Effective coverage of childbirths in health facilities in Nepal: cross-sectional study combining Demographic and Health Survey 2022 and Health Facility Survey 2021

Background: Crude intervention coverage, such as percentage of facility-based childbirths, does not reflect care quality. Effective coverage provides a more accurate measure by accounting for the quality of maternal health services. This study aimed to estimate effective coverage of facility-based childbirth in enabling environments in Nepal. Methods: We used data from Nepal’s Demographic and Health Survey 2022 including 1,977 women and the Health Facility Survey 2021 with a sample of 804 facilities. We calculated the percentages of births by facility type and the percentage of facility types with enabling environments for childbirth services. We combined the results from two surveys to estimate effective coverage of births for routine childbirth, basic and comprehensive emergency obstetric and newborn care (BEmONC and CEmONC). Results: Around 80 % of all births occurred in health facilities nationwide. This reduced to 18.5% nationwide when only births in facilities equipped for routine childbirth were considered, and further to 12.9% and 12.2%, respectively for BEmONC and CEmONC. The reduction between crude and effective coverage across facility types varied from 36.8% to 13.5% in government hospitals, from 16.1% to 4.7% in private hospitals for routine childbirth. While, 20.1% of births were in health posts, no health posts had enabling environments for routine childbirth. Conclusions: Fewer than one in five births occur in health facilities with enabling environments for acceptable quality care. This emphasizes the need for policymakers to prioritize the quality of childbirth services in well-equipped and well-staffed facility environments to improve maternal and neonatal outcomes

A Novel Approach to Assessing the Potential of Electronic Decision Support Systems to Improve the Quality of Antenatal Care in Nepal.

INTRODUCTION: Electronic decision-support systems (EDSSs) aim to improve the quality of antenatal care (ANC) through adherence to evidence-based guidelines. We assessed the potential of the mHealth integrated model of hypertension, diabetes, and ANC EDSS and the World Health Organization EDSS to improve the quality of ANC in primary-level health care facilities in Nepal. METHODS: From December 2021 to January 2023, we conducted a mixed-methods evaluation in 19 primary-level ANC facilities in Bagmati Province, Nepal. Implementation was from March 2022 to August 2022. We conducted a health facility survey, ANC clinical observations, longitudinal case studies and validation workshop, in-depth interviews, monitoring visits, research team debriefing meetings, health care provider attitude survey, and stakeholder engagement and feedback meetings. Results were integrated using concurrent triangulation to develop explanations about the EDSS implementation process and the effects observed. RESULTS: We identified 9 themes on implementation challenges that hindered the EDSS from generating the desired improvements to ANC quality. Facility readiness and provider confidence in using the EDSS were mixed. It was not always used or used as intended, and the approach to ANC provision did not change. EDSS inflexibility did not reflect how staff made decisions about pregnant women's needs or ensure that tests were done at the right time. There was mixed evidence that ANC staff believed that the EDSS benefited their work. The EDSS did not become fully integrated into existing health systems. Engagement of essential stakeholders fell short. CONCLUSION: Different understandings of and inconsistent use of the EDSS highlighted the need for increased training and support periods, greater stakeholder engagement, and further integration into existing health systems. Our novel approach to integrating findings from multiple substudies offers uniquely valuable insights into the many factors needed for the successful implementation of an EDSS to improve the quality of ANC in Nepal

Impact of digital antenatal care intervention on paper-based antenatal care recordkeeping: a before-and-after study in primary healthcare facilities in Nepal

