The power of peers: An effectiveness evaluation of a cluster-controlled trial of group antenatal care in rural Nepal

Background: Reducing the maternal mortality ratio to less than 70 per 100,000 live births globally is one of the Sustainable Development Goals. Approximately 830 women die from pregnancy-or childbirth-related complications every day. Almost 99% of these deaths occur in developing countries. Increasing antenatal care quality and completion, and institutional delivery are key strategies to reduce maternal mortality, however there are many implementation challenges in rural and resource-limited settings. In Nepal, 43% of deliveries do not take place in an institution and 31% of women have insufficient antenatal care. Context-specific and evidence-based strategies are needed to improve antenatal care completion and institutional birth. We present an assessment of effectiveness outcomes for an adaptation of a group antenatal care model delivered by community health workers and midwives in close collaboration with government staff in rural Nepal. Methods: The study was conducted in Achham, Nepal, via a public private partnership between the Nepali non-profit, Nyaya Health Nepal, and the Ministry of Health and Population, with financial and technical assistance from the American non-profit, Possible. We implemented group antenatal care as a prospective non-randomized, cluster-controlled, type I hybrid effectiveness-implementation study in six village clusters. The implementation approach allowed for iterative improvement in design by making changes to improve the quality of the intervention. We evaluated effectiveness through a difference in difference analysis of institutional birth rates between groups prior to implementation of the intervention and 1 year after implementation. Additionally, we assessed the change in knowledge of key danger signs and the acceptability of the group model compared with individual visits in a nested cohort of women receiving home visit care and home visit care plus group antenatal care. Using a directed content and thematic approach, we analyzed qualitative interviews to identify major themes related to implementation. Results: At baseline, there were 457 recently-delivered women in the six village clusters receiving home visit care and 214 in the seven village clusters receiving home visit care plus group antenatal care. At endline, there were 336 and 201, respectively. The difference in difference analysis did not show a significant change in institutional birth rates nor antenatal care visit completion rates between the groups. There was, however, a significant increase in both institutional birth and antenatal care completion in each group from baseline to endline. We enrolled a nested cohort of 52 participants receiving home visit care and 62 participants receiving home visit care plus group antenatal care. There was high acceptability of the group antenatal care intervention and home visit care, with no significant differences between groups. A significantly higher percentage of women who participated in group antenatal care found their visits to be 'very enjoyable' (83.9% vs 59.6%, p = 0.0056). In the nested cohort, knowledge of key danger signs during pregnancy significantly improved from baseline to endline in the intervention clusters only (2 to 31%, p < 0.001), while knowledge of key danger signs related to labor and childbirth, the postpartum period, and the newborn did not in either intervention or control groups. Qualitative analysis revealed that women found that the groups provided an opportunity for learning and discussion, and the groups were a source of social support and empowerment. They also reported an improvement in services available at their village clinic. Providers noted the importance of the community health workers in identifying pregnant women in the community and linking them to the village clinics. Challenges in birth planning were brought up by both participants and providers. Conclusion: While there was no significant change in institutional birth and antenatal care completion at the population level between groups, there was an increase of these outcomes in both groups. This may be secondary to the primary importance of community health worker involvement in both of these groups. Knowledge of key pregnancy danger signs was significantly improved in the home visit plus group antenatal care cohort compared with the home visit care only group. This initial study of Nyaya Health Nepal's adapted group care model demonstrates the potential for impacting women's antenatal care experience and should be studied over a longer period as an intervention embedded within a community health worker program. Trial registration: ClinicalTrials.gov Identifier: NCT02330887, registered 01/05/2015, retroactively registered

Compliance with the smoke-free public places legislation in Nepal: A cross-sectional study from Biratnagar Metropolitan City

