Cross-country analysis of contextual factors and implementation strategies in under-5 mortality reduction in six low- and middle-income countries 2000-2015.

BACKGROUND: The Exemplars in Under-5 Mortality (U5M) was a multiple cases study of how six low- and middle-income countries (LMICs), Bangladesh, Ethiopia, Nepal, Peru, Rwanda, and Senegal, implemented health system-delivered evidence-based interventions (EBIs) to reduce U5M between 2000 and 2015 more effectively than others in their regions or with similar economic growth. Using implementation research, we conducted a cross-country analysis to compare decision-making pathways for how these countries chose, implemented, and adapted strategies for health system-delivered EBIs that mitigated or leveraged contextual factors to improve implementation outcomes in reducing amenable U5M. METHODS: The cross-country analysis was based on the hybrid mixed methods implementation research framework used to inform the country case studies. The framework included a common pathway of Exploration, Preparation, Implementation, Adaptation, and Sustainment (EPIAS). From the existing case studies, we extracted contextual factors which were barriers, facilitators, or determinants of strategic decisions; strategies to implement EBIs; and implementation outcomes including acceptability and coverage. We identified common factors and strategies shared by countries, and individual approaches used by countries reflecting differences in contextual factors and goals. RESULTS: We found the six countries implemented many of the same EBIs, often using similar strategies with adaptations to local context and disease burden. Common implementation strategies included use of data by decision-makers to identify problems and prioritize EBIs, determine implementation strategies and their adaptation, and measure outcomes; leveraging existing primary healthcare systems; and community and stakeholder engagement. We also found common facilitators included culture of donor and partner coordination and culture and capacity of data use, while common barriers included geography and culture and beliefs. We found evidence for achieving implementation outcomes in many countries and EBIs including acceptability, coverage, equity, and sustainability. DISCUSSION: We found all six countries used a common pathway to implementation with a number of strategies common across EBIs and countries which contributed to progress, either despite contextual barriers or by leveraging facilitators. The transferable knowledge from this cross-country study can be used by other countries to more effectively implement EBIs known to reduce amenable U5M and contribute to strengthening health system delivery now and in the future.

Integrated Management of Childhood Illness implementation in Nepal: understanding strategies, context, and outcomes.

BACKGROUND: Health system-delivered evidence-based interventions (EBIs) are important to reducing amenable under-5 mortality (U5M). Implementation research (IR) can reduce knowledge gaps and decrease lags between new knowledge and its implementation in real world settings. IR can also help understand contextual factors and strategies useful to adapting EBIs and their implementation to local settings. Nepal has been a leader in dropping U5M including through adopting EBIs such as integrated management of childhood illness (IMCI). We use IR to identify strategies used in Nepal's adaptation and implementation of IMCI. METHODS: We conducted a mixed methods case study using an implementation research framework developed to understand how Nepal outperformed its peers between 2000-2015 in implementing health system-delivered EBIs known to reduce amenable U5M. We combined review of existing literature and data supplemented by 21 key informant interviews with policymakers and implementers, to understand implementation strategies and contextual factors that affected implementation outcomes. We extracted relevant results from the case study and used explanatory mixed methods to understand how and why Nepal had successes and challenges in adapting and implementing one EBI, IMCI. RESULTS: Strategies chosen and adapted to meet Nepal's specific context included leveraging local research to inform national decision-makers, pilot testing, partner engagement, and building on and integrating with the existing community health system. These cross-cutting strategies benefited from facilitating factors included community health system and structure, culture of data use, and local research capacity. Geography was a critical barrier and while substantial drops in U5M were seen in both the highest and lowest wealth quintiles, with the wealth equity gap decreasing from 73 to 39 per 1,000 live births from 2001 to 2016, substantial geographic inequities remained. CONCLUSIONS: Nepal's story shows that implementation strategies that are available across contexts were key to adopting and adapting IMCI and achieving outcomes including acceptability, effectiveness, and reach. The value of choosing strategies that leverage facilitating factors such as investments in community-based and facility-based approaches as well as addressing barriers such as geography are useful lessons for countries working to accelerate adaptation and implementation of strategies to implement EBIs to continue achieving child health targets.

Inequity in the face of success: understanding geographic and wealth-based equity in success of facility-based delivery for under-5 mortality reduction in six countries.

