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Abstract COVID‐19 hit Lebanon at the worst time, amid an economic downward spiral and national protests regarding living conditions and political corruption. The first case was found on February 21, 2020, and the first batch of vaccines arrived on March 24, 2021. Although neither natural infection nor mass vaccination truly provided herd immunity, the latter was a more effective way to handle the pandemic, and Lebanon fell short on that path. During the pandemic, a myriad of factors complicated its response to the virus. Thanks to the COVAX program, the country received 1086,720 doses donated and 1626,390 deliveries. All in all, over 5.8 million doses have been administered. A total of 2.74 million people received at least one dose, and 2.4 million had a complete primary vaccination series. However, around 98% of the population were infected with the virus. Issues that stopped the vaccination campaigns include a lack of trust in government officials and news media, leading to false information propagating and remaining unchallenged online. Other factors include the economic collapse, which led to the Lebanese currency losing over 98% of its initial worth. Some Lebanese people might find themselves either unable to reach proper health facilities or unwilling to adopt the narrative pushed by the political elite. Poverty also worsened affected infected individuals’ prognosis and mortality. A bigger emphasis must be put on reaching individuals with disabilities or in low‐income areas, as they were the most affected by the pandemic. Problems these communities face include the lack of funding for special education schools and the lack of accessibility to medical information promoted by the government. Lebanon must learn from the issues that arose during this pandemic and focus on fixing them in advance to prepare for any other health emergency that might turn up in the future.

BackgroundImprovements in standard precaution related to infection prevention and control (IPC) at the national and local-level health facilities (HFs) are critical to ensuring patient's safety, preventing healthcare-associated infections (HAIs), mitigating Antimicrobial Resistance (AMR), protecting health workers, and improving trust in HFs. This study aimed to assess HF's readiness to implement standard precautions for IPC in Nepal.MethodsThis study conducted a secondary analysis of the nationally-representative Nepal Health Facility Survey (NHFS) 2021 data and used the Service Availability and Readiness Assessment (SARA) Manual from the World Health Organization (WHO) to examine the HF's readiness to implement standard precautions for IPC. The readiness score for IPC was calculated for eight service delivery domains based on the availability of eight tracer items: guidelines for standard precautions, latex gloves, soap and running water or alcohol-based hand rub, single use of standard disposal or auto-disable syringes, disinfectant, safe final disposal of sharps, safe final disposal of infectious wastes, and appropriate storage of infectious waste. We used simple and multiple linear regression and quantile regression models to examine the association of HF's readiness with their characteristics. Results were presented as beta (β) coefficients and 95% confidence interval (95% CI).ResultsThe overall readiness scores of all HFs, federal/provincial hospitals, local HFs, and private hospitals were 59.9±15.6, 67.1±14.4, 59.6±15.6, and 62.6±15.5, respectively. Across all eight health service delivery domains, the HFs' readiness for tuberculosis services was the lowest (57.8±20.0) and highest for delivery and newborn care services (67.1±15.6). The HFs performing quality assurance activities (β = 3.68; 95%CI: 1.84, 5.51), reviewing clients' opinions (β = 6.66; 95%CI: 2.54, 10.77), and HFs with a monthly meeting (β = 3.28; 95%CI: 1.08, 5.49) had higher readiness scores. The HFs from Bagmati, Gandaki, Lumbini, Karnali and Sudurpaschim had readiness scores higher by 7.80 (95%CI: 5.24, 10.36), 7.73 (95%CI: 4.83, 10.62), 4.76 (95%CI: 2.00, 7.52), 9.40 (95%CI: 6.11, 12.68), and 3.77 (95%CI: 0.81, 6.74) compared to Koshi.ConclusionThe readiness of HFs to implement standard precautions was higher in HFs with quality assurance activities, monthly HF meetings, and mechanisms for reviewing clients' opinions. Emphasizing quality assurance activities, implementing client feedback mechanisms, and promoting effective management practices in HFs with poor readiness can help to enhance IPC efforts.

