An analysis of Nepal's Draft Mental Health Act 2006-2017: Competing values and power.

This qualitative study maps the process of drafting and consulting on Nepal's mental health legislation from 2006 to 2017. Fourteen people were interviewed, and interviews were analysed thematically. These themes were subsequently interpreted in light of Shiffman and Smith's policy analysis framework, as the process was found to be at the agenda-setting stage. Two groups of actors were identified with different views on appropriate policy content and how the policy process should be conducted. The first group included psychiatrists who initiated and controlled the drafting process, and who did not consider people with psychosocial disabilities to be equal partners. The psychiatrists viewed forced detention and treatment as upholding people's Right to Health and lobbied the Ministry of Health and Population (MoHP) to pass the draft Acts to Parliament. The second included the rights-based civil society actors and lawyers who saw the Right to Equality before the Law as of utmost priority, opposed forced detention and treatment, and actively blocked the draft Acts at the MoHP. There is no clear legal definition of mental health and illness in Nepal, legal and mental capacity are not differentiated, and people with mental and behavioural conditions are assumed to lack capacity. The analysis indicates that there were few favourable conditions to support the progression of this policy into law. It is unclear whether the drafters or blockers will prevail in the future, but we predict that professionals will continue to have more input into content than service users due to national policy dynamics.

Nepal needs Continuing Professional Development for Re-registration in Nursing and Midwifery.

The nursing and midwifery profession needs to stay up to date with the latest developments.  In this Viewpoint, we shall be referring to 'nurses' and 'nursing' to mean 'nurses and midwives' and 'nursing and midwifery' respectively. Nurses must continue to update their skills and competences to meet changing future population health needs effectively and safely. However, the reality is that many staff are reporting difficulty accessing and completing Continuing Professional Development (CPD) in all settings. Keywords: CPD; midwifery; nursing; post-registration education; training.

Participatory policy analysis in health policy and systems research: reflections from a study in Nepal.

BACKGROUND: Participatory policy analysis (PPA) as a method in health policy and system research remains underexplored. Using our experiences of conducting PPA workshops in Nepal to explore the impact of the country's move to federalism on its health system, we reflect on the method's strengths and challenges. We provide an account of the study context, the design and implementation of the workshops, and our reflections on the approach's strengths and challenges. Findings on the impact of federalism on the health system are beyond the scope of this manuscript. MAIN BODY: We conducted PPA workshops with a wide range of health system stakeholders (political, administrative and service-level workforce) at the local and provincial levels in Nepal. The workshops consisted of three activities: river of life, brainstorming and prioritization, and problem-tree analysis. Our experiences show that PPA workshops can be a valuable approach to explore health policy and system issues - especially in a context of widespread systemic change which impacts all stakeholders within the health system. Effective engagement of stakeholders and activities that encourage both individual- and system-level reflections and discussions not only help in generating rich qualitative data, but can also address gaps in participants' understanding of practical, technical and political aspects of the health system, aid policy dissemination of research findings, and assist in identifying short- and long-term practice and policy issues that need to be addressed for better health system performance and outcomes. Conducting PPA workshops is, however, challenging for a number of reasons, including the influence of gatekeepers and power dynamics between stakeholders/participants. The role and skills of researchers/facilitators in navigating such challenges are vital for success. Although the long-term impact of such workshops needs further research, our study shows the usefulness of PPA workshops for researchers, for participants and for the wider health system. CONCLUSIONS: PPA workshops can effectively generate and synthesize health policy and system evidence through collaborative engagement of health system stakeholders with varied roles. When designed with careful consideration for context and stakeholders' needs, it has great potential as a method in health policy and systems research.

'I might have cried in the changing room, but I still went to work'. Maternity staff balancing roles, responsibilities, and emotions of work and home during COVID-19: An appreciative inquiry.

PROBLEM: Knowing how to help staff thrive and remain in practice in maternity services. BACKGROUND: A chronic shortage of staff in maternity services in the United Kingdom and high levels of stress and burnout in midwifery and medical staff. PURPOSE: To understand how to support and enhance the wellbeing of staff in a small UK maternity service. METHODS: An appreciative inquiry using interviews with n = 39 maternity staff and n = 4 group discussions exploring meaningful experiences, values and factors that helped their wellbeing. RESULTS: Staff members were highly motivated, managing a complex melee of emotions and responsibilities including challenges to professional confidence, mental health, family situation, and conflict between work-life roles. Despite staff shortages, a demanding workload, professional and personal turmoil, and the pandemic participants still found meaning in their work and relationships. DISCUSSION: A 'whole person' approach provided insight into the multiple stressors and emotional demands staff faced. It also revealed staff resourcefulness in managing their professional and personal roles. They invested in relationships with women but were also aware of their limits - the need to be self-caring, employ strategies to switch-off, set boundaries or keep a protective distance. CONCLUSION: Staff wellbeing initiatives, and research into wellbeing, would benefit from adopting a holistic approach that incorporates home and family with work. Research on emotion regulation strategies could provide insights into managing roles, responsibilities, and the emotional demands of working in maternity services. Emotion regulation strategies could be included in midwifery and obstetric training.