BACKGROUND: Between 2000-2015, many low- and middle-income countries (LMICs) implemented evidence-based interventions (EBIs) known to reduce under-5 mortality (U5M). Even among LMICs successful in reducing U5M, this drop was unequal subnationally, with varying success in EBI implementation. Building on mixed methods multi-case studies of six LMICs (Bangladesh, Ethiopia, Nepal, Peru, Rwanda, and Senegal) leading in U5M reduction, we describe geographic and wealth-based equity in facility-based delivery (FBD), a critical EBI to reduce neonatal mortality which requires a trusted and functional health system, and compare the implementation strategies and contextual factors which influenced success or challenges within and across the countries. METHODS: To obtain equity gaps in FBD coverage and changes in absolute geographic and wealth-based equity between 2000-2015, we calculated the difference between the highest and lowest FBD coverage across subnational regions and in the FBD coverage between the richest and poorest wealth quintiles. We extracted and compared contextual factors and implementation strategies associated with reduced or remaining inequities from the country case studies. RESULTS: The absolute geographic and wealth-based equity gaps decreased in three countries, with greatest drops in Rwanda - decreasing from 50 to 5% across subnational regions and from 43 to 13% across wealth quintiles. The largest increases were seen in Bangladesh - from 10 to 32% across geography - and in Ethiopia - from 22 to 58% across wealth quintiles. Facilitators to reducing equity gaps across the six countries included leadership commitment and culture of data use; in some countries, community or maternal and child health insurance was also an important factor (Rwanda and Peru). Barriers across all the countries included geography, while country-specific barriers included low female empowerment subnationally (Bangladesh) and cultural beliefs (Ethiopia). Successful strategies included building on community health worker (CHW) programs, with country-specific adaptation of pre-existing CHW programs (Rwanda, Ethiopia, and Senegal) and cultural adaptation of delivery protocols (Peru). Reducing delivery costs was successful in Senegal, and partially successful in Nepal and Ethiopia. CONCLUSION: Variable success in reducing inequity in FBD coverage among countries successful in reducing U5M underscores the importance of measuring not just coverage but also equity. Learning from FBD interventions shows the need to prioritize equity in access and uptake of EBIs for the poor and in remote areas by adapting the strategies to local context.

Spatial distribution of stunting and wasting in 6-59 months children in Nepal: analysis using a Bayesian distributional bivariate probit model.

The combined burden of stunting and wasting in children under five years is a serious public health concern. The present study aimed to estimate the joint burden of stunting and wasting among children aged 6-59 months and explore its spatial variation across Nepal. The 2016 Nepal Demographic and Health Survey data was used to study acute and chronic childhood malnutrition. A Bayesian distributional bivariate probit geoadditive model was designed to study the linear association and geographical variation of stunting and wasting among 6-59 months, children. Child-related factors such as low birth weight, fever in the last 2 weeks preceding the survey and fourth or greater birth order were associated with a higher likelihood of stunting. The likelihood of a child being stunted was significantly less in the wealthiest households, having improved toilet facilities, and if mothers were overweight. Children from severely food insecure households were significantly more likely, and children from poorer households were significantly less likely to suffer both acute and chronic malnutrition simultaneously. Results from spatial effect showed that children from Lumbini and Karnali had a higher burden of stunting, and the likelihood that achild would have been wasted was significantly higher in Madhesh and Province 1. Immediate nutritional efforts are vital in low-income and severely food insecure households to lessen the risk of stunting and wasting in under children. Disproportionate geographic variations in stunting and wasting warrant sub-regional-specific nutrition intervention to achieve nutrition targets and reduce the burden of childhood malnutrition across the country.

Inequalities in full vaccination coverage based on maternal education and wealth quintiles among children aged 12-23 months: further analysis of national cross-sectional surveys of six South Asian countries.

