Traditional Healers and Mental Health in Nepal: A Scoping Review.

Despite extensive ethnographic and qualitative research on traditional healers in Nepal, the role of traditional healers in relation to mental health has not been synthesized. We focused on the following clinically based research question, "What are the processes by which Nepali traditional healers address mental well-being?" We adopted a scoping review methodology to maximize the available literature base and conducted a modified thematic analysis rooted in grounded theory, ethnography, and phenomenology. We searched five databases using terms related to traditional healers and mental health. We contacted key authors and reviewed references for additional literature. Our scoping review yielded 86 eligible studies, 65 of which relied solely on classical qualitative study designs. The reviewed literature suggests that traditional healers use a wide range of interventions that utilize magico-religious explanatory models to invoke symbolic transference, manipulation of local illness narratives, roles, and relationships, cognitive restructuring, meaning-making, and catharsis. Traditional healers' perceived impact appears greatest for mild to moderate forms of psychological distress. However, the methodological and sample heterogeneity preclude uniform conclusions about traditional healing. Further research should employ methods which are both empirically sound and culturally adapted to explore the role of traditional healers in mental health

Factors associated with stillbirth in selected countries of South Asia : a systematic review of observational studies

Background: Despite having the high rate of stillbirth in most of the countries of South Asia, there is a lack of synthesized evidence based on factors associated with stillbirth. This study systematically synthesizes the evidence on factors associated with stillbirth in the four selected countries of South Asia. Methods: This review was conducted using Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Studies that examined factors associated with stillbirth in South Asia were searched using five major electronic search databases including MEDLINE, CINAHL, Embase, PsycINFO, and Scopus, published between January 2000 and December 2019. In the meta-analysis, significant heterogeneity was detected among studies (I2 >50%), and hence a random effect model was used. Results: A total of 20 studies met the inclusion criteria. The pooled rate of stillbirth from the studies in Bangladesh, India, Nepal, and Pakistan was 25.15 per 1000 births. Pregnancy complications, maternal health conditions, fetal complications, lack of antenatal care, and lower Socio Economic Status (SES) were the most common factors associated with stillbirth in countries of South Asia. Conclusion: This study confirmed that stillbirth in selected countries of South Asia remains high. To reduce stillbirth, a greater focus needs to be on timely management of preterm labor, maternal hypertension, and provision of financial support for quality antenatal and delivery care. The interventions should be targeted for women living in remote areas, who are less educated and those with low SES

L’araire de Jumla. Un araire archaïque en Himalaya

De tous les araires actuellement en usage dans la chaîne himalayenne, celui du bassin supérieur de la Karnali est parmi les plus archaïques. Traditionnellement en bois, sans aucune partie métallique, cet instrument s’avère efficace pour ameublir les sols, enfouir le compost et recouvrir les semences. Sa chaîne opératoire de fabrication et son utilisation dans le système de production agraire sont examinées en détail, ainsi que le contexte social dans lequel il est employé.Midst the ploughs (ards) nowadays used in the Himalayan arc, the one employed in upper basin of the Karnali can be classed among the more archaic. Entirely made of wood and equipped with a wooden share, this instrument is efficient for working the soil, burying the compost and covering over the sown seeds. In this article not only the process of fabrication and the manner of utilization of this ard are described in detail but also emphasis is placed on position held by those performing these tasks within the social context.El arado de la cuenca superior del río Karnali es uno de los más arcaicos entre los que se utilizan hoy en día en la cordillera del Himalaya. Tradicionalmente, es de madera, sin ninguna parte metálica. Este instrumento es eficaz para mullir los suelos, enterrar el abono compuesto y recubrir las semillas. La cadena operatoria de su fabricación y su utilización en el sistema de producción se examinan detalladamente, así como el contexto social de su uso

Validation of cross-cultural child mental health and psychosocial research instruments: adapting the Depression Self-Rating Scale and Child PTSD Symptom Scale in Nepal

