The road to tuberculosis treatment in rural Nepal: A qualitative assessment of 26 journeys

BACKGROUND: The fact that tuberculosis can be treated with the DOTS strategy (Directly Observed Treatment, Short-course) is not enough to control the disease. Patients have to find their way to tuberculosis treatment first. To better understand the route to tuberculosis treatment in rural Nepal we interviewed twenty-six patients under treatment. METHODS: In semi-structured interviews patients shared their disease history and health seeking behaviour. The analysis focused on the encounters with the health care system before enrolment in the tuberculosis treatment program. RESULTS: Patient routes often started in the medical shop and led via intricate routes with multiple providers to facilities with higher qualified and more competent staff where tuberculosis was diagnosed. Several factors influenced the route to tuberculosis treatment. Besides known patients factors (such as severity of complaints, the ability to pay for services, availability of services and peer support for choosing a provider) specific health services factors were also identified. These included the perceived quality, costs and service level of a provider, and lack of provider initiated referral. Self referral because of waned trust in the provider was very common. In contrast, once tuberculosis was considered a possible diagnosis, referral to diagnostic testing and tuberculosis treatment was prompt. CONCLUSION: Patient routes towards tuberculosis treatment are characterised by self referral and include both private and public health care providers. Once tuberculosis is suspected referral for diagnosis and treatment is prompt. Given the importance of the private practitioners in the patient routes, quality improvement initiatives need to address not only the public sector but the private health care sector as well

Challenges in prevention and timely care of uterine prolapse in Nepal

Background: Uterine prolapse is a common reproductive health problem in low-income countries like Nepal. Physical symptoms of this condition influence women’s quality of life. Current data insufficiently determine women’s awareness of this condition. Health care seeking practices for uterine prolapse in Nepal are inadequate. Aims: This Thesis aimed to assess women’s knowledge of uterine prolapse and its associated factors, explore how this affects quality of life, and describe health care seeking practices. We also aimed to determine the prevalence of UP in both rural and peri-urban settings of Nepal. Methods: This Thesis used cross-sectional descriptive studies. The mixed-method approach included quantitative interviews with 115 respondents and qualitative in-depth interviews with 16 UP-affected women in rural Nepal. Nationally, we conducted structured interviews with 4,693 married women aged 15–49 years in 25 districts that represent all 5 administrative regions and 3 ecological zones of Nepal. To assess how uterine prolapse affects quality of life, we conducted structured interviews with 3,124 women during a household survey in the peri-urban Jhaukhel-Duwakot Health Demographic Surveillance Site outside Kathmandu and also with 48 attendees at a screening camp for uterine prolapse. A community-based case control study traced self-reported cases identified by a previous household survey and in a control group (women not having uterine prolapse) from the screening camp. Results: Most participants (>85%) described major physical discomforts, including difficulty with walking, standing, working, sitting, and lifting. Compared to stage I, women with Stage III uterine prolapse suffered adverse effects on quality of life. They endured humiliation, harassment, torture, and severe emotional stress from their husbands and other family members due to their inability to perform household chores or fulfill their husband’s sexual desires. The prevalence of uterine prolapse in our peri-urban setting was 2.11%, where more than 53% of our participants had comprehensive knowledge of uterine prolapse (compared to only 37% in a national survey). Contributing factors included parity, education, and family structure. Knowledge gaps in the national survey associated with geography, age group, education, caste/ethnic group, and media exposure. Possible factors that influenced women’s health care seeking practices for uterine prolapse included access barriers, low socioeconomic status, gender inequality, a culture of silence, lack of autonomy for health care, and lack of regular community-based services. Conclusions: Major challenges for the prevention and timely care of uterine prolapse include knowledge gaps and associated factors such as geography, caste/ethnic group, education, and media exposure

Nutritional Status of Children and Its Associated Factors in Selected Earthquake-Affected VDCs of Gorkha District, Nepal

Background. Malnutrition is a major public health problem and most enveloping cause of morbidity and mortality among children and adolescents throughout the world. This study was aimed at assessing the nutritional status and associated factors among 6-10-year-old children in selected earthquake-affected areas of Gorkha district, Nepal. Methods. A community-based cross-sectional study among 420 mothers having children of age groups 6-10 years (with anthropometric measurement among children) was conducted using a mixed method in selected earthquake-affected areas of Gorkha district, Nepal, from October 2015 to April 2016. Gorkha was selected purposively from 14 earthquake-affected districts. Two village development committees were selected randomly among 6 having severe impact. Randomly, 5 wards were selected from each of the 2 village development committees. As the sample was 420, 42 children were selected randomly from every ward. Result. Among the 420 children, 31.9% were underweight, 51.9% were stunted, and 2.9% were wasted after the earthquake. Children who were more prone to being underweight were the following: male children (RR=1.34 95% CI: 1.01-1.78) and children from illiterate mothers (RR=2.49, 95% CI: 1.85-3.36), illiterate fathers (RR=1.73, 95% CI: 1.32-2.27), and homemaker mothers (RR=0.28, 95% CI: 0.20-0.38); children whose families were using nonimproved sources of water (RR=2.60, 95% CI: 1.07-6.60); and households having food insecurity (RR=12.97, 95% CI: 3.29-51.18). Similarly, children of illiterate fathers (RR=1.67, 95% CI: 1.41-1.97), children of illiterate mothers (RR=2.32, 95% CI: 1.91-2.83), children of homemaker mothers (RR=0.59, 95% CI: 0.49-0.70), children whose family were using treated water (RR=0.32, 95% CI: 0.15-0.67), and children from food insecure households (RR=10.52, CI: 4.05-27.33) were found to be stunted. After adjustment, children from households consuming nonimproved water were 6 times more likely (OR=6.75; 95% CI: 1.59-28.62) to be wasted. Conclusion. Illiterate mothers, illiterate fathers, mothers engaged in occupation other than household work, and food insecure households were found to be independent predictors of underweight and stunting. Nonimproved source of drinking water was found to be independent predictors of wasting

Uterine prolapse and its impact on quality of life in the Jhaukhel-Duwakot Health Demographic Surveillance Site, Bhaktapur, Nepal

BACKGROUND: Uterine prolapse (UP) is a reproductive health problem and public health issue in low-income countries including Nepal. OBJECTIVE: We aimed to identify the contributing factors and stages of UP and its impact on quality of life in the Jhaukhel-Duwakot Health Demographic Surveillance Site of Bhaktapur, Nepal. DESIGN: Our three-phase study used descriptive cross-sectional analysis to assess quality of life and stages of UP and case-control analysis to identify contributing factors. First, a household survey explored the prevalence of self-reported UP (Phase 1). Second, we used a standardized tool in a 5-day screening camp to determine quality of life among UP-affected women (Phase 2). Finally, a 1-month community survey traced self-reported cases from Phase 1 (Phase 3). To validate UP diagnoses, we reviewed participants' clinical records, and we used screening camp records to trace women without UP. RESULTS: Among 48 affected women in Phase 1, 32 had Stage II UP and 16 had either Stage I or Stage III UP. Compared with Stage I women (4.62%), almost all women with Stage III UP reported reduced quality of life. Decreased quality of life correlated significantly with Stages I-III. Self-reported UP prevalence (8.7%) included all treated and non-treated cases. In Phase 3, 277 of 402 respondents reported being affected by UP and 125 were unaffected. The odds of having UP were threefold higher among illiterate women compared with literate women (OR=3.02, 95% CI 1.76-5.17), 50% lower among women from nuclear families compared with extended families (OR=0.56, 95% CI 0.35-0.90) and lower among women with 1-2 parity compared to >5 parity (OR=0.33, 95% CI 0.14-0.75). CONCLUSIONS: The stages of UP correlated with quality of life resulting from varied perceptions regarding physical health, emotional stress, and social limitation. Parity, education, age, and family type associated with UP. Our results suggest the importance of developing policies and programs that are focused on early health care for UP. Through family planning and health education programs targeting women, as well as women empowerment programs for prevention of UP, it will be possible to restore quality of life related to UP

Understanding and living with glaucoma and non-communicable diseases like hypertension and diabetes in the Jhaukhel-Duwakot Health Demographic Surveillance Site: : a qualitative study from Nepal

BACKGROUND: Primary open-angle glaucoma (POAG) is one of the most common causes of irreversible blindness. A possible association between POAG and non-communicable diseases such as hypertension and diabetes suggests that the incidence of POAG may increase. People with POAG in Nepal usually present late to hospital and have poor knowledge of glaucoma. OBJECTIVES: Anticipating a knowledge gap regarding these diseases, this study aimed to explore the knowledge of POAG, hypertension, and diabetes in the community and barriers to health care. DESIGN: We conducted this qualitative study in the Jhaukhel-Duwakot Health Demographic Surveillance Site (JD-HDSS), a peri-urban community near Kathmandu, a capital city of Nepal. To study how disease influences knowledge, we conducted focus group discussions separately for men and women with and without pre-existing POAG, hypertension, and diabetes. Data were analyzed using the framework analysis approach. RESULTS: Although people suffering from POAG, hypertension, and/or diabetes exhibited adequate knowledge of hypertension and diabetes, they lacked in-depth knowledge of POAG. People believed mostly in internal health locus of control. Perception of disease consequences and impact of disease on daily life was influenced by pre-existing POAG, hypertension, and/or diabetes but only in men. Gender disparity was observed regarding health literacy, health perception, and health barriers, which put women in a more difficult situation to tackle their health. We also revealed a gap between knowledge, attitude, and practice of health among women and healthy men. CONCLUSION: Although people in JD-HDSS exhibited adequate knowledge regarding hypertension and diabetes, they lacked in-depth knowledge about POAG. This study demonstrated gender difference in health literacy and access to health care, making women more vulnerable towards disease. We also demonstrated a gap between knowledge, attitude, and practice of health. However, tailored health literacy programs may bring changes in the health status in the community

A cluster-randomized evaluation of an intervention to increase skilled birth attendant utilization in mid- and far-western Nepal

Skilled birth attendant (SBA) utilization is low in remote and rural areas of Nepal. We designed and implemented an evaluation to assess the effectiveness of a five-component intervention that addressed previously identified barriers to SBA services in mid- and far-western Nepal. We randomly and equally allocated 36 village development committees with low SBA utilization among 1-year intervention and control groups. The eligible participants for the survey were women that had delivered a baby within the past 12 months preceding the survey. Implementation was administered by trained health volunteers, youth groups, mothers' groups and health facility management committee members. Post-intervention, we used difference-in-differences and mixed-effects regression models to assess and analyse any increase in the utilization of skilled birth care and antenatal care (ANC) services. All analyses were done by intention to treat. Our trial registration number was ISRCTN78892490 (http://www.isrctn.com/ISRCTN78892490). Interviewees included 1746 and 2098 eligible women in the intervention and control groups, respectively. The 1-year intervention was effective in increasing the use of skilled birth care services (OR = 1.57; CI 1.19-2.08); however, the intervention had no effect on the utilization of ANC services. Expanding the intervention with modifications, e.g. mobilizing more active and stable community groups, ensuring adequate human resources and improving quality of services as well as longer or repeated interventions will help achieve greater effect in increasing the utilization of SBA.CC BY-NC 4.0</p

Jhaukhel-Duwakot Health Demographic Surveillance Site, Nepal: 2012 follow-up survey and use of skilled birth attendants

Background: Estimates of disease burden in Nepal are based on cross-sectional studies that provide inadequate epidemiological information to support public health decisions. This study compares the health and demographic indicators at the end of 2012 in the Jhaukhel-Duwakot Health Demographic Surveillance Site (JD-HDSS) with the baseline conducted at the end of 2010. We also report on the use of skilled birth attendants (SBAs) and associated factors in the JD-HDSS at the follow-up point. Design: We used a structured questionnaire to survey 3,505 households in the JD-HDSS, Bhaktapur, Nepal. To investigate the use of SBAs, we interviewed 434 women who had delivered a baby within the prior 2 years. We compared demographic and health indicators at baseline and follow-up and assessed the association of SBA services with background variables. Results: Due to rising in-migration, the total population and number of households in the JD-HDSS increased (13,669 and 2,712 in 2010 vs. 16,918 and 3,505 in 2012). Self-reported morbidity decreased (11.1% vs. 7.1%, respectively), whereas accidents and injuries increased (2.9% vs. 6.5% of overall morbidity, respectively). At follow-up, the proportion of institutional delivery (93.1%) exceeded the national average (36%). Women who accessed antenatal care and used transport (e.g. bus, taxi, motorcycle) to reach a health facility were more likely to access institutional delivery. Conclusions: High in-migration increased the total population and number of households in the JD-HDSS, a peri-urban area where most health indicators exceed the national average. Major morbidity conditions (respiratory diseases, fever, gastrointestinal problems, and bone and joint problems) remain unchanged. Further investigation of reasons for increased proportion of accidents and injuries are recommended for their timely prevention. More than 90% of our respondents received adequate antenatal care and used institutional delivery, but only 13.2% accessed adequate postnatal care. Availability of transport and use of antenatal care was associated positively with institutional delivery

Women's experiences and health care-seeking practices in relation to uterine prolapse in a hill district of Nepal

BACKGROUND: Although uterine prolapse (UP) occurs commonly in Nepal, little is known about the physical health and care-seeking practices of women with UP. This study aimed to explore women's experiences of UP and its effect on daily life, its perceived causes, and health care-seeking practices. METHODS: Using a convenience sampling method, we conducted 115 semi-structured and 16 in-depth interviews with UP-affected women during September-December 2012. All interviews occurred in outreach clinics in villages of the Dhading district. RESULTS: Study participants were 23-82 years of age. Twenty-four percent were literate, 47.2% had experienced a teenage pregnancy, and 29% had autonomy to make healthcare decisions. Most participants (&gt;85%) described the major physical discomforts of UP as difficulty with walking, standing, working, sitting, and lifting. They also reported urinary incontinence (68%) bowel symptoms (42%), and difficulty with sexual activity (73.9%). Due to inability to perform household chores or fulfill their husband's sexual desires, participants endured humiliation, harassment, and torture by their husbands and other family members, causing severe emotional stress. Following disclosure of UP, 24% of spouses remarried and 6% separated from the marital relationship. Women perceived the causes of UP as unsafe childbirth, heavy work during the postpartum period, and gender discrimination. Prior to visiting these camps some women (42%) hid UP for more than 10 years. Almost half (48%) of participants sought no health care; 42% ingested a herb and ate nutritious food. Perceived barriers to accessing health care included shame (48%) and feeling that care was unnecessary (12.5%). Multiple responses (29%) included shame, inability to share, male service provider, fear of stigma and discrimination, and perceiving UP as normal for childbearing women. CONCLUSIONS: UP adversely affects women's daily life and negatively influences their physical, mental, and social well-being. The results of our study are useful to generate information on UP symptoms and female health care seeking practices. Our findings can be helpful for effective development of UP awareness programs to increase service utilization at early stages of UP and thereby might contribute to both primary and secondary prevention of UP

Barriers to using skilled birth attendants' services in mid- and far-western Nepal : a cross-sectional study.

BACKGROUND: Skilled birth attendants (SBAs) provide important interventions that improve maternal and neonatal health and reduce maternal and neonatal mortality. However, utilization and coverage of services by SBAs remain poor, especially in rural and remote areas of Nepal. This study examined the characteristics associated with utilization of SBA services in mid- and far-western Nepal. METHODS: This cross-sectional study examined three rural and remote districts of mid- and far-western Nepal (i.e., Kanchanpur, Dailekh and Bajhang), representing three ecological zones (southern plains [Tarai], hill and mountain, respectively) with low utilization of services by SBAs. Enumerators assisted a total of 2,481 women. All respondents had delivered a baby within the past 12 months. We used bivariate and multivariate analyses to assess the association between antenatal and delivery care visits and the women's background characteristics. RESULTS: Fifty-seven percent of study participants had completed at least four antenatal care visits and 48% delivered their babies with the assistance of SBAs. Knowing the danger signs of pregnancy and delivery (e.g., premature labor, prolonged labor, breech delivery, postpartum hemorrhage, severe headache) associated positively with four or more antenatal care visits (OR = 1.71; 95% CI: 1.41-2.07). Living less than 30 min from a health facility associated positively with increased use of both antenatal care (OR = 1.44; 95% CI: 1.18-1.77) and delivery services (OR = 1.25; CI: 1.03-1.52). Four or more antenatal care visits was a determining factor for the utilization of SBAs. CONCLUSIONS: Less than half of the women in our study delivered babies with the aid of SBAs, indicating a need to increase utilization of such services in rural and remote areas of Nepal. Distance from health facilities and inadequate transportation pose major barriers to the utilization of SBAs. Providing women with transportation funds before they go to a facility for delivery and managing transportation options will increase service utilization. Moreover, SBA utilization associates positively with women's knowledge of pregnancy danger signs, wealth quintile, and completed antenatal care visits. Nepal's health system must develop strategies that generate demand for SBAs and also reduce financial, geographic and cultural barriers to such services