OBJECTIVE: This study was conducted to compare full vaccination coverage and its inequalities (by maternal education and household wealth quintile). DESIGN: This further analysis was based on the data from national-level cross-sectional Demographic and Health Survey (DHS) from six countries in South Asia. SETTING: We used most recent DHS data from six South Asian countries: Nepal, India, Pakistan, Bangladesh, Afghanistan and the Maldives. The sample size of children aged 12-23 months ranged from 6697 in the Maldives to 628 900 in India. PRIMARY AND SECONDARY OUTCOME MEASURES: To measure absolute and relative inequalities of vaccination coverage, we used regression-based inequality measures, slope index of inequality (SII) and the relative index of inequality (RII), respectively, by maternal education and wealth quintile. RESULTS: Full vaccination coverage was the highest in Bangladesh (84%) and the lowest in Afghanistan (46%), with an average of 61.5% for six countries. Pakistan had the largest inequalities in coverage both by maternal education (SII: -50.0, RII: 0.4) and household wealth quintile (SII: -47.1, RII: 0.5). Absolute inequalities were larger by maternal education compared with wealth quintile in four of the six countries. The relative index of inequality by maternal education was lower in Pakistan (0.5) and Afghanistan (0.5) compared with Nepal (0.7), India (0.7) and Bangladesh (0.7) compared with rest of the countries. By wealth quintiles, RII was lower in Pakistan (0.5) and Afghanistan (0.6) and higher in Nepal (0.9) and Maldives (0.9). CONCLUSIONS: The full vaccination coverage in 12-23 months old children was below 85% in all six countries. Inequalities by maternal education were more profound than household wealth-based inequalities in four of six countries studied, supporting the benefits of maternal education to improve child health outcome.

Carotid Intima-media Thickness in Patients with Non-alcoholic Fatty Liver Disease Attending a Tertiary Care Center: A Descriptive Cross-sectional Study.

INTRODUCTION: Non-alcoholic fatty liver disease is fatty infiltration of the liver in the absence of other causes of steatosis. It is strongly associated with central adiposity, high body mass index, insulin resistance states, hypertension, hyperlipidemia which are features of metabolic syndrome. The objective of study is to find out the carotid intima-media thickness of non alcoholic fatty liver disease patients attending a tertiary care center. METHODS: This was a descriptive cross sectional study conducted at National Academy of Medical Sciences, Bir Hospital from July 2018 to June 2019 among 70 diagnosed cases of non alcoholic fatty liver disease based on ultrasound findings. Data collection was started after receiving ethical approval from Institutional Review Board of the Institute. Convenience sampling method was used. Data were entered using Microsoft Excel. The carotid intima-media thickness of both sides were measured by ultrasound. Statistical Package for Social Sciences version 20 was used for analysis. RESULTS: Out of 70 cases, the mean carotid intima-media thickness was 0.7140±0.1796mm on right and 0.7161±0.1828mm on left side. Among 70 cases 45 (64.3%) were Grade II non alcoholic fatty liver disease and 25 (35.7%) were Grade I. It was 0.5720±0.1275mm and 0.7929±0.1546mm in Grade I and II non alcoholic fatty liver disease cases respectively on right side whereas it was 0.5676±0.1259mm and 0.7987±0.1557mm respectively on left side. CONCLUSIONS: This study showed increased carotid intima-media thickness in non alcoholic fatty liver disease cases.

Basic emergency obstetric and newborn care service availability and readiness in Nepal: Analysis of the 2015 Nepal Health Facility Survey.

BACKGROUND: Achieving maternal and newborn related Sustainable Development Goals targets is challenging for Nepal, mainly due to poor quality of maternity services. In this context, we aim to assess the Basic Emergency Obstetric and Newborn Care (BEmONC) service availability and readiness in health facilities in Nepal by analyzing data from Nepal Health Facility Survey (NHFS), 2015. METHODS: We utilized cross-sectional data from the nationally representative NHFS, 2015. Service availability was measured by seven signal functions of BEmONC, and service readiness by the availability and functioning of supportive items categorized into three domains: staff and guidelines, diagnostic equipment, and basic medicine and commodities. We used the World Health Organization's service availability and readiness indicators to estimate the readiness scores. We performed a multiple linear regression to identify important factors in the readiness of the health facilities to provide BEmONC services. RESULTS: The BEmONC service readiness score was significantly higher in public hospitals compared with private hospitals and peripheral public health facilities. Significant factors associated with service readiness score were the facility type (14.69 points higher in public hospitals, P<0.001), number of service delivery staff (2.49 points increase per each additional delivery staff, P<0.001), the service hours (4.89 points higher in facilities offering 24-hour services, P = 0.01) and status of periodic review of maternal and newborn deaths (4.88 points higher in facilities that conducted periodic review, P = 0.043). CONCLUSIONS: These findings suggest that BEmONC services in Nepal could be improved by increasing the number of service delivery staff, expanding service hours to 24-hours a day, and conducting periodic review of maternal and newborn deaths at health facilities, mainly in the peripheral public health facilities. The private hospitals need to be encouraged for BEmONC service readiness.