Background Smoke-free legislation banning tobacco smoking in public places was implemented across Nepal in 2014 with the ambition to reduce the impact of second-hand smoking. As part of a comprehensive policy package on tobacco control, the implementation of the legislation has seen a marked reduction in tobacco consumption. Yet there remains uncertainty about the level of compliance with smoke-free public places. Objectives This study assesses the compliance with smoke-free laws in public places and the factors associated with active smoking in public places in Biratnagar Metropolitan City, Nepal. Methods A cross-sectional study was conducted in the Biratnagar metropolitan city in Province 1 of Nepal from July to December 2019. A total of 725 public places within the metropolitan city were surveyed using a structured survey tool. Active smoking was the primary outcome of the study which was defined as smoking by any person during the data collection time at the designated public place. Results The overall compliance with smoke-free legislation was 56.4%. The highest compliance (75.0%) was observed in Government office buildings. The lowest compliance was observed in eateries, entertainment, and shopping venues (26.3%). There was a statistically significant association between active smoking and the presence of ‘no smoking’ notices appended at the entrance and the odds of active smoking in eateries, entertainment, hospitality, shopping venues, transportations and transits was higher compared to education and health care institutions. None of the ‘no smoking’ notices displayed fully adhered to the contents as prescribed by the law. Conclusion As more than half of the public places complied with the requirements of the legislation, there was satisfactory overall compliance with the smoke-free public places law in this study. The public venues (eateries, shopping venues and transportations) that are more frequently visited and have a high turnover of the public have lower compliance with the legislation. The content of the message in the ‘no smoking’ notices needs close attention to adhere to the legal requirements

Measuring fidelity, feasibility, costs: an implementation evaluation of a cluster-controlled trial of group antenatal care in rural Nepal

Background Access to high-quality antenatal care services has been shown to be beneficial for maternal and child health. In 2016, the WHO published evidence-based recommendations for antenatal care that aim to improve utilization, quality of care, and the patient experience. Prior research in Nepal has shown that a lack of social support, birth planning, and resources are barriers to accessing services in rural communities. The success of CenteringPregnancy and participatory action women’s groups suggests that group care models may both improve access to care and the quality of care delivered through women’s empowerment and the creation of social networks. We present a group antenatal care model in rural Nepal, designed and implemented by the healthcare delivery organization Nyaya Health Nepal, as well as an assessment of implementation outcomes. Methods The study was conducted at Bayalata Hospital in Achham, Nepal, via a public private partnership between the Nepali non-profit, Nyaya Health Nepal, and the Ministry of Health and Population, with financial and technical assistance from the American non-profit, Possible. We implemented group antenatal care as a prospective non-randomized cluster-controlled, type I hybrid effectiveness-implementation study in six village clusters. The implementation approach allows for iterative improvement in design, making changes to improve the quality of the intervention. Assessments of implementation process and model fidelity were undertaken using a mobile checklist completed by nurse supervisors, and observation forms completed by program leadership. We evaluated data quarterly using descriptive statistics to identify trends. Qualitative interviews and team communications were analyzed through immersion crystallization to identify major themes that evolved during the implementation process. Results A total of 141 group antenatal sessions were run during the study period. This paper reports on implementation results, whereas we analyze and present patient-level effectiveness outcomes in a complementary paper in this journal. There was high process fidelity to the model, with 85.7% (95% CI 77.1–91.5%) of visits completing all process elements, and high content fidelity, with all village clusters meeting the minimum target frequency for 80% of topics. The annual per capita cost for group antenatal care was 0.50 USD. Qualitative analysis revealed the compromise of stable gestation-matched composition of the group members in order to make the intervention feasible. Major adaptations were made in training, documentation, feedback and logistics. Conclusion Group antenatal care provided in collaboration with local government clinics has the potential to provide accessible and high quality antenatal care to women in rural Nepal. The intervention is a feasible and affordable alternative to individual antenatal care. Our experience has shown that adaptation from prior models was important for the program to be successful in the local context within the national healthcare system. Trial registration ClinicalTrials.gov Identifier: NCT02330887, registered 01/05/2015, retroactively registered

Autoethnography: A Method of Research and Teaching for Transformative Education

This paper discusses the thesis that autoethnography as tool in research provides the researcher to examine his or her pedagogical and research practices from his or lived evocative experiences. The essence of this paper is to seek the possibilities of linking autoethnography as a method of inquiry that catalyses the transformative pedagogy positively in mathematics education. It is an outcome of my dissertation of Masters of Philosophy (M.Phil.) in Education. I highlights the importance of autoethnography in research in a way that permits researchers to apply flexible modes of inquiry from their life experiences with motives of change to take place in educational institutions and classroom practices

