowledge and usage of AMs across human and animal health is impacted by socio-structural factors, limited Government regulation, inadequate supply of AMs in local government health facilities and the presence of various unregulated health providers that co-exist within the health system. Novel ideas such as the use of visual and smart technology, for instance mobile phones and social media exposure, can enable access to information about AMs and AMR. CONCLUSION: This study shows that terminology that is understandable by the community referring to AMs and AMR in Nepali and Awadhi languages does not exist, but full explanatory sentences and colloquial names are used. Despite regular utilisation, communities have incomplete knowledge regarding AMs. Since, knowledge alone cannot improve behaviour, behavioural interventions are required to address AMR via community engagement to co-produce their own solutions. TRIAL REGISTRATION: Not applicable.

Addressing antimicrobial resistance through community engagement: a framework for developing contextually relevant and impactful behaviour change interventions.

Background: Community engagement (CE) interventions often explore and promote behaviour change around a specific challenge. Suggestions for behaviour change should be co-produced in partnership with the community. To facilitate this, it is essential that the intervention includes key content that unpacks the challenge of interest via multiple sources of knowledge. However, where community lived experience and academic evidence appear misaligned, tensions can appear within the co-production dynamic of CE. This is specifically so within the context of antimicrobial resistance (AMR) where ideal behaviours are often superseded by what is practical or possible in a particular community context. Methods: Here we describe a framework for the equitable development of contextually appropriate, clearly evidenced behavioural objectives for CE interventions. This framework explores different sources of knowledge on AMR, including the potentially competing views of different stakeholders. Findings: The framework allows key content on AMR to be selected based upon academic evidence, contextual appropriateness and fit to the chosen CE approach. A case study of the framework in action exemplifies how the framework is applicable to a range of contexts, CE approaches and One Health topics beyond just AMR. Conclusions: Within CE interventions, academic evidence is crucial to develop well-informed key content. However, this formative work should also involve community members, ensuring that their contextual knowledge is valued. The type of CE approach also needs careful consideration because methodological constraints may limit the breadth and depth of information that can be delivered within an intervention, and thus the scope of key content.

Co-designing community-based interventions to tackle antimicrobial resistance (AMR): what to include and why.

Antimicrobial resistance (AMR) is a social and biological problem. Although resistance to antimicrobials is a natural phenomenon, many human behaviors are increasing the pressure on microbes to develop resistance which is resulting in many commonly used treatments becoming ineffective. These behaviors include unregulated use of antimicrobial medicines, pesticides and agricultural chemicals, the disposal of heavy metals and other pollutants into the environment, and human-induced climatic change. Addressing AMR thus calls for changes in the behaviors which drive resistance. Community engagement for antimicrobial resistance (CE4AMR) is an international and interdisciplinary network focused on tackling behavioural drivers of AMR at community level. Since 2019 this network has worked within Low-Middle Income Countries (LMICs), predominantly within Southeast Asia, to tackle behavioral drivers of AMR can be mitigated through bottom-up solutions championed by local people. This commentary presents seven Key Concepts identified from across the CE4AMR portfolio as integral to tackling AMR. We suggest it be used to guide future interventions aimed at addressing AMR via social, participatory, and behavior-change approaches.

Service availability and readiness for basic emergency obstetric and newborn care: Analysis from Nepal Health Facility Survey 2021.