Abstract Introduction Underrepresentation of disabled groups in clinical trials results in an inadequate evidence base for their clinical care, which drives health inequalities. This study aims to review and map the potential barriers and facilitators to the recruitment of disabled people in clinical trials to identify knowledge gaps and areas for further extensive research. The review addresses the question: ‘What are the barriers and facilitators to recruitment of disabled people to clinical trials?’. Methods The Joanna Briggs Institute (JBI) Scoping review guidelines were followed to complete the current scoping review. MEDLINE and EMBASE databases were searched via Ovid. The literature search was guided by a combination of four key concepts from the research question: (1) disabled populations, (2) patient recruitment, (3) barriers and facilitators, and (4) clinical trials. Papers discussing barriers and facilitators of all types were included. Papers that did not have at least one disabled group as their population were excluded. Data on study characteristics and identified barriers and facilitators were extracted. Identified barriers and facilitators were then synthesised according to common themes. Results The review included 56 eligible papers. The evidence on barriers and facilitators was largely sourced from Short Communications from Researcher Perspectives (N = 22) and Primary Quantitative Research (N = 17). Carer perspectives were rarely represented in articles. The most common disability types for the population of interest in the literature were neurological and psychiatric disabilities. A total of five emergent themes were determined across the barriers and facilitators. These were as follows: risk vs benefit assessment, design and management of recruitment protocol, balancing internal and external validity considerations, consent and ethics, and systemic factors. Conclusions Both barriers and facilitators were often highly specific to disability type and context. Assumptions should be minimised, and study design should prioritise principles of co-design and be informed by a data-driven assessment of needs for the study population. Person-centred approaches to consent that empower disabled people to exercise their right to choose should be adopted in inclusive practice. Implementing these recommendations stands to improve inclusive practices in clinical trial research, serving to produce a well-rounded and comprehensive evidence base.

The coronavirus disease 2019 (COVID-19) pandemic has resulted in a substantial decline in routine immunisation coverage in children globally, especially in low- and middle-income countries (LMICs). This study summarises the reasons for disruptions to routine child immunisations in LMICs. A systematic review (PROSPERO CRD42021286386) was conducted following PRISMA 2020 guidelines. Six databases were searched: MEDLINE, Embase, Global Health, CINAHL, Scopus and MedRxiv, on 11/02/2022. Observational and qualitative studies published from January 2020 onwards were included if exploring reasons for missed immunisations during the COVID-19 pandemic in LMICs. Study appraisal used National Heart, Lung, and Blood Institute and Critical Appraisal Skills Programme tools. Reasons for disruption were defined with descriptive codes; cross-sectional (quantitative) data were summarised as mean percentages of responses weighted by study population, and qualitative data were summarised narratively. A total of thirteen studies were included describing reasons behind disruptions; 7 cross-sectional (quantitative), 5 qualitative and 1 mixed methods. Seventeen reasons for disruptions were identified. In quantitative studies (total respondents = 2,853), the most common reasons identified were fear of COVID-19 and consequential avoidance of health centres (41.2%, SD ±13.3%), followed by transport challenges preventing both families and healthcare professionals from reaching vaccination services (11.1% SD ±16.6%). Most reasons stemmed from reduced healthcare-seeking (83.4%), as opposed to healthcare-delivery issues (15.2%). Qualitative studies showed a more even balance of healthcare-seeking (49.5%) and healthcare-delivery issues (50.5%), with fear of COVID-19 remaining a major identified issue (total respondents = 92). The most common reasons for disruption were parental fear of COVID-19 and avoidance of health services. Health systems must therefore prioritise public health messaging to encourage vaccine uptake and recovery of missed immunisations.

Abstract While medical education has traditionally been designed, led and delivered exclusively by clinicians and academics, there has been an increasing shift towards diversifying actors involved in training future generations of health professionals. Public and patient involvement in learning increases the likelihood that learning is relevant to the communities we purport to serve. This article explores the experiences of medical students who were partnered with a community‐based organisation (CBOs) as part of the intercalated Global Health BSc at Imperial College London. Students involved in this programme highlight opportunities to understand the needs of communities they were placed with, beyond what is possible to understand in clinical practice; this is essential to support them in becoming holistic, patient‐centred practitioners. Students also found this opportunity helpful to gain insight into the role and value of the voluntary sector in healthcare and develop transferrable skills in project leadership and management. It is hypothesised that the benefits of this partnership extend to community‐organisations; they gain experience working with students, who provide an external view of their services and may be helpful in the delivery of quality‐improvement projects. Communities could also benefit from interactions with students by sharing insight into their needs and priorities, and in turn, shaping students’ priorities as future health professionals and co‐designers of voluntary‐sector initiatives within the community. Whilst the establishment of these partnerships does not come without its challenges, this article also highlights lessons for students and institutions undergoing similar programmes, including clarification of goals, stakeholder consultation, sustainability of interventions, voicing the community, timetable flexibility and funding.