<p>Abstract</p> <p>Background</p> <p>The lack of culturally adapted and validated instruments for child mental health and psychosocial support in low and middle-income countries is a barrier to assessing prevalence of mental health problems, evaluating interventions, and determining program cost-effectiveness. Alternative procedures are needed to validate instruments in these settings.</p> <p>Methods</p> <p>Six criteria are proposed to evaluate cross-cultural validity of child mental health instruments: (i) purpose of instrument, (ii) construct measured, (iii) contents of construct, (iv) local idioms employed, (v) structure of response sets, and (vi) comparison with other measurable phenomena. These criteria are applied to transcultural translation and alternative validation for the Depression Self-Rating Scale (DSRS) and Child PTSD Symptom Scale (CPSS) in Nepal, which recently suffered a decade of war including conscription of child soldiers and widespread displacement of youth. Transcultural translation was conducted with Nepali mental health professionals and six focus groups with children (n = 64) aged 11-15 years old. Because of the lack of child mental health professionals in Nepal, a psychosocial counselor performed an alternative validation procedure using psychosocial functioning as a criterion for intervention. The validation sample was 162 children (11-14 years old). The Kiddie-Schedule for Affective Disorders and Schizophrenia (K-SADS) and Global Assessment of Psychosocial Disability (GAPD) were used to derive indication for treatment as the external criterion.</p> <p>Results</p> <p>The instruments displayed moderate to good psychometric properties: DSRS (area under the curve (AUC) = 0.82, sensitivity = 0.71, specificity = 0.81, cutoff score ≥ 14); CPSS (AUC = 0.77, sensitivity = 0.68, specificity = 0.73, cutoff score ≥ 20). The DSRS items with significant discriminant validity were "having energy to complete daily activities" (DSRS.7), "feeling that life is not worth living" (DSRS.10), and "feeling lonely" (DSRS.15). The CPSS items with significant discriminant validity were nightmares (CPSS.2), flashbacks (CPSS.3), traumatic amnesia (CPSS.8), feelings of a foreshortened future (CPSS.12), and easily irritated at small matters (CPSS.14).</p> <p>Conclusions</p> <p>Transcultural translation and alternative validation feasibly can be performed in low clinical resource settings through task-shifting the validation process to trained mental health paraprofessionals using structured interviews. This process is helpful to evaluate cost-effectiveness of psychosocial interventions.</p

Feasibility study of a family- and school-based intervention for child behavior problems in Nepal.

Background: This study evaluates the feasibility, acceptability, and outcomes of a combined school- and family-based intervention, delivered by psychosocial counselors, for children with behavior problems in rural Nepal. Methods: Forty-one children participated at baseline. Two students moved to another district, meaning 39 children, ages 6-15, participated at both baseline and follow-up. Pre-post evaluation was used to assess behavioral changes over a 4-month follow-up period (n = 39). The primary outcome measure was the Disruptive Behavior International Scale-Nepal version (DBIS-N). The secondary outcome scales included the Child Functional Impairment Scale and the Eyberg Child Behavior Inventory (ECBI). Twelve key informant interviews were conducted with community stakeholders, including teachers, parents, and community members, to assess stakeholders\u27 perceptions of the intervention. Results: The study found that children\u27s behavior problems as assessed on the DBIS-N were significantly lower at follow-up (M = 13.0, SD = 6.4) than at baseline (M = 20.5, SD = 3.8), p \u3c 0.001, CI [5.57, 9.35]. Similarly, children\u27s ECBI Intensity scores were significantly lower at follow-up (M = 9.9, SD = 8.5) than at baseline (M = 14.8, SD = 7.7), p \u3c 0.005, 95% CI [1.76, 8.14]. The intervention also significantly improved children\u27s daily functioning. Parents and teachers involved in the intervention found it acceptable and feasible for delivery to their children and students. Parents and teachers reported improved behaviors among children and the implementation of new behavior management techniques both at home and in the classroom. Conclusions: Significant change in child outcome measures in this uncontrolled evaluation, alongside qualitative findings suggesting feasibility and acceptability, support moving toward a controlled trial to determine effectiveness

Health systems context(s) for integrating mental health into primary health care in six Emerald countries:a situation analysis