BACKGROUND: Although there has been a significant focus on improving maternal and newborn health and expanding services in Nepal, the expected positive impact on the health of mothers and newborns has not been achieved to the desired extent. Nepal not only needs to focus on improving access to and coverage of services but also the quality to achieve Sustainable Development Goals (SDG) by 2030. In this context, we aimed to analyze Basic Emergency Obstetric and Neonatal Care (BEmONC) service availability and readiness in Health Facilities (HFs) of Nepal. METHODS: We analyzed data from nationally representative Nepal Health Facility Survey (NHFS), 2021. BEmONC service availability and readiness in HFs was measured based on the "Service Availability and Readiness" manual of World Health Organization (WHO). We measured service availability by seven BEmONC signal functions. The readiness score was calculated for three domains- guidelines and staff training, essential equipment/supplies, and essential medicines on a scale of 100, and the average score for the three domains was the overall readiness score. We performed weighted descriptive and inferential analysis to account complex survey design of NHFS 2021. We summarized continuous variables with descriptive statistics like mean, standard deviation, median and interquartile range whereas categorical variables with percent and 95% confidence interval (CI). We applied simple, and multivariate linear regression to determine factors associated with the readiness of HFs for BEmONC services, and results were presented as beta (ß) coefficients and 95% CI. RESULTS: Of total 804 HFs offering normal vaginal delivery services, 3.1%, 89.2%, 7.7% were federal/provincial hospitals, local HFs, and private hospitals respectively. A total of 45.0% (95% CI: 34.9, 55.6) federal/provincial hospitals, 0.3% (95% CI: 0.2, 0.6), local HFs (district hospital, primary health care centers, health posts, urban health centers) and 10.5% (95% CI: 6.6, 16.4) private hospitals, had all seven BEmONC signal functions. The overall readiness of federal/provincial hospitals, local HFs, and private hospitals were 72.9±13.6, 54.2±12.8, 53.1±15.1 respectively. In multivariate linear regression, local HFs (ß = -12.64, 95% CI: -18.31, -6.96) and private hospitals had lower readiness score (ß = -18.08, 95% CI: -24.08, -12.08) compared to federal/provincial level hospitals. HFs in rural settings (ß = 2.60, 95% CI: 0.62, 4.58), mountain belts (ß = 4.18, 95% CI: 1.65, 6.71), and HFs with external supervision (ß = 2.99, 95% CI:1.08, 4.89), and quality assurance activities (ß = 3.59, 95% CI:1.64, 5.54) had better readiness scores. CONCLUSION: The availability of all seven BEmONC signal functions and readiness of HFs for BEmONC services are relatively low in local HFs and private hospitals. Accelerating capacity development through training centers at the federal/provincial level, onsite coaching, and mentoring, improving procurement and supply of medicines through federal/provincial logistic management centers, and regular supportive supervision could improve the BEmONC service availability and readiness in facilities across the country.

Understanding gender and its intersection with social stratifiers on prevention and care seeking behavior of lymphatic filariasis in Nepal.

BACKGROUND: Lymphatic filariasis (LF) is a debilitating and painful neglected tropical disease and is one of the leading causes of permanent disability. In many countries, the intersection of gender with various social stratifiers has influenced exposure to LF and ultimately impacting the disease burden and its elimination. This study aimed to explore the influence of gender and its intersection with other social stratifiers for the prevention and care seeking behavior of LF in Nepal. METHODS: This study employed qualitative research methods: in-depth interviews (IDIs) and focus group discussions (FGDs) for data collection in Bardiya, Nepal. A total of 22 IDIs (11 male, 11 female) and 2 FGDs (1 male and 1 female) were conducted with the community people between January and March 2020. The participants were purposively selected to represent different social stratifiers including age, sex, ethnicity, occupation. The data collected were analyzed using a thematic framework approach with use of intersectional gender analysis matrix. RESULTS: The study findings revealed that men spend more time outside their household compared to women while fulfilling their roles and responsibilities, largely determined by societal expectations and gender norms. This resulted in limited access to preventive health services for men, as they often missed annual mass drug administration programme in their community and limited access to preventive methods. Further traditional occupation, specific to particular ethnicity, influenced the vulnerability to LF for certain ethnic groups. The ability to prevent exposure varied among individuals. Although women made decisions regarding the use of protective methods, it was influenced by patriarchal and gender norms. They often felt a responsibility to take care and priorities males and other family members when resources are limited. The intersectionality of gender with other social stratifiers such as marital status, ethnicity, and geographical areas influenced individual's ability to access information related to LF and care seeking. CONCLUSIONS: Overall, the findings emphasized how access to resources, division of work, norms and values and decision-making power alone and its interaction with various social stratifiers shaped peoples' vulnerability to disease, ability to prevent exposure and response to illness.