The impact of decentralisation on health systems: a systematic review of reviews.

BACKGROUND: Decentralisation is a common mechanism for health system reform; yet, evidence of how it impacts health systems remains fragmented. Despite published findings from primary and secondary research illustrating range of impacts, a comprehensive and clear understanding is currently lacking. This review synthesised the existing evidence to assess how decentralisation (by devolution) impacts each of the six WHO building blocks, and the health system. METHOD: We systematically searched five electronic databases for reviews exploring impact of decentralisation on health systems, globally. Reviews, both systematic and non-systematic, published in the English language from January 1990 to February 2022 were included. Data were synthesised across each of six building blocks. Quality assessment of the reviews was conducted using Critical Appraisal Skills Program for systematic and Scale for Assessment of Narrative Review Articles for non-systematic reviews. RESULTS: Nine reviews, each addressing somewhat different questions, contexts and issues, were included. A range of positive and negative impacts of decentralisation on health system building blocks were identified; yet, overall, the impacts were more negative. Although inconclusive, evidence suggested that the impacts on leadership and governance and financing components in particular shape the impact on overall health system. Assessment of how the impact on building blocks translates to the broader impact on health systems is challenged by the dynamic complexities related to contexts, process and the health system itself. CONCLUSIONS: Decentralisation, even if well intentioned, can have unintended consequences. Despite the difficulty of reaching universally applicable conclusions about the pros and cons of decentralisation, this review highlights some of the common potential issues to consider in advance. PROSPERO REGISTRATION NUMBER: CRD42022302013.

Overcoming the challenges facing Nepal's health system during federalisation: an analysis of health system building blocks.

INTRODUCTION: Nepal's move to a federal system was a major constitutional and political change, with significant devolution of power and resources from the central government to seven newly created provinces and 753 local governments. Nepal's health system is in the process of adapting to federalism, which is a challenging, yet potentially rewarding, task. This research is a part of broader study that aims to explore the opportunities and challenges facing Nepal's health system as it adapts to federalisation. METHODS: This exploratory qualitative study was conducted across the three tiers of government (federal, provincial, and local) in Nepal. We employed two methods: key informant interviews and participatory policy analysis workshops, to offer an in-depth understanding of stakeholders' practical learnings, experiences, and opinions. Participants included policymakers, health service providers, local elected members, and other local stakeholders. All interviews were audio-recorded, transcribed, translated into English, and analysed thematically using the six WHO (World Health Organization) health system building blocks as a theoretical framework. RESULTS: Participants noted both opportunities and challenges around each building block. Identified opportunities were: (a) tailored local health policies and plans, (b) improved health governance at the municipality level, (c) improved health infrastructure and service capacity, (d) improved outreach services, (e) increased resources (health budgets, staffing, and supplies), and (f) improved real-time data reporting from health facilities. At the same time, several challenges were identified including: (a) poor coordination between the tiers of government, (b) delayed release of funds, (c) maldistribution of staff, (d) problems over procurement, and (e) limited monitoring and supervision of the quality of service delivery and data reporting. CONCLUSION: Our findings suggest that since federalisation, Nepal's health system performance is improving, although much remains to be accomplished. For Nepal to succeed in its federalisation process, understanding the challenges and opportunities is vital to improving each level of the health system in terms of (a) leadership and governance, (b) service delivery, (c) health financing, (d) health workforce, (e) access to essential medicines and technologies and (f) health information system.

Perceptions around COVID-19 and vaccine hesitancy: A qualitative study in Kaski district, Western Nepal.

