Non medical interventions for childhood diarrhoea control: way forward in Nepal.

BACKGROUND: Diarrhoeal diseases remain a major cause of mortality of children aged under-five years in the developing countries including Nepal. The transmission of diarrhoea mostly caused by biological agents and is facilitated by the behavioural, social and environmental factors. More recently, the concept of prevention altering these factors is getting momentum. OBJECTIVE: To recommend the most effective non medical intervention that can prevent and control childhood diarrhoeal disease in Nepal. METHODS: Literature review was conducted to analyse the successful interventions in developing countries. Peer review articles were accessed from "Science Direct", "Google Scholar", and "PubMed". Interventions focussing on social and environmental determinants of diarrhoea were included. RESULTS: Four interventions (with primary focus in social and environmental determinants of diarrhoeal disease) were purposively selected, summarized and discussed. Saniya programme (Burkina Faso 1995 to 1998) is considered successful in modifying the risk behaviours. Intensive hand washing programme (Pakistan 2002 to 2003), a cluster randomized controlled trail, was not sustainable as the results did not last long once the free supply of soap was stopped. School Led Total Sanitation (Nepal 2006) is a participatory, community centred program whose focus is on local ownership. This program approach is effective and feasible for scaling up in Nepal. Global Public Private Partnership for Hand washing with Soap (Ghana 2002) was based on the marketing researches and hence yielded effective results. CONCLUSION: Combination of School Led Total Sanitation and Global Public Private Partnership for hand washing with soap suits Nepal. These interventions focus on creating demand, changing behaviour and thereby, improving the sanitation status.

Practices and perceptions on contraception acceptance among clients availing safe abortion services in Nepal.

BACKGROUND: The Government of Nepal has implemented safe abortion policy since 2002. There are 245 approved sites providing safe abortion services to women across the country. Family planning counselling is one of the components of the safe abortion policy, which is important to reduce unwanted pregnancy, maternal morbidity and mortality due to the consequences of unsafe abortion and the service burden. OBJECTIVES: This study explains the perceptions, practices and factors affecting the use of family planning among abortion clients attending safe abortion services in Nepal. METHODS: A cross sectional study was carried out on September, 2008 enrolling 58 women who were waiting in the dressing room for safe abortion services in Paropkar Maternity Hospital, Nepal. All women attending hospital clinic for receiving safe abortion services were approached for interview till the targeted number was fulfilled. A convenience sampling was applied to reach the sample size. RESULTS: Of the 58 respondents, majority of the respondents were Hindus (83%), residing in Kathmandu district (76%); of the age group 20-29 years (69%); and 98% were married. One fifth (20.68 %) of the respondents had previous history of spontaneous or induced abortion. The main reason for abortion did not want any more babies/ complete family (45%). The knowledge of modern contraception was high (98.27%). The knowledge of emergency contraception was low (25.9%). Side effects was the main reason (48%, n=31) for discontinuation of contraceptives. Intention to use some modern family planning methods after the abortion was expressed by 83% clients. The major enabling factor for continued contraceptive use was the absence of side effects. The family planning counselling was acceptable for 91% clients. CONCLUSION: Knowledge, acceptance of counselling service and intention to use family planning measure was high in the study participants. There is need to provide skills on adapting with the adverse effect of family planning measure through continuous education and reinforcement.

The prevalence and characteristics of disability in Eastern Nepal.

BACKGROUND: Disability is related to poverty and development. Enough information and documentation is not available for developing countries like Nepal. AIMS AND OBJECTIVES: To assess the self-reported prevalence of disability in terms of age, sex, types, cause and age of onset. METHODOLOGY: A cross-sectional house to house census was carried out by means of structured questionnaires. RESULTS: A total of 31,160 individuals (4.87%) were found disabled out of a total of 640,259 individuals. The three most common types of disability are physical affecting limbs, hearing and vision. The most common perceived cause of disability is inborn syndrome followed by injury/accidents. DISCUSSION: Various publications for the prevalence of reported disability show a figure between three and ten percent, with physical disability affecting locomotion and manipulation as the leading type of disability. The prevalence rate can vary depending upon the disability indicators, methods and population surveyed and perceptions of the people. CONCLUSION: The self-reported prevalence of disability in Sunsari District is 4.87%, with inborn-syndrome as the leading perceived cause.

HIV and conflict in Nepal: relation and strategy for response.

Conflict and displacement make affected population more vulnerable to HIV infection. Refugees and internally displaced persons, in particular women and children, are at increased risk of exposure to HIV. In Nepal, there is considerable increase in the number of HIV infection since 1996 when conflict started. Along with poverty, stigma and lack of awareness, conflict related displacement, economic migration, and closure of HIV programmes have exacerbated the HIV situation in Nepal. Government has established "National AIDS Council" and launched HIV/AIDS Strategy. The strategy has not included the specific needs of displaced persons. While launching an HIV prevention programme in the conflict situation, the guidelines developed by Inter Agency Standing Committee (IASS) are important tools. This led to suggestion of an approach with implementations steps in the case of Nepal in this report.

Institutionalising of public health.

Though public health situation in Nepal is under-developed, the public health education and workforce has not been prioritised. Nepal should institutionalise public health education by means of accrediting public health courses, registration of public health graduates in a data bank and increasing job opportunities for public health graduates in various institutions at government sector.

How did Nepal reduce the maternal mortality? A result from analysing the determinants of maternal mortality.

Nepal reportedly reduced the maternal mortality ratio by 48% within one decade between 1996-2005 and received the Millennium development goal award for this. However, there is debate regarding the accuracy of this figure. On the basis of framework of determinants of maternal mortality proposed by McCarthy and Maine in 1992 and successive data from Nepal demographic health survey of 1996, 2001 and 2006, a literature analysis was done to identify the important factors behind this decline. Although facility delivery and skilled birth attendants are acclaimed as best strategy of reducing maternal mortality, a proportionate increase in these factors was not found to account the maternal mortality rate reduction in Nepal. Alternatively, intermediate factors particularly women awareness, family planning and safe abortion might have played a significant role. Hence, Nepal as well as similar other developing countries should pay equal attention to such intermediate factors while concentrating on biomedical care strategy.

Primary health care development: where is Nepal after 30 years of Alma Ata Declaration?

The year 2008 has witnessed the global conversation to return to tenets of Alma-Ata and to review its 30 years of journey. We reviewed Nepal's journey on Primary Health Care development: policy formulation, structure development, progress and constraints. Though Nepal has institutionalised the PHC approach in health policy, strategy and health care delivery system, this has not been effectively translated into actions, and the results are mixed. Nepal has gained impressive achievements in selective primary health care markers: 45.43% maternal mortality and 62.34% child mortality reduction during 1990-2005. But gain in comprehensive health care markers is not impressive: 18.7% Skilled Birth Attendant (4% in poorest quintile and 45% in richest quintile), 39% having access to improved sanitation and 55.7% of females are literate as compared to males. Socio-political environment until recently was not favourable for comprehensive primary health care, allowing limited health sector decentralisation and community empowerment. Health activities were focussed more on selective health care strategy in the form of disease control, immunisation, vitamin A supplementation, oral rehydration solution use and contraceptive use. Nepal's rural hilly geography posed great challenge on logistic supply, communication and retention of health workers rendering public health centres of low quality with negative perceptions of consumers. Nepal is on the pathway to build equitable comprehensive primary health care.