Using freeze-preventive cold boxes in rural Nepal: A study of equipment performance, acceptability, system fit, and cost.

We conducted a field evaluation using qualitative and quantitative methods to assess freeze prevention of vaccines transported and stored in a recently developed, World Health Organization-prequalified freeze-preventive cold box (FPCB) as compared to currently used standard cold boxes (SCBs). The study assessed the FPCB's practical use, health worker acceptance, health system fit (including cost considerations), and challenges faced by health workers in variable conditions and geographical settings. The evaluation took place in five health facilities across hilly and plains districts of Nepal in two phases: Phase 1 involved FPCBs in simulated use alongside SCBs. In Phase 2, actual vaccines were used in the FPCBs. The study gathered quantitative data from logbooks and electronic temperature monitors placed inside and outside the cold boxes. Qualitative data were collected from health workers, cold chain personnel, and immunization program managers involved in the vaccine cold chain at multiple levels. No damage, durability issues, or freezing incidents were observed when using FPCBs, but two incidents of freezing occurred when using SCBs. FPCBs also took longer to cool down than SCBs. Participants mostly found the FPCB to be safe and user friendly for vaccine transportation and short-term storage. Advantages of the FPCB as compared to the SCB include its ability to minimize vaccine wastage, to keep freeze-sensitive vaccines safe (the average value of freeze-sensitive vaccines transported per shipment was $1,704), and to ease preparation through elimination of the need to condition ice packs. Procurement price ranges for FPCBs overlap those for SCBs. Disadvantages of the FPCB include its greater size and weight, which require more personnel and vehicles during transportation. This suggests that lighter and smaller FPCBs would be more effective and acceptable for the Nepal immunization program and other, similar immunization programs conducted globally.

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.

COVID-19 vaccination up-take in three districts of Nepal.

Vaccine hesitancy during the COVID-19 pandemic continues to be an issue in terms of global efforts to decrease transmission rates. Despite high demand for the vaccines in Nepal, the country still contends with challenges related to vaccine accessibility, equitable vaccine distribution, and vaccine hesitancy. Study objectives were to identify: 1) up-take and intention for use of COVID-19 vaccines, 2) factors associated with vaccine up-take, and 3) trusted communication strategies about COVID-19 and the vaccines. A quantitative survey was implemented in August and September 2021 through an initiative at the Nepali Ministry of Health and Population Department of Health Services, Family Welfare Division. Data were collected from 865 respondents in three provinces (Bagmati, Lumbini, and Province 1). Ordinal multivariate logistic regression was utilized to determine relationships between vaccination status and associated factors. Overall, 62% (537) respondents were fully vaccinated and 18% (159) were partially vaccinated. Those respondents with higher education (p < .001) and higher household income (p < .001) were more likely vaccinated. There were also significant differences in vaccine up-take across the three provinces (p < .001). Respondents who were vaccinated were significantly more likely to perceive vaccines as efficacious in terms of preventing COVID-19 (p = .004) and preventing serious outcomes (p = .010). Among both vaccinated and unvaccinated individuals, there was a high level of trust in information about COVID-19 vaccines provided through local health-care workers [e.g. nurses and physicians]. These results are consistent with other findings within the South Asia region. Targeted advocacy and outreach efforts are needed to support ongoing COVID-19 vaccination campaigns throughout Nepal.

Facilitators and barriers to the self-management of COPD: a qualitative study from rural Nepal.

OBJECTIVE: To understand the facilitators and barriers to the self-management of chronic obstructive pulmonary disease (COPD) in rural Nepal. SETTINGS: Community and primary care centres in rural Nepal. PARTICIPANTS: A total of 14 participants (10 people with COPD and 4 health care providers) were interviewed. PRIMARY AND SECONDARY OUTCOME MEASURES: People with COPD and healthcare provider's experience of COPD self-management in rural Nepal. RESULTS: Facilitators and barriers affecting COPD self-management in Nepal operated at the patient-family, community and service provider levels. People with COPD were found to have a limited understanding of COPD and medications. Some participants reported receiving inadequate family support and described poor emotional health. At the community level, widespread use of complementary and alternative treatment was found to be driven by social networks and was used instead of western medicine. There were limited quality controls in place to monitor the safe use of alternative treatment. While a number of service level factors were identified by all participants, the pertinent concerns were the levels of trust and respect between doctors and their patients. Service level factors included patients' demands for doctor time and attention, limited confidence of people with COPD in communicating confidently and openly with their doctor, limited skills and expertise of the doctors in promoting behavioural change, frustration with doctors prescribing too many medicines and the length of time to diagnose the disease. These service level factors were underpinned by resource constraints operating in rural areas. These included inadequate infrastructure and resources, limited skills of primary level providers and lack of educational materials for COPD. CONCLUSIONS: The study findings suggest the need for a more integrated model of care with multiple strategies targeting all three levels in order to improve the self-management practices among people with COPD.