Surgical outcome and clinical profile of emergency versus elective cases of colorectal cancer in College of Medical Sciences, Nepal

Background:&nbsp;Patients who undergo emergency colorectal cancer surgery has poor outcome compared to elective surgery, both in terms of morbidity and mortality. Approximately 15 to 30% of colorectal cancers present as an emergency, most often as obstruction or perforation. Objective:&nbsp;To compare surgical outcome and clinical profiles of emergency and elective cases for colorectal cancer. Methods:&nbsp;Retrospective analysis of 34 cases who underwent surgery for colorectal cancer between December 2011 to January 2013was carried out and their surgical outcomes, clinical presentation, demographic profile were analyzed. Results:&nbsp;The total numbers of patients included in this study were 34. Out of which 52.94 %( n=18) were emergency cases and 47.05 %( n=16) were elective. Male female ratio was 3:1 in emergency cases and 2.6:1 in elective cases. Per rectal bleeding (56%) and altered bowel habit (31.25%) was predominant clinical presentation in elective cases whereas intestinal obstruction (55.55%) and peritonitis (22.22%) were predominant clinical presentation in emergency cases. In emergency cases most of the tumors were located in left side (77.77%) and in elective cases rectum was common site (37.5%). Left hemicolectomy was the commonest surgery performed (72.22%) in emergency set up. In elective cases, right hemicolectomy, left hemicolectomy, APR and LAR was done in 31.25%, 31.25%, 25% and 25% cases respectively. In the emergency group 11.11% (n=2) developed enterocutaneous fistula and early mortality within 30 days was observed in 5% (n=1) of emergency cases only. Conclusion:&nbsp;In emergency conditions, colorectal cancer presented with intestinal obstruction where as elective cases presented with per rectal bleeding and altered bowel habits. Compared with the elective patients, the emergency patients had higher rate of morbidity and mortality. Because of higher incidence of colorectal cancer in our institution, in all emergency cases who presents with features of intestinal obstruction and peritonitis, we have to rule out colorectal cancer especially if the patients are elderly. Therefore, we should encourage screening programme for early detection of colorectal cancers for better outcome of surgery. Journal of College of Medical Sciences-Nepal, 2013, Vol-9, No-2, 25-30 DOI: http://dx.doi.org/10.3126/jcmsn.v9i2.9684</p

Idealism as an educational philosophy of mathematics teachers in Al Ain City Schools of the United Arab Emirates

Educational philosophy, in general, is at the heart of the growth of education. It outlines the institution’s goals, subject matters, teaching methods, roles of teachers as well as the role of students, assessment methods, and teaching/learning experiences. The study aimed to identify the educational philosophical implications of idealism in schools in Al Ain city of the United Arab Emirates from the perspectives of mathematics teachers. The researchers used a questionnaire with thirty-two Likert-type items as a quantitative method for data collection. The instrument was administered to a randomly selected sample of 82 (46 male and 36 female) mathematics teachers in Al Ain city. The data were analyzed in IBM SPSS version 28 for one sample t-tests and independent samples t-tests to compare teachers’ perceptions of curriculum, education values, school functions, roles of teachers, and teaching methods with gender and school type. Further analyses included a one-way ANOVA for teaching experiences and teaching cycles, bivariate correlations between the variables, and a generalized linear model to identify the significant predictors of the teaching method. The findings of the study showed that mathematics teachers in Al Ain city embrace an idealistic philosophy of curriculum, educational values, the role of schools and teachers, and teaching methods in general. The teachers’ perceptions of the curriculum and school functions were found to be significant predictors of their teaching methods. These findings have both pedagogical and curricular implications

Finite-strain Landau theory applied to the high-pressure phase transition of lead titanate

Standard Landau theory coupled to infinitesimal strain allows a concise description of the temperature-driven ferroelectric tetragonal-to-cubic phase transition in PbTiO3 at ambient pressure. Unfortunately, it fails to cover its high-pressure counterpart at ambient temperature. For example, the experimental transition pressure is vastly underestimated and neither the change from first to second order with increasing pressure nor the unusual pressure dependence of the tetragonal unit cell parameters observed in experiment are reproduced. Here we demonstrate that a combination of density functional theory and a recently constructed finite-strain extension of Landau theory provides a natural mechanism for resolving these discrepancies between theory and experiment. Our approach also allows us to determine the full tetragonal-cubic phase boundary in the (P,T) plane including an estimate of the tricritical point. We show that a careful analysis of the thermal elastic baseline is an essential ingredient to the success of this theory