Objective To assess the impact of introducing electronic decision support systems (EDSS)—electronic data entry implemented alongside existing paper-based antenatal care (ANC) records—on the completeness and agreement of ANC records. Design Two-phase cross-sectional (before and after) substudy of the mobile health integrated model of hypertension, diabetes and ANC (mIRA project) process evaluation. Setting Four rural districts in Bagmati Province, Nepal, in 19 primary healthcare facilities. Participants ANC records from pregnant women attending facilities before (n=136) and after (n=138) EDSS implementation. Main outcome measures For selected indicators in the ANC card and ANC register, we estimated the percentage completeness (any value recorded) and agreement (whether values matched) before and after EDSS implementation. We also reported the completeness of indicators in the EDSS and calculated the agreement between the ANC card and EDSS. χ2or Fisher’s exact test, as appropriate, was used to assess differences in completeness before and after implementation. Results Completeness of paper-based ANC records was high before implementation (>90%) for all indicators, except tetanus vaccination (<80%). After EDSS implementation, there was >15% improvement in the completeness of tetanus vaccination date in paper-based ANC records (77.0%–96.4% for ANC cards and 81.9%–98.9% for ANC register). Agreement between the ANC card and ANC register increased slightly for all indicators after implementation, and the tetanus vaccination date showed the largest increase (38.2%–57.2%). Indicator completeness in the EDSS was low, ranging from 38.2% to 88.7%. Conclusion We found slight improvements in the completeness and agreement of paper-based ANC records following EDSS implementation. The lower percentage of completeness in the EDSS suggests that any large-scale implementation should consider how to integrate digital and paper-based records to decrease the data entry burden on ANC providers. However, the study’s small sample size limited the ability to examine variation in effects

Workload in antenatal care before and after implementation of an electronic decision support system: an observed time-motion study of healthcare providers in Nepal.

Background: Healthcare interventions are shaped by the resources needed to implement them, including staff time. This study, part of a process evaluation, aims to compare time spent on antenatal care (ANC) and related recordkeeping in two rural primary-level health facilities in Nepal, before and after implementation of an electronic decision support system intervention to improve ANC quality that required additional electronic documentation. Methods: The study is a before-and-after, observational time-motion assessment. Researchers used the WOMBAT (Work Observation Method By Activity Timing) software to observe and record activities performed by auxiliary nurse midwives providing ANC in two rounds of data collection. We summed the observation time (in minutes) spent on activity categories for each day of observation, in each round of data collection. For each auxiliary nurse midwife, we estimated the proportion of total observation time spent on activities and compared these proportions before and after intervention implementation. We also compared the mean minutes per day spent on ANC and recordkeeping in the two rounds. Results: Six auxiliary nurse midwives were observed over two data collection rounds (41 total observation days). Prior to intervention, providers spent 7% of their workday on ANC and 6% on related recordkeeping, and time spent on these activities did not change after intervention implementation. Only one of the six auxiliary nurse midwives demonstrated a statistically significant increase in time spent on ANC and recordkeeping after implementation. There was considerable day-to-day variation in ANC time, and substantial periods of "non-work" time (on break or not engaged in work-related activity). Non-work time reduced from 42% in the first round to 26% in the second round of data collection. Conclusions: Time spent on ANC and related recordkeeping was low and did not change after implementation of the electronic decision support system. ANC and recordkeeping time was sensitive to day-to-day fluctuations in numbers of women attending for ANC at these rural facilities, which may have masked the intervention's effects. However, the large amount of non-work time observed suggests time constraints during the workday were not a major factor inhibiting use of the electronic decision support system

When health data go dark: the importance of the DHS Program and imagining its future

The suspension and/or termination of many programmes funded through the United States Agency for International Development (USAID) by the new US administration has severe short- and long-term negative impacts on the health of people worldwide. We draw attention to the termination of the Demographic and Health Surveys (DHS) Program, which includes nationally representative surveys of households, DHS, Malaria Indicator Surveys [MIS]) and health facilities (Service Provision Assessments [SPA]) in over 90 low- and middle-income countries. USAID co-funding and provision of technical support for these surveys has been shut down. The impact of these disruptions will reverberate across local, regional, national, and global levels and severely impact the ability to understand the levels and changes in population health outcomes and behaviours. We highlight three key impacts on (1) ongoing data collection and data processing activities; (2) future data collection and consequent lack of population-level health indicators; and (3) access to existing data and lack of support for it. We call for immediate action on multiple fronts. In the short term, universal access to existing data and survey materials should be restored, and surveys which were planned or in progress should be completed. In the long term, this crisis should serve as a tipping point for transforming these vital surveys. We call on national governments, regional organisations, and international partners to develop sustainable alternatives that preserve the principles (standardised questionnaires, backward compatibility, open access data with rigorous documentation) which made the DHS Program an invaluable global health resource

Perceived risk and associated factors of healthcare waste in selected hospitals of Kathmandu, Nepal.