Abstract We identify ten public health challenges that need to be closely tracked in 2022. These challenges are COVID‐19, inadequate human resources for health, poor health systems financing, conflict and humanitarian crises, mental health, poverty, climate change, the health of children, reproductive health issues, and the infodemic. These global priorities, based on opinion of experts and current evidence and literature, need immediate attention and scaled‐up actions. This list of priorities does not discount the existence of other major public health challenges. We forecast and highlight those that may impact global public health in 2022 in order to progress and to achieve the United Nations’ Sustainable Development Goals (SDG). Thus, we advocate for stronger international cooperation, solidarity, and sustainable funding to address these challenges, and improve health across and within populations globally.

Definitions of health literacy have evolved from notions of health-related literacy to a multidimensional concept that incorporates the importance of social and cultural knowledge, practices and contexts. This evolution is evident in the development of instruments that seek to measure health literacy in different ways. Health literacy measurement is important for global health because diverse stakeholders, including the WHO, use these data to inform health practice and policy, and to understand sources of inequity. In this Practice paper, we explore the potential for negative consequences, bias and epistemic injustice to occur when health literacy instruments are used across settings without due regard for the lived experiences of people in various contexts from whom data are collected. A health literacy measurement approach that is emic-sensitive, strengths based and solution oriented is needed to minimise biased data interpretation and use and to avoid epistemic injustice.

Observed weather and projected climate change suggest an increase in the transmission of vector-borne diseases (VBDs) in the Hindu Kush Himalayan (HKH) region. In this study, we systematically explore the literature for empiric associations between the climate variables and specific VBDs and their vectors in the HKH region. We conducted a systematic synthesis of the published literature on climate variables, VBDs and vectors in the HKH region until the 8th of December 2020. The majority of studies show significant positive associations of VBDs with climatic factors, such as temperature, precipitation, relative humidity, etc. This systematic review allowed us to identify the most significant variables to be considered for evidence-based trend estimates of the effects of climate change on VBDs and their vectors in the HKH region. This evidence-based trend was set into the context of climate change as well as the observed expansion of VBDs and disease vectors in the HKH region. The geographic range of VBDs expanded into previously considered non-endemic areas of highlands (mountains) in the HKH region. Based on scarce, but clear evidence of a positive relationship of most climate variables and VBDs and the observed climatic changes, we strongly recommend an expansion of vector control and surveillance programmes in areas of the HKH region that were previously considered to be non-endemic.

BackgroundThe COVID-19 pandemic has disrupted routine childhood vaccinations worldwide with low- and middle-income countries (LMICs) most affected. This study aims to quantify levels of disruption to routine vaccinations in LMICs.MethodsA systematic review (PROSPERO CRD42021286386) was conducted of MEDLINE, Embase, Global Health, CINAHL, Scopus and MedRxiv, on the 11th of February 2022. Primary research studies published from January 2020 onwards were included if they reported levels of routine pediatrics vaccinations before and after March 2020. Study appraisal was performed using NHLBI tool for cross-sectional studies. Levels of disruption were summarized using medians and interquartile ranges.ResultsA total of 39 cross-sectional studies were identified. These showed an overall relative median decline of −10.8% [interquartile range (IQR) −27.6%, −1.4%] across all vaccines. Upper-middle-income countries (upper-MICs) (−14.3%; IQR −24.3%, −2.4%) and lower-MICs (−18.0%; IQR −48.6%, −4.1%) showed greater declines than low-income countries (−3.1%; IQR −12.8%, 2.9%), as did vaccines administered at birth (−11.8%; IQR −27.7%, −3.5%) compared to those given after birth (−8.0%; IQR −28.6%, −0.4%). Declines during the first 3 months of the pandemic (−8.1%; IQR −35.1%, −1.4%) were greater than during the remainder of 2020 (−3.9%; IQR −13.0%, 11.4%) compared to baseline.ConclusionThere has been a decline in routine pediatric vaccination, greatest in MICs and for vaccines administered at birth. Nations must prioritize catch-up programs alongside public health messaging to encourage vaccine uptake.Systematic review registrationIdentifier: CRD42021286386.