Clinical profile, management and early outcome of gall bladder cancer

Objective To evaluate the clinical profile, management and early outcome of patients with gallbladder cancer. Methods This is a single institution based retrospective study of patients with gallbladder cancer who presented at College of Medical Sciences and Teaching Hospital, Bharatpur, Chitwan, Nepal. Patients presenting during one year period from August 2012 to July 2013 were reviewed. Results Twelve cases of Gall Bladder Cancer were reviewed in this series. Out of 12 patients, 9 were females (75%) and 3 were males (25%), showing female preponderance. Most of the patients (75%) were in age group of 51-70 years. Only one patient (8%) was below 50 years of age. Main symptom was pain associated with anorexia, nausea &amp; vomiting. Major signs were palpable mass, hepatomegaly and jaundice. All the cases had association with gall bladder stone. Of the total population, 50%(n=6) underwent extended cholecystectomy and rest of 6 cases were inoperable. Histopathological reports of all the operated cases were adenocarcinoma. Conclusion Prevalence of gall bladder cancer is higher in females in our series. Most of the patients were in fifth to seventh decade of life. Non specific symptoms like abdominal pain nausea and vomiting were the predominant symptoms. Only 50% of the cases were operable. So we have to do early screening by USG abdomen and CT scan to diagnose the disease earlier.&nbsp;&nbsp; Journal of College of Medical Sciences-Nepal, 2013, Vol-9, No-3, 12-16 &nbsp; DOI:&nbsp;http://dx.doi.org/10.3126/jcmsn.v9i3.10209 &nbsp;</p

Idealism as an educational philosophy of mathematics teachers in Al Ain City Schools of the United Arab Emirates.

Educational philosophy, in general, is at the heart of the growth of education. It outlines the institution's goals, subject matters, teaching methods, roles of teachers as well as the role of students, assessment methods, and teaching/learning experiences. The study aimed to identify the educational philosophical implications of idealism in schools in Al Ain city of the United Arab Emirates from the perspectives of mathematics teachers. The researchers used a questionnaire with thirty-two Likert-type items as a quantitative method for data collection. The instrument was administered to a randomly selected sample of 82 (46 male and 36 female) mathematics teachers in Al Ain city. The data were analyzed in IBM SPSS version 28 for one sample t-tests and independent samples t-tests to compare teachers' perceptions of curriculum, education values, school functions, roles of teachers, and teaching methods with gender and school type. Further analyses included a one-way ANOVA for teaching experiences and teaching cycles, bivariate correlations between the variables, and a generalized linear model to identify the significant predictors of the teaching method. The findings of the study showed that mathematics teachers in Al Ain city embrace an idealistic philosophy of curriculum, educational values, the role of schools and teachers, and teaching methods in general. The teachers' perceptions of the curriculum and school functions were found to be significant predictors of their teaching methods. These findings have both pedagogical and curricular implications

Carcinoma of the appendix – A diagnostic challenge

INTRODUCTION Primary tumors of the appendix are rare. They are usually diagnosed after pathologic inspection of the appendix removed for suspected appendicitis. The main presentation is that of an acute appendicitis or as a palpable mass, mainly in the right lower quadrant. It mimics ovarian pathology in female because of close proximity to its anatomical structures. CASE PRESENTATION We report a case of 52 years female who presented to us in casualty with complains of pain abdomen and other findings suggestive of acute appendicitis. In spite of extensive preoperative investigations, the diagnosis was confirmed only after opening the abdomen as giant mucocele of appendix demanding right hemicolectomy as a treatment modality. CONCLUSION Although primary tumors of appendix is rare identity in the arena of surgery, it should be in the corner of thought as a possible diagnosis which require extensive surgery when compared to simple Appendicectomy.DOI: http://dx.doi.org/10.3126/jcmsn.v10i2.12953 Journal of College of Medical Sciences-Nepal, 2014, Vol.10(2); 36-40</p