Burgeoning morbidity and mortality due to COVID-19 pandemic including the peaks in outbreaks due to different variants have attracted global attention. Although the development and rolling out of vaccines have been impressive, low- and middle-income countries suffer from a double burden: (1) lack of adequate vaccines; and (2) low vaccine uptake (vaccine hesitancy). The main objective of this study was to explore perceptions around COVID-19 and vaccine hesitancy among urban and rural population in Western Nepal. A qualitative study was conducted in six urban wards of Pokhara municipality and four rural municipalities in Kaski district of Nepal. A semi-structured interview guide was used to interview participants who were selected purposively to explore the perceived burden of COVID-19 pandemic, roles, and contributions of vaccine. Nineteen interviews were conducted by telephone following a government recommendation to avoid face-to-face meetings. Audio-recorded interviews were thematically analysed after transcription and translation into English. COVID-19 is a major (public) health concern and affects people at an individual, societal and national level. People dreaded its health hazards and consequences and seemed to be compliant with public health measures such as maintaining social distance, wearing masks and maintaining hygiene. Vaccine was considered to be a major intervention to fight the pandemic, nonetheless, the rationale and benefits of vaccines were blemished by the perceived lack of the vaccine's effectiveness, duration of protection, and its potential side-events. Expedited development of vaccine was embraced with suspicion that vaccine may have incurred compromise in quality. Science and rationale behind vaccine were smeared by misinformation and clearly counteracting the misinformation were deemed critical. Providing information about vaccines through government entities (who are trusted) and respected individuals may engender trust and uptake of vaccine. Fighting off misinformation of COVID-19 is critical to curb the course of pandemic. Increased attention towards monitoring and investing in legitimacy of information and offering information through trusted sources can help improve the vaccine coverage.

Stakeholders' perceptions of continuing professional development among Nepalese nurses: A focus group study.

AIM: This study explores perceptions of Continuing Professional Development (CPD) opportunities among stakeholders in the profession of nursing in Nepal. DESIGN: Qualitative study using focus group discussions (FGDs). METHODS: Eight FGDs were conducted in three major cities of Nepal with nursing stakeholders including nurse managers, matrons and directors/managers of private and public nursing colleges, representatives of nursing organizations, government officials, nursing academics and practitioners from the government and private sectors. The data were analysed thematically using Creswell's six steps of analysis and the Standards for Reporting Qualitative Research (SRQR) guideline was followed. RESULTS: The study generated three major themes: (a) policy level including the national situation of CPD, political influence and training guided by the policy; (b) organizational level incorporating perceptions towards forms of CPD, staff shortage, poor staff retention, seniority for training, financial constraints and lack of continuity of training; and (c) individual level including motivation for training and lack of relevant training.

Need for evidence synthesis for quality control of healthcare decision-making.

Systematic reviews that are out-of-date delay policymaking, create controversy, and can erode trust in research. To avoid this issue, it is preferable to keep summaries of the study evidence. Living evidence is a synthesis approach that provides up-to-date rigorous research evidence summaries to decision-makers. This strategy is particularly useful in rapidly expanding research domains, uncertain existing evidence, and new research that may impact policy or practice, ensuring that physicians have access to the most recent evidence. Addressing global challenges - ranging from public health crises to climate change or political instability - requires evidence-based judgements. An obsolete, biased, or selective information poses risks of poor decisions and resource misallocation. The relatively nascent practice of living evidence proves invaluable in maintaining continuous interest and team engagement. The concept of living evidence has been particularly relevant during the COVID-19 pandemic due to the rapidly evolving nature of the virus, the urgent need for timely information, and the continuous emergence of new research findings. Although the COVID-19 pandemic accelerated the adoption of evidence systems, researchers and funders of research should rigorously test the living-evidence model across diverse domains to further advance and optimize its methodology.

A survey of Post-Traumatic Stress Disorder, Anxiety and Depression among Flood Affected Populations in Kerala, India.

Background: Globally, post traumatic stress disorder (PTSD) is one of the most common psychiatric illnesses following a disaster. We aimed to evaluate the relationship between the socio-economic and flood exposure factors with PTSD, depression and anxiety among the flood-affected populations in Kerala, India. Methods: A cross-sectional household survey was conducted from November 2019 to January 2020 in Kozhikode district of Kerala, India. Adults (≥ 18 years), who were permanent residents and had been directly exposed to the flood, were invited to take part in the study. Individuals with a history of mental health issues and those who had other stressful situations in the past were excluded. The survey questionnaire was based on three screening tools: (1) PTSD Checklist for DSM-5 (PCL-5); (2) patient health questionnaire (PHQ-9); and (3) generalized anxiety disorder (GAD-7). Data included sociodemographic factors and flood exposure variables. The primary outcome variable was psychiatric morbidity (PTSD, anxiety and depression). Results: A total of 276 respondents (150 males/126 females) participated in the study. A significant correlation was observed between total score on PCL-5 and GAD-7 (r=0.339, p=0.001) and PHQ-9 (r=0.262, p=0.001). Females had significantly higher total PTSD symptom severity scores (8.24±5.88 vs. 6.07±5.22; p=0.001), severity of symptoms of intrusion (4.66±3.60 vs. 3.69±3.20; p=0.04), increased level of anxiety (2.54±1.94 vs. 1.79±1.53; p=0.001) and depression (3.02±2.26 vs. 2.04±1.67; p=0.001) compared to males. However, the gender difference for PTSD symptoms disappeared when controlling for age. Conclusion: The findings of this survey revealed that the vast majority of respondents (92 percent females and 87 percent males) still had subclinical psychiatric symptoms one year after the flood. Therefore, tailored psychological interventions are warranted to counter the long-lasting impact of flooding on the mental health of individuals.