Exploring determinants of hydrocele surgery coverage related to Lymphatic Filariasis in Nepal: An implementation research study.

BACKGROUND: Hydrocele is a chronic condition in males in which there is an excessive collection of straw-colored fluid, which leads to enlargement of the scrotum. It is a common manifestation of lymphatic filariasis (LF) affecting nearly 25 million men worldwide. Surgery is the recommended treatment for hydrocele and is available free of cost in all government hospitals in Nepal. This research explored patient, provider, and community factors related to accessing hydrocele surgery services by the patients. METHODS: This study employed a qualitative method. The research was conducted in two LF endemic districts, namely Kanchanpur and Dhading, which are reported to have the highest number of hydrocele cases during morbidity mapping conducted in 2016. In addition to five key informant interviews with the LF focal persons (one national and 4 district-level), nine in-depth interviews were conducted with hydrocele patients (5 of whom had undergone surgery and 4 who had not undergone surgery) and with 3 family members, and two focus group discussions with the female community health volunteers. RESULTS: Most of the respondents did not have knowledge of hydrocele as one of the clinical manifestations of LF nor that it is transmitted through a mosquito bite. Although perceived as treatable with surgery, most of the patients interviewed believed in as well as practiced home remedies. Meanwhile, fear of surgery, embarrassment, lack of money, along with no knowledge of the free hydrocele surgery acted as barriers for accessing the surgery. On the other hand, financial support, flexible guidelines enabling the hospital to conduct surgery, decentralization and scaling up of morbidity mapping along with free hydrocele surgery camps in any remaining endemic districts were identified as enablers for accessing surgery. CONCLUSION: Hydrocele surgery coverage could be improved if the program further addresses community awareness. There is a need for more focus on information dissemination about hydrocele and hydrocele surgery.

Transmission Dynamics and Short-Term Forecasts of COVID-19: Nepal 2020/2021.

Nepal was hard hit by a second wave of COVID-19 from April-May 2021. We investigated the transmission dynamics of COVID-19 at the national and provincial levels by using data on laboratory-confirmed RT-PCR positive cases from the official national situation reports. We performed 8 week-to-week sequential forecasts of 10-days and 20-days at national level using three dynamic phenomenological growth models from 5 March 2021-22 May 2021. We also estimated effective and instantaneous reproduction numbers at national and provincial levels using established methods and evaluated the mobility trends using Google's mobility data. Our forecast estimates indicated a declining trend of COVID-19 cases in Nepal as of June 2021. Sub-epidemic and Richards models provided reasonable short-term projections of COVID-19 cases based on standard performance metrics. There was a linear pattern in the trajectory of COVID-19 incidence during the first wave (deceleration of growth parameter (p) = 0.41-0.43, reproduction number (Rt) at 1.1 (95% CI: 1.1, 1.2)), and a sub-exponential growth pattern in the second wave (p = 0.61 (95% CI: 0.58, 0.64)) and Rt at 1.3 (95% CI: 1.3, 1.3)). Across provinces, Rt ranged from 1.2 to 1.5 during the early growth phase of the second wave. The instantaneous Rt fluctuated around 1.0 since January 2021 indicating well sustained transmission. The peak in mobility across different areas coincided with an increasing incidence trend of COVID-19. In conclusion, we found that the sub-epidemic and Richards models yielded reasonable short-terms projections of the COVID-19 trajectory in Nepal, which are useful for healthcare utilization planning.

Status of Maternal and Child Health Seeking Behavior among Women Aged 15-45 Years during Earthquake of 2015 in Nepal: A Mixed Method Study.

BACKGROUND: Delivery of the maternal and child health services are generally affected during the time of disaster. This study aims to assess the maternal and child health service utilization in areas in Nepal affected by the 2015 earthquake. METHODS: A mixed method study was carried in 29 Village Development Committees from nine earthquake-affected districts in Nepal. Quantitative data on maternal, neonatal and child health indicators before and after the earthquake were collected from the Health Management Information System. Focus group discussions and key informant interviews with different stakeholders were conducted to collect qualitative data. Quantitative data was analyzed using Microsoft Excel 2013. Qualitative data was analyzed manually using thematic analysis technique. RESULTS: Most of the indicators were comparable before and after the earthquake. Indicators such as Bacille Calmette-Guerin vs. Measles-Rubella vaccine drop-out rate, 1st antenatal care visit, delivery by skilled birth attendant and 1st postnatal care visit within 24 hours of delivery improved after the earthquake. Though most of the health facilities were damaged, health services resumed under tents or in open spaces. Some of the common problems among pregnant women included stomachache, headache, malnutrition, diarrhea, and mental stress. CONCLUSIONS: There was not much effect in the delivery of maternal neonatal and child health services. This reflects the coordinated efforts from government as well as non-government organizations and civil societies during and after the earthquake in Nepal.

Self-Reported Changes in Risk Behaviours of Cardiovascular Diseases among School Adolescents in Nepal: Application of an Integrated Experiential Learning Approach.

Cardiovascular diseases (CVDs) account for the largest proportion of all deaths in Nepal (30%). Studies report that CVDs often begin with modifiable lifestyle risk behaviours established during adolescence which manifest later. This study aimed to measure changes in the five mortality-associated CVD risk behaviours (i.e., consumption of tobacco, alcohol, and junk food, physical inactivity, and stress among school adolescents) using an integrative intervention with the experiential learning approach. The study was carried out for 24 weeks (25 credit hours) among 4,225 students from grades 8 to 10 in community schools in seven provinces in Nepal. Pre- and post-intervention in-class self-reported surveys were conducted for assessing change in the students' aggregate risk behaviours. These percent changes were assessed through bivariate analysis. Key-informant interviews of teachers were conducted to assess their perceptions of the effectiveness of the intervention. At 24 weeks, the percentages of students reporting consumption of cigarettes and smokeless tobacco declined by 25% and 28% respectively, consumption of alcohol declined by 29%, consumption of instant noodles by 11%, and consumption of coke by 43%. The proportion of students reporting 'going to school by foot every day' increased by 11%, and those 'exercising until they sweat' increased by 29%. The percentage of students who reported feeling that their 'life has been running as desired' increased by 16%. Key-informant interviews of the teachers revealed that the intervention had contributed to improved motivation, knowledge, and attitude among students towards mitigating the risk behaviours. These interviews also recommended continuation of the intervention. The sample in this study has shown positive changes in school adolescents' self-reported aggregate CVD risk behaviours using the experiential learning approach. However, further research should be conducted to explore the sustainability and scaling of these learning modules through the existing non-communicable disease (NCD) school curriculum activities in Nepal.

Drivers of stunting reduction in Nepal: a country case study.

BACKGROUND: Chronic child malnutrition represents a serious global health concern. Over the last several decades, Nepal has seen a significant decline in linear growth stunting - a physical manifestation of chronic malnutrition - despite only modest economic growth and significant political instability. OBJECTIVE: This study aimed to conduct an in-depth assessment of the determinants of stunting reduction in Nepal from 1996 to 2016, with specific attention paid to national-, community-, household-, and individual-level factors, as well as relevant nutrition-specific and -sensitive initiatives rolled out within the country. METHODS: Using a mixed-methods approach, 4 types of inquiry were employed: 1) a systematic review of published peer-reviewed and gray literature; 2) retrospective quantitative data analyses using Demographic and Health Surveys from 1996 to 2016; 3) a review of key nutrition-specific and -sensitive policies and programs; and 4) retrospective qualitative data collection and analyses. RESULTS: Mean height-for-age z-scores (HAZ) improved by 0.94 SDs from 1996 to 2016. Subnational variation and socioeconomic inequalities in stunting outcomes persisted, with the latter widening over time. Decomposition analysis for children aged under 5 y explained 90.9% of the predicted change in HAZ, with key factors including parental education (24.7%), maternal nutrition (19.3%), reduced open defecation (12.3%), maternal and newborn health care (11.5%), and economic improvement (9.0%). Key initiatives focused on decentralizing the health system and mobilizing community health workers to increase accessibility; long-standing nationwide provision of basic health interventions; targeted efforts to improve maternal and child health; and the prioritization of nutrition-sensitive initiatives by both government and donors. National and community stakeholders and mothers at village level highlighted a mixture of poverty reduction, access to health services, improved education, and increased access to water, sanitation, and hygiene as drivers of stunting reduction. CONCLUSIONS: Improvements in both nutrition-specific and nutrition-sensitive sectors have been critical to Nepal's stunting decline, particularly in the areas of poverty reduction, health, education, and sanitation.