Readiness of health facilities to provide services related to non-communicable diseases in Nepal: evidence from nationally representative Nepal Health Facility Survey 2021.

OBJECTIVE: To assess the readiness of public and private health facilities (HFs) in delivering services related to non-communicable diseases (NCDs) in Nepal. METHODS: We analysed data from nationally representative Nepal Health Facility Survey 2021 to determine the readiness of HFs for cardiovascular diseases (CVDs), diabetes mellitus (DM), chronic respiratory diseases (CRDs) and mental health (MH)-related services using Service Availability and Readiness Assessment Manual of the WHO. Readiness score was measured as the average availability of tracer items in per cent, and HFs were considered 'ready' for NCDs management if they scored ≥70 (out of 100). We performed weighted univariate and multivariable logistic regression to determine the association of HFs readiness with province, type of HFs, ecological region, quality assurance activities, external supervision, client's opinion review and frequency of meetings in HFs. RESULTS: The overall mean readiness score of HFs offering CRDs, CVDs, DM and MH-related services was 32.6, 38.0, 38.4 and 24.0, respectively. Guidelines and staff training domain had the lowest readiness score, whereas essential equipment and supplies domain had the highest readiness score for each of the NCD-related services. A total of 2.3%, 3.8%, 3.6% and 3.3% HFs were ready to deliver CRDs, CVDs, DM and MH-related services, respectively. HFs managed by local level were less likely to be ready to provide all NCD-related services compared with federal/provincial hospitals. HFs with external supervision were more likely to be ready to provide CRDs and DM-related services and HFs reviewing client's opinions were more likely to be ready to provide CRDs, CVDs and DM-related services. CONCLUSION: Readiness of the HFs managed by local level to provide CVDs, DM, CRDs and MH-related services was relatively poor compared with federal/provincial hospitals. Prioritisation of policies to reduce the gaps in readiness and capacity strengthening of the local HFs is essential for improving their overall readiness to provide NCD-related services.

Contextual factors affecting the implementation of an anemia focused virtual counseling intervention for pregnant women in plains Nepal: a mixed methods process evaluation.

BACKGROUND: Anemia is estimated to cause 115,000 maternal deaths each year. In Nepal, 46% of pregnant women have anemia. As part of an integrated anemia-prevention strategy, family engagement and counseling of pregnant women can increase compliance to iron folic acid tablets, but marginalized women often have lower access to these interventions. We implemented the VALID (Virtual antenatal intervention for improved diet and iron intake) randomized controlled trial to test a family-focused virtual counseling mHealth intervention designed to inclusively increase iron folic acid compliance in rural Nepal; here we report findings from our process evaluation research. METHODS: We conducted semi structured interviews with 20 pregnant women who had received the intervention, eight husbands, seven mothers-in-laws and four health workers. We did four focus groups discussions with intervention implementers, 39 observations of counseling, and used routine monitoring data in our evaluation. We used inductive and deductive analysis of qualitative data, and descriptive statistics of monitoring data. RESULTS: We were able to implement the intervention largely as planned and all participants liked the dialogical counseling approach and use of story-telling to trigger conversation. However, an unreliable and inaccessible mobile network impeded training families about how to use the mobile device, arrange the counseling time, and conduct the counseling. Women were not equally confident using mobile devices, and the need to frequently visit households to troubleshoot negated the virtual nature of the intervention for some. Women's lack of agency restricted both their ability to speak freely and their mobility, which meant that some women were unable to move to areas with better mobile reception. It was difficult for some women to schedule the counseling, as there were competing demands on their time. Family members were difficult to engage because they were often working outside the home; the small screen made it difficult to interact, and some women were uncomfortable speaking in front of family members. CONCLUSIONS: It is important to understand gender norms, mobile access, and mobile literacy before implementing an mHealth intervention. The contextual barriers to implementation meant that we were not able to engage family members as much as we had hoped, and we were not able to minimize in-person contact with families. We recommend a flexible approach to mHealth interventions which can be responsive to local context and the situation of participants. Home visits may be more effective for those women who are most marginalized, lack confidence in using a mobile device, and where internet access is poor.

Exploring the potential for children to act on antimicrobial resistance in Nepal: Valuable insights from secondary analysis of qualitative data.

This study explores the perceived roles of children in antimicrobial resistance (AMR) in two sites across Nepal. AMR is a global challenge and underpinned by many complex behavioural drivers including how antimicrobial medicines are sourced and used. Because of this social dynamic, several research groups are using community engagement (CE) approaches to understand AMR at community level. However, most data negate the importance of children in behaviours linked to, and potentially driving AMR. In this study, authors apply secondary analysis methods to 10 transcripts representing the views of 23 adults engaged in an AMR-focused film-making project. By focusing on participants' reference to children, we reveal that antimicrobial usage and adherence to health providers' messages can be influenced by the age of the patient. Secondly that children are involved in some of the behaviours which are known to drive antimicrobial resistance such as purchasing over-the-counter antibiotic drugs. Finally, community members discuss that, with careful creation of resources, AMR could be meaningfully presented in educational settings with a view to children acting as agents of change around AMR-driving behaviours. Findings suggest that age-inclusive community engagement projects could be effective in tackling AMR at community level in Nepal and other low resource settings.

Health worker perspectives on access to antenatal care in rural plains Nepal during the COVID-19 pandemic.

The COVID-19 pandemic affected access to antenatal care in low and middle-income countries where anaemia in pregnancy is prevalent. We analyse how health workers provided antenatal care and the factors affecting access to antenatal care during the COVID-19 pandemic in Kapilvastu district in the western plains of Nepal. We used qualitative and quantitative methodologies, conducting eight semi-structured interviews with health workers who provided antenatal care during the pandemic, and a questionnaire containing open and closed questions with 52 female community health volunteers. Antenatal care was severely disrupted during the pandemic. Health workers had to find ways to provide care with insufficient personal protective equipment and guidance whilst facing extreme levels of stigmatisation which prevented them from providing outreach services. Pregnant women were fearful or unable to visit health institutions during the pandemic because of COVID-19 control measures. Pre-pandemic and during the pandemic health workers tried to contact pregnant and postpartum women and families over the phone, but this was challenging because of limited access to phones, and required pregnant women to make at least one antenatal care visit to give their phone number. The pandemic prevented new pregnancies from being registered, and therefore the possibilities to provide services over the phone for these pregnancies were limited. To reach the most marginalised during a pandemic or other health emergency, health volunteers and households need to exchange phone numbers, enabling proactive monitoring and care-seeking. Strengthening procurement and coordination between the municipal, provincial, and federal levels of government is needed to ensure adequacy of antenatal supplies, such as iron folic acid tablets, in health emergencies. Community engagement is important to ensure women and families are aware of the need to access antenatal care and iron folic acid, and to address stigmatisation of health workers.

Study protocol for a randomised controlled trial of a virtual antenatal intervention for improved diet and iron intake in Kapilvastu district, Nepal: VALID.

INTRODUCTION: Despite evidence that iron and folic acid (IFA) supplements can improve anaemia in pregnant women, uptake in Nepal is suboptimal. We hypothesised that providing virtual counselling twice in mid-pregnancy, would increase compliance to IFA tablets during the COVID-19 pandemic compared with antenatal care (ANC alone. METHODS AND ANALYSIS: This non-blinded individually randomised controlled trial in the plains of Nepal has two study arms: (1) control: routine ANC; and (2) 'Virtual' antenatal counselling plus routine ANC. Pregnant women are eligible to enrol if they are married, aged 13-49 years, able to respond to questions, 12-28 weeks' gestation, and plan to reside in Nepal for the next 5 weeks. The intervention comprises two virtual counselling sessions facilitated by auxiliary nurse midwives at least 2 weeks apart in mid-pregnancy. Virtual counselling uses a dialogical problem-solving approach with pregnant women and their families. We randomised 150 pregnant women to each arm, stratifying by primigravida/multigravida and IFA consumption at baseline, providing 80% power to detect a 15% absolute difference in primary outcome assuming 67% prevalence in control arm and 10% loss-to-follow-up. Outcomes are measured 49-70 days after enrolment, or up to delivery otherwise. PRIMARY OUTCOME: consumption of IFA on at least 80% of the previous 14 days. SECONDARY OUTCOMES: dietary diversity, consumption of intervention-promoted foods, practicing ways to enhance bioavailability and knowledge of iron-rich foods. Our mixed-methods process evaluation explores acceptability, fidelity, feasibility, coverage (equity and reach), sustainability and pathways to impact. We estimate costs and cost-effectiveness of the intervention from a provider perspective. Primary analysis is by intention-to-treat, using logistic regression. ETHICS AND DISSEMINATION: We obtained ethical approval from Nepal Health Research Council (570/2021) and UCL ethics committee (14301/001). We will disseminate findings in peer-reviewed journal articles and by engaging policymakers in Nepal. TRIAL REGISTRATION NUMBER: ISRCTN17842200.