Mixed-methods research on androgen abuse - a review.

PURPOSE OF REVIEW: This paper reviews the mixed-methods studies from the last 2 years (2021-2022) into androgen use to highlight the most relevant developments within the field. RECENT FINDINGS: The literature review found seven papers from 2021 to 2022. These seven cover a range of important considerations, including interventions to reduce androgen use, educational tools to increase professionals' knowledge, explorations on the comorbidity of use with other substances, motivations for use, potential risks factors for androgens' initiation, or risks of using androgens. Key findings include a greater understanding of motivations for use, particularly in females and older males; identification of potential risks for starting use/using androgens; benefits of including practical strength exercises in preventive intervention programmes and the efficacy of e-learning tools to increase professionals' knowledge of androgens use, as well as an increase in their confidence to support androgen users. SUMMARY: The key implications for clinical practice are that we still need to support healthcare professionals to overcome the barriers for increasing their skills and knowledge around androgen use. A recognition that people who have become dependent on androgen use are potentially at risk of considerable harm, with further research needed into sub-groups of androgen users. VIDEO ABSTRACT: , http://links.lww.com/COE/A35.

Fear, Stigma and Othering: The Impact of COVID-19 Rumours on Returnee Migrants and Muslim Populations of Nepal.

The paper explores how COVID-19-related moral panics have led to fear and othering practices among returnee Nepalese migrants from India and Muslims living in Nepal. This qualitative study included in-depth interviews with 15 returnee migrants, 15 Muslims from Kapilvastu and Banke districts of Nepal, and eight interviews with media and health professionals, and representatives from migration organisations. Four themes emerged from our data analysis: (1) rumours and mis/disinformation; (2) impact of rumours on marginalised groups (with three sub-themes: (i) perceived fear; (ii) othering practices; (iii) health and social impact); (3) resistance; and (4) institutional response against rumours. Findings suggest that rumours and misinformation were fuelled by various media platforms, especially social media (e.g., Facebook, YouTube) during the initial months of the lockdown. This created a moral panic which led to returnee migrants and Muslim populations experiencing fear and social isolation. Resistance and effective institutional responses to dispel rumours were limited. A key contribution of the paper is to highlight the lived experiences of COVID-19 related rumours on marginalised groups. The paper argues that there is a need for clear government action using health promotion messages to tackle rumours (health-related or otherwise), mis/disinformation and mitigating the consequences (hatred and tensions) at the community level.

COVID-19 restrictions and psychological well-being of fathers with infants admitted to NICU-An exploratory cross-sectional study.

AIM: To describe the impact of the COVID-19 restrictions on the caregiving activities and psychological well-being of fathers with infants admitted to neonatal units. METHODS: Cross-sectional study using adapted COPE-IS and COPE-IU tools. Participants' recruitment occurred online via social media and parents' associations. Online survey in English, French and Italian were distributed and promoted via websites and social media platforms of parent's associations. The study was undertaken across 12 countries in Asia, Australia, Africa and Europe. RESULTS: A total of 108 fathers of NICU infants completed the survey. COVID-19 related restrictions were categorised into 3 types: no restrictions, partial and severe restrictions. Fathers who experienced partial restrictions reported more involvement in caregiving activities but high levels of emotional difficulties and sleeping problems compared to those who experienced full or no restrictions. CONCLUSION: Given the impact on the psychological well-being of fathers, restrictions should be avoided as much as possible in the neonatal unit and fathers given free access to their infants if they follow appropriate infection control precautions.

The Growing Importance of Mixed-Methods Research in Health.

This paper illustrates the growing importance of mixed-methods research to many health disciplines ranging from nursing to epidemiology. Mixed-methods approaches requires not only the skills of the individual quantitative and qualitative methods but also a skill set to bring two methods/datasets/findings together in the most appropriate way. Health researchers need to pay careful attention to the 'best' approach to designing, implementing, analysing, integrating both quantitative (number) and qualitative (word) information and writing this up in a way offers greater insights and enhances its applicability. This paper highlights the strengths and weaknesses of mixed-methods approaches as well as some of the common mistakes made by researchers applying mixed-methods for the first time.