Functional quality evaluation and shelf life study of synbiotic yacon juice.

The research aimed to utilize the prebiotic potential of yacon fruit by preparation of synbiotic yacon juice containing probiotic microorganism Lactobacillus acidophilus (La5) and studying the changes in physicochemical properties during storage. The fresh juice extracted was added with probiotic microorganism and was subjected for storage at refrigerated (4°C) and room condition (25°C) along with control (nonfermented) juice. The viability of probiotic strains in the juice was found to be at the satisfactory level (106 CFU/ml) for 27 and 15 days, respectively, in refrigerated and room condition. Total soluble solid, pH, acidity, bioactive compounds (ascorbic acid, carotenoid content, and total phenol), and antioxidant capacity of the products were evaluated. Total soluble solid of the prepared synbiotic juice stored at refrigerated and nonrefrigerated conditions decreased from 7.8 ± 0.05 to 5.5 ± 0.26 and 5.3 ± 0.10 while the acidity increased from 0.067 ± 0.05 to 0.80 ± 0.06 and 1.02 ± 0.04 after 27 and 15 days of storage, respectively. Similarly, yeast and mold count, total plate count, and the coliform count were determined during the storage period. The low amount of yeast and mold count and absence of coliform in the synbiotic juice even after 27 and 15 days of storage indicated that the synbiotic juice can be continued to be consumed as a normal juice even after the viability decreased below the satisfactory level. Ascorbic acid, phenolic content, and antioxidant activity were higher in fermented juice when compared to control juice stored at the refrigerated conditions for the same period (p < .05). High therapeutic properties and numerous health benefits of yacon, when combined with the health benefits of probiotic bacteria, could lead to the development of commercial beverages with high health and nutritional values.

Implementing Federalism in the Health System of Nepal: Opportunities and Challenges.

Nepal moved from unitary system with a three-level federal system of government. As federalism accelerates, the national health system can also speed up its own decentralization process, reduce disparities in access, and improve health outcomes. The turn towards federalism creates several potential opportunities for the national healthcare system. This is because decision making has been devolved to the federal, provincial and local governments, and so they can make decisions that are more representative of their localised health needs. The major challenge during the transition phase is to ensure that there are uninterrupted supplies of medical commodities and services. This requires scaling up the ability of local bodies to manage drug procurement and general logistics and adequate human resource in local healthcare centres. This article documents the efforts made so far in context of health sector federalization and synthesizes the progress and challenges to date and potential ways forward. This paper is written at a time while it is critical to review the federalism initiatives and develop way forward. As Nepal progress towards the federalized health system, we propose that the challenges inherent with the transition are critically analysed and mitigated while unfolding the potential of federal health system.

The Health Sector Response to the 2015 Earthquake in Nepal.

In April 2015, Nepal experienced an earthquake of a magnitude of 7.6 on the Richter scale that resulted in deaths, morbidities, and infrastructure damage. In the post-earthquake period, 4 different workshops and a national "Lessons Learnt" conference were organized to assess the adequacy of the preparedness and response of the health sector. This article summarizes the main conclusions of these discussions relating to leadership, timely search and rescue, referral operations, medical relief to response activities, awareness campaigns, and support from the national and international levels, and epidemiological surveillance. The earthquake response was channeled through rapid response teams that spanned from the community level to the central level via a cluster coordination approach. Overall, the health sector's response was concluded to be largely satisfactory because it focused not only on emergency medical care, but also on the resumption of basic health services and preventive health care (eg, hygiene, risk communication) equally. Post-disaster disease outbreak did not occur because effective surveillance and outbreak monitoring was one of the priority actions. However, services related to birthing centers, neonatal services, and vaccinations were impeded in some rural areas. Some weaknesses in planning, coordination, and management were also noted. The lessons learned can provide the impetus to strengthen future preparedness and response mechanisms. (Disaster Med Public Health Preparedness. 2018;12:543-547).