Assessing food-based strategies to address anaemia in pregnancy in rural plains Nepal: a mixed methods study.

Anaemia in pregnancy is a persistent health problem in Nepal and could be reduced through nutrition counselling and strengthened iron folic acid supplementation programmes. We analysed 24-hour diet recall data from 846 pregnant women in rural plains Nepal, using linear programming to identify the potential for optimised food-based strategies to increase iron adequacy. We then conducted qualitative research to analyse how anaemia was defined and recognised, how families used food-based strategies to address anaemia, and the acceptability of optimised food-based strategies. We did 16 interviews of recently pregnant mothers, three focus group discussions with fathers, three focus group discussions with mothers-in-law and four interviews with key informants. Dietary analyses showed optimised diets did not achieve 100 % of recommended iron intakes, but iron intakes could be doubled by increasing intakes of green leaves, egg and meat. Families sought to address anaemia through food-based strategies but were often unable to because of the perceived expense of providing an 'energy-giving' diet. Some foods were avoided because of religious or cultural taboos, or because they were low status and could evoke social consequences if eaten. There is a need for counselling to offer affordable ways for families to optimise iron adequacy. The participation of communities in tailoring advice to ensure cultural relevance and alignment with local norms is necessary to enable its effectiveness.

Serum Uric Acid to Creatinine Ratio with Estimated Glomerular Filtration Rate in Type 2 Diabetes Patients.

BACKGROUND: Diabetes mellitus is a metabolic disorder associated with cardiovascular and renal complications. The serum uric acid to creatinine ratio and estimated glomerular filtration rate are important markers used to assess kidney function in patients with type 2 diabetes. This study aimed to find the correlation between serum uric acid to creatinine ratio and estimated glomerular filtration rate to various parameters among the diabetes patients. METHODS: It is an observational hospital-based, cross-sectional study. Patients with a diagnosis of diabetes for three years or more duration were selected. This study designed to serum uric acid to creatinine ratio with estimated glomerular filtration rate and its relationship with other biochemical parameters. The Modification of Diet in Renal Disease formula was used to calculate estimated glomerular filtration rate (eGFR). eGFR (mL/min∙1.73 m2) = 186 × (Scr) -1.154 × (age) - 0.203 × (0.742 female). Low eGFR was defined as eGFR<60 mL/min∙1.73 m2. The data were analyzed by SPSS version 20. Mean values of different variables, standard deviations and p-values were calculated. RESULTS: Mean serum uric acid to creatinine ratio was 6.09±1.71 and elevated among 49.1%. Mean blood urea and serum creatinine levels were 28.0±10.72 and 1.01±0.18, respectively. There was a significant positive correlation between eGFR and serum uric acid : serum creatinine ( r = 0.246, p = 0.007) in this study. CONCLUSIONS: The serum uric acid to creatinine ratio can serve as an early marker for renal injury, showing a positive correlation with estimated glomerular filtration rate (eGFR). Monitoring serum uric acid to creatinine ratio levels alongside eGFR can assistance in the identification and management of kidney damage in its early stages.