BackgroundHealthcare waste management is the subject of a neglected issue in many developing countries. Health care facilities are facing a major challenge in handling healthcare wastes and reducing their potential risks to human health and the environment. Insufficient understanding of the risk associated with healthcare waste by health workforce can contribute to poor waste management practices. The main aim of this study is to assess risk perception towards healthcare waste among hospital attendants and to identify associated factors.MethodologyWe carried out a cross-sectional hospital-based study among 120 attendants of a private and public hospital in Kathmandu, Nepal. We used two-stage random sampling for the selection of hospital and participants. We conducted a face-to-face interview with the participants using semi-structured questionnaires. Based on the mean score, we classified risk perception as good and poor. Bivariate and multivariate analysis was carried out to determine associates of risk perception towards healthcare waste.ResultsApproximately 51.0% of hospital attendants had poor risk perception of healthcare waste. Nearly half of the participants (49.2%) had inadequate knowledge and 43.0% had a negative attitude. Factors such as healthcare waste management training (p = 0.028), housekeeping department (p = 0.036) and attitude (p = 0.001) were associated with risk perception of healthcare waste.ConclusionHospital attendants had a poor understanding of risk perception of healthcare waste. Periodic training on healthcare waste management and edification on the risk associated with healthcare waste is essential to boost awareness among all healthcare workers. Communication on behavioral improvements for appropriate waste management must be prioritized to change the perception of health workers

Role of cancer literacy in cancer screening behaviour among adults of Kaski district, Nepal

Cancer Screening is a key approach to detect cancer at an early stage and help reduce cancer mortality globally. Inadequate Cancer Literacy may pose a barrier to patient engagement in getting screened for cancer. This study assessed Cancer Screening behavior and its association with Cancer Literacy and other factors among adults of Kaski district, Nepal. A cross-sectional study was carried out among 180 adults from March to August 2019, selected using a multi-stage random sampling method. Data on demographics, history of cancer, use of naturopathy, fatalism, family support, cancer literacy and cancer screening behaviour were collected using a semi-structured questionnaire, with the aid of face-to-face interviews. Cancer Literacy was measured using a cancer health literacy tool (CHLT-6), and Cancer Screening behaviour was assessed on the basis of the self reported information about having gone through any type of cancer screening in the past. Odds ratio (OR) with 95% Confidence Interval (CI) was calculated to determine the strength of association using Multivariate Logistic Regression analysis. Only 43.4% of the respondents had Cancer Literacy scores more than the median and only 11.7% had ever gone through any Cancer Screening test in the past. In this study, Cancer Screening behaviour was significantly associated with Cancer Literacy [OR = 1.43, 95% CI (1.01–2.02)]. Similarly, significant association was found between Cancer Screening behaviour and other exposure variables such as age [OR = 1.06, 95% CI (1.02–1.11)] and gender [OR = 0.06, 95% CI (0.01–0.35)]. This study showed low cancer screening and cancer literacy scores amongst the respondents. This suggests that to tackle the ever increasing burden of cancer and hence, to increase cancer screening, we need to focus on improving knowledge and awareness about cancer, as well as, on targeting efforts towards people’s understanding of basic health and cancer terminologies.</jats:p

Risk perception towards healthcare waste among community people in Kathmandu, Nepal.

BackgroundHealthcare waste management is a serious issue in context of developing countries. Better assessment of both risks and effects of exposure would permit improvements in the management of healthcare waste. However, there is not yet clear understanding of risks, and as consequences, inadequate management practices are often implemented.ObjectivesThis study primarily aims to assess risk perception towards healthcare waste and secondly to assess knowledge, attitude and identify the factors associated with risk perception.ResultsA cross-sectional community based study was carried out among 270 respondents selected through multistage sampling technique. Face-to-face interview was conducted using semi-structured questionnaires. Risk perception was classified as good and poor based on mean score. Bivariate and multivariate analyses were carried out to determine the associates of risk perception. More than half, 52% of the sampled population had a poor risk perception towards healthcare waste. More than a quarter 26.3% had inadequate knowledge and forty percent (40%) had a negative attitude towards health care waste management. Having knowledge (OR = 3.31; CI = 1.67-6.58) was a strong predictor of risk perception towards healthcare waste. The perception of risk towards healthcare waste among community people was poor. This highlights the need for extensive awareness programs. Promoting knowledge on healthcare waste is a way to change the perception in Nepal. Community engaged research approach is needed to address environmental health concerns among public residents