Abstract Background Mental, neurological and substance use disorders contribute to a significant proportion of the world\u2019s disease burden, including in low and middle income countries (LMICs). In this study, we focused on the health systems required to support integration of mental health into primary health care (PHC) in Ethiopia, India, Nepal, Nigeria, South Africa and Uganda. Methods A checklist guided by the World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS) was developed and was used for data collection in each of the six countries participating in the Emerging mental health systems in low and middle-income countries (Emerald) research consortium. The documents reviewed were from the following domains: mental health legislation, health policies/plans and relevant country health programs. Data were analyzed using thematic content analysis. Results Three of the study countries (Ethiopia, Nepal, Nigeria, and Uganda) were working towards developing mental health legislation. South Africa and India were ahead of other countries, having enacted recent Mental Health Care Act in 2004 and 2016, respectively. Among all the 6 study countries, only Nepal, Nigeria and South Africa had a standalone mental health policy. However, other countries had related health policies where mental health was mentioned. The lack of fully fledged policies is likely to limit opportunities for resource mobilization for the mental health sector and efforts to integrate mental health into PHC. Most countries were found to be allocating inadequate budgets from the health budget for mental health, with South Africa (5%) and Nepal (0.17%) were the countries with the highest and lowest proportions of health budgets spent on mental health, respectively. Other vital resources that support integration such as human resources and health facilities for mental health services were found to be in adequate in all the study countries. Monitoring and evaluation systems to support the integration of mental health into PHC in all the study countries were also inadequate. Conclusion Integration of mental health into PHC will require addressing the resource limitations that have been identified in this study. There is a need for up to date mental health legislation and policies to engender commitment in allocating resources to mental health services

Experience of implementing new mental health indicators within information systems in six low- and middle-income countries

Background Successful scale up of integrated primary mental health care requires routine monitoring of key programme performance indicators. A consensus set of mental health indicators has been proposed but evidence on their use in routine settings is lacking. Aims To assess the acceptability, feasibility, perceived costs and sustainability of implementing indicators relating to integrated mental health service coverage in six South-Asian (India, Nepal) and sub-Saharan African countries (Ethiopia, Nigeria, South Africa, Uganda). Method A qualitative study using semi-structured key informant interviews (n=128) was conducted. The ‘Performance of Routine Information Systems’ framework for assessing the performance of the implementation of new forms to measure mental health indicators served as the basis of a coding framework covering three main categories: (1) technical; (2) organisation; and (3) behavioural determinants. Results Most mental health indicators were deemed relevant and potentially useful for improving care, and therefore acceptable to end users. Exceptions were indicators on functionality, cost and severity. The simplicity of the data capturing formats contributed to the feasibility of using forms to generate data on mental health indicators. Health workers reported increasing confidence in their capacity to record the mental health data and minimal additional cost to initiate mental health reporting. However, overstretched primary care staff and the time-consuming reporting process affected perceived sustainability. Conclusion Use of the newly developed, contextually-appropriate mental health indicators in health facilities providing primary care services was seen largely to be feasible in the six Emerald countries, mainly because of the simplicity of the forms and continued support in the design and implementation stage. However, approaches to implementation of new forms generating mental health indicators need to be customised to the specific health system context of different countries. Further work is needed to identify ways to utilise mental health data to monitor and improve the quality of mental health services

Scaling up integrated primary mental health in six low- and middle-income countries: obstacles, synergies and implications for systems reform

Background There is a global drive to improve access to mental healthcare by scaling up integrated mental health into primary healthcare (PHC) systems in low- and middle-income countries (LMICs). Aims To investigate systems-level implications of efforts to scale-up integrated mental healthcare into PHC in districts in six LMICs. Method Semi-structured interviews were conducted with 121 managers and service providers. Transcribed interviews were analysed using framework analysis guided by the Consolidated Framework for Implementation Research and World Health Organization basic building blocks. Results Ensuring that interventions are synergistic with existing health system features and strengthening of the healthcare system building blocks to support integrated chronic care and task-sharing were identified as aiding integration efforts. The latter includes (a) strengthening governance to include technical support for integration efforts as well as multisectoral collaborations; (b) ring-fencing mental health budgets at district level; (c) a critical mass of mental health specialists to support task-sharing; (d) including key mental health indicators in the health information system; (e) psychotropic medication included on free essential drug lists and (f) enabling collaborative and community- oriented PHC-service delivery platforms and continuous quality improvement to aid service delivery challenges in implementation. Conclusions Scaling up integrated mental healthcare in PHC in LMICs is more complex than training general healthcare providers. Leveraging existing health system processes that are synergistic with chronic care services and strengthening healthcare system building blocks to provide a more enabling context for integration are important