Dementia care landscape in Nepal: Understanding the context, barriers, and opportunities for the development of a national dementia care plan.

OBJECTIVE: This study was conducted to comprehensively understand the context, barriers, and opportunities for improving dementia care, treatment, and support. The objective is to guide the development of a national dementia care plan. METHODOLOGY: This document review was conducted by analyzing literature available in the public domain, including scientific publications, project documents/reports, media reports, and hospital records. Additionally, annual reports published by the Department of Health Services, national census and demographic and health survey reports, Old Age Homes, and other relevant government reports were examined. Firsthand information was gathered from relevant stakeholders based on the World Health Organization's situational analysis framework for dementia plans. This framework encompasses four domains: Policy context (national ministries, legislation, policies, strategies, plans related to dementia, mental health, aging, and disability), service delivery assessment (health and social care workforces, services, support and treatment programmes, and promotion of awareness and understanding), and epidemiological indicators (prevalence and incidence rates of dementia, risk factors). Ethical clearance was obtained from the Institutional Review Committee (IRC) of B.P. Koirala Institute of Health Sciences (IRC no.2658/023). RESULTS: Existing policies in Nepal inadequately address the needs of people with dementia and their caregivers. Concerning health services, the Government of Nepal provides financial subsidies to individuals diagnosed with dementia; however, numerous hurdles impede access to care. These obstacles include geographical and structural barriers, an inefficient public healthcare system, weak governance, financial constraints, low awareness levels, stigma, and inadequate workforce. Furthermore, the absence of robust nationally representative epidemiological studies on dementia in Nepal hampers the development of evidence-based plans and policies. Similarly, there are no interventions targeted at caregivers of people with dementia, and no initiatives for dementia prevention are in place. CONCLUSIONS: This review underscores the urgent need to formulate a comprehensive national dementia care plan to address the growing challenges. Key priority action areas include the integration of dementia care into primary healthcare services, training workforce to provide the care, increasing awareness, mitigating stigma, developing caregiver support programs, and initiating high-quality research to inform evidence-based policymaking.

Mental health-related structural stigma and discrimination in health and social policies in Nepal: A scoping review and synthesis.

AIMS: National policies can be used to reveal structural stigma and discrimination in relation to mental health. This review assesses how structural stigma and discrimination are manifested in the policies and legislations of Government of Nepal. METHODS: Scoping review methodology was followed to review policy documents (acts of parliament, legislation, policies, strategies, guidelines and official directives) drafted or amended after 2010. RESULTS: Eighty-nine policies were identified related to health, social welfare, development and regulations which were relevant to people with psychosocial and mental disabilities or have addressed the mental health agendas. Several critical policy failings and gaps are revealed, such as the use of stigmatizing language (e.g., 'insane' or 'lunatic'), inconsistencies within and between policies, deviation from international protocols defining legal capacity and consent, lack of inclusion of the mental health agenda in larger development policies and lack of cost-effective interventions and identification of financing mechanisms. Provisions for people living with mental health conditions included adequate standard of living; attaining standard mental health; the right to exercise legal capacity, liberty and security; freedom from torture or discrimination; and right to live independently. However, other policies contradicted these rights, such as prohibiting marriage, candidacy for and retention of positions of authority and vulnerability to imprisonment. CONCLUSION: Mental health-related structural stigma and discrimination in Nepal can be identified through the use of discriminator language and provisions in the policies. The structural stigma and discrimination may be addressed through revision of the discriminating policies, integrating the mental health agenda into larger national and provincial policies, and streamlining policies to comply with national and international protocols.

Feasibility of Group Problem Management Plus (PM+) to improve mental health and functioning of adults in earthquake-affected communities in Nepal.

AIMS: Psychological interventions that are brief, acceptable, effective and can be delivered by non-specialists are especially necessary in low- and middle-income countries, where mental health systems are unable to address the high level of psychosocial needs. Problem Management Plus (PM+) is a five-session intervention designed for those impaired by psychological distress while living in communities affected by adversity. Individual PM+ has demonstrated effectiveness in reducing distress in Kenya and Pakistan, and a group version of PM+ (Group PM+) was effective for conflict-affected women in Pakistan. This paper describes a feasibility and acceptability trial of locally adapted Group PM+ for women and men in an earthquake-affected region of rural Nepal. METHODS: In this feasibility cluster randomised controlled trial, participants in the experimental arm were offered five sessions of Group PM+ and participants in the control arm received enhanced usual care (EUC), which entailed brief psycho-education and providing referral options to primary care services with health workers trained in the mental health Gap Action Programme Intervention Guide (mhGAP-IG). A mixed-methods design was used to assess the feasibility and acceptability of Group PM+. Feasibility was assessed with criteria including fidelity and retention of participants. Acceptability was assessed through in-depth interviews with participants, family members, programme staff and other stakeholders. The primary clinical outcome was depression symptoms assessed using the Patient Health Questionnaire (PHQ-9) administered at baseline and 8-8.5 weeks post-baseline (i.e. after completion of Group PM+ or EUC). RESULTS: We recruited 121 participants (83% women and 17% men), with equal allocation to the Group PM+ and EUC arms (1:1). Group PM+ was delivered over five 2.5-3 hour sessions by trained and supervised gender-matched local non-specialists, with an average attendance of four out of five sessions. The quantitative and qualitative results demonstrated feasibility and acceptability for non-specialists to deliver Group PM+. Though the study was not powered to assess for effectiveness, for all five key outcome measures, including the primary clinical outcome, the estimated mean improvement was larger in the Group PM+ arm than the EUC arm. CONCLUSION: The intervention and trial procedures were acceptable to participants, family members, and programme staff. The communities and participants found the intervention to be beneficial. Because feasibility and acceptability were established in this trial, a fully powered randomised controlled trial will be conducted for larger scale implementation to determine the effectiveness of the intervention in Nepal.