Objectives To assess the attitude of medical students towards cultural diversity aiming to elucidate our current status in understanding cultural awareness and sensitivity.Design, setting and participants A web-based cross-sectional study was carried out among 601 undergraduate health science students (medical and dental courses) at a health sciences university in eastern Nepal via various modes of social-media platforms like WhatsApp, Messenger, Gmail, etc.Outcome measures Medical students’ attitude towards cultural diversity and its association with the sociodemographic profile of the students.Results A total of 601 students participated in the study, out of which, 64.2% were men with a sex ratio of 1.8:1 and a mean age of 22.3±1.9 years. More than two-thirds (77.2%) of the students had an excellent to good attitude towards cultural diversity. The proportion of students reporting ‘excellent’ attitude towards cultural diversity was higher among male students compared with female students (37.8% vs 20.5%) and students aged >22 years compared with younger students (37.1% vs 26.7%). Gender (p

Introduction: Globally, reproductive health and quality of life among female population has been found to be unsatisfactory in developing world. Until 1963, Nepal’s 1854 legal code known as MulukiAin was revised numerous times that banned abortion exempting risk of women’s life. Enactment of New Abortion Policy from 2003 brought landmark reforms to the women’s choice in family planning methods and ended the sufferings of lengthy prison sentences for abortion crimes. This study was conducted to explore the level of awareness about abortion law with regard to health care utilization among women of reproductive age group along with its association with socio-demographic characteristics. Methodology: A cross-sectional study was conducted in March 2014, in Inarwa Municipality among women of reproductive age group (16 to 49 years). Convenient sampling was done to collect data from households. Data was entered and analyzed in SPSS 11.5 and presented in tabular form. Chi-square test was used to show association of awareness of abortion law and socio-demographic variables. Results: education, age at first marriage and age at 1st pregnancy was found to be significant (p value:

Abstract Background Every year, neonatal infections account for approximately 750,000 neonatal deaths globally. It is the third major cause of neonatal death, globally and in Nepal. There is a paucity of data on clinical aetiology and outcomes of neonatal infection in Nepal. This paper aims to assess the incidence and risk factors of neonatal infection in babies born in public hospitals of Nepal. Methods This is a prospective cohort study conducted for a period of 14 months, nested within a large-scale cluster randomized control trial which evaluated the Helping Babies Breathe Quality Improvement package in 12 public hospitals in Nepal. All the mothers who consented to participate within the study and delivered in these hospitals were included in the analysis. All neonates admitted into the sick newborn care unit weighing > 1500 g or/and 32 weeks or more gestation with clinical signs of infection or positive septic screening were taken as cases and those that did not have an infection were the comparison group. Bivariate and multi-variate analysis of socio-demographic, maternal, obstetric and neonatal characteristics of case and comparison group were conducted to assess risk factors associated with neonatal infection. Results The overall incidence of neonatal infection was 7.3 per 1000 live births. Babies who were born to first time mothers were at 64% higher risk of having infection (aOR-1.64, 95% CI, 1.30–2.06, p-value

Prehypertension is a state of transition between normal blood pressure and hypertension. Adolescent prehypertension is a strong predictor of hypertension in adults and is now considered for cardiovascular intervention or risk reduction. This study was conducted among adolescents to assess the burden of pre-hypertension and its predictors. A cross-sectional study was conducted among grade 11 and 12 students in three districts in eastern Nepal namely Jhapa, Morang and Sunsari. Sampling was done using a multistage stratified proportionate random method. A semi-structured questionnaire adapted from the WHO STEPwise approach to the non-communicable disease risk factor surveillance (STEPS) instrument was used as a study tool after modification and pre-testing in addition to the anthropometric and blood pressure measurements by the investigators. The prevalence of prehypertension was assessed along with the identification of its predictors through multivariable binary logistic regression modelling. A total of 806 participants aged 15 to 19 years, with 57.1% female, participated in the study. Prehypertension was found in 20.8% (24.6% in males and 18.0% in females) of the participants, while 7.1% of them were hypertensive (9.2% males and 5.4% females). Obesity and central obesity were seen among 6.3% and 17.7% of the respondents respectively. Age, sex, ethnicity and obesity were found to be significantly associated with prehypertension. A significant proportion of prehypertension was seen among the adolescent population along with a notable presence of risk factors such as smoking, alcohol consumption, obesity, and eating out. This warrants careful consideration and identification of relevant strategies to reduce the burden of prehypertension via school-based interventions to reduce the modifiable risk factors.

Maternity service providers have struggled to provide high-quality services to women and newborns during the ongoing COVID-19 pandemic which has substantially impacted health systems and disrupted maternity services globally. Nepal is a resources-limited country that reported a significant impact of the pandemic on maternal health services. It is therefore important to understand better the perspective of health care professionals in this context. This study intends to explore the experiences of nurses providing maternity care in the public sector during the COVID-19 pandemic in Nepal. A qualitative study using a phenomenological design was conducted. Altogether ten nurses working in maternity services were selected using purposive sampling technique. Data were collected by face-to-face in-depth interviews using a semi-structured interview guide. Thematic analysis was conducted using Clarke and Braun 2006 technique. The findings of the study were organized into codes, sub-themes and themes. The six themes identified were fear of COVID-19 at work, challenges at work, changes at work and services, motivations to work, stigma due to COVID-19, and impact on services. Participants described how maternity services could not be stopped during the pandemic. They had experienced decreased utilization of antenatal services as a consequence of 'lockdown' thereby leading to an increase in maternal and neonatal mortality. Respondents reported ineffective human resource management compromising the quality of care. The professional responsibility to cope with adverse circumstances and serve society is a major source of motivation that health workers relied upon to get them through the pandemic period. A wide range of challenges were faced by service providers during the pandemic which requires action and support of all levels of government, institutions and society-at-large to assure the continued provision of safe maternity care during such a protracted period of challenging work.

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.

BackgroundMorbidity increases with age and enhances the burden of health problems that result in new challenges to meet additional demands. In the ageing population, health problems, and health care utilization should be assessed carefully and addressed. This study aimed to identify chronic morbidities, health problems, health care seeking behaviour and health care utilization among the elderly.MethodsWe conducted a community based, cross-sectional study in urban areas of the Sunsari district using face-to-face interviews. A total of 530 elderly participants were interviewed and selected by a simple proportionate random sampling technique.ResultsAbout half, 48.3%, elderly were suffering from pre-existing chronic morbidities, of which, 30.9% had single morbidity, and 17.4% had multi-morbidities. This study unfurled more than 50.0% prevalence of health ailments like circulatory, digestive, eye, musculoskeletal and psychological problems each representing the burden of 68.7%, 68.3%, 66.2%, 65.8% and 55.7% respectively. Our study also found that 58.7% preferred hospitals as their first contact facility. Despite the preferences, 46.0% reported visiting traditional healers for treatment of their ailments. About 68.1% reported having difficulty seeking health care and 51.1% reported visits to a health care facility within the last 6 months period. The participants with pre-existing morbidity, health insurance, and an economic status above the poverty line were more likely to visit health care facilities.ConclusionElderly people had a higher prevalence of health ailments, but unsatisfactory health care seeking and health care utilization behaviour. These need further investigation and attention by the public health system in order to provide appropriate curative and preventive health care to the elderly. There is an urgent need to promote geriatric health services and make them available at the primary health care level, the first level of contact with a national health system.

Background: COVID-19 vaccine hesitancy is one of the major concerns in the roll out of vaccines in many countries. The aim of the study was to assess the level of COVID-19 vaccine acceptability among the population in Herat, Afghanistan, the third largest city in the country. Methods: This cross-sectional study was conducted between 15 April 2021 and 20 April 2021 among the general population of Herat City to examine the acceptability rate of COVID-19 vaccine. Sample size was calculated at 555. Different variables were collected using a questionnaire developed. Data were evaluated in IBM SPSS program. Results: Only 10.63% of the participants were willing to receive COVID-19 vaccine without having any concern and reservation. 45% were willing to receive the COVID-19 vaccine. 66.5% were concerned about the vaccine and its side effects and 29% were afraid of being infected by transmission of COVID-19 through the administration of vaccine on them. Conclusion: This research demonstrates that, concerns about the vaccine, myths and misinformation are widespread which will undermine the vaccination process. This study recommends the initiation of more health-related campaigns and awareness programs by the government for general population to enhance and expedite the roll out of COVID-19 vaccine.

Vietnam's close proximity to China where the COVID-19 outbreak started made it one of the countries expected to have widespread transmission of the virus. However, the country opposed this expectation and attained low spread of COVID-19 infection due to its proactive approaches in containing the disease. As of March 11, 2021, Vietnam has a total of 2529 confirmed cases, equivalent to 26 cases per one million population-compared to the global rate of 15,223 cases. The low-cost model approach used by Vietnam in dealing with previous public health issues, tackle the importance of a strategic public health system, good governance, and citizen cooperation in the fight against COVID 19 pandemic. This paper aims to analyze Vietnam's achievement in its early and continued success in combating COVID-19 by taking into account various aspects of its health system and experience on outbreaks that have previously occurred and how these can be applied to current COVID-19 responses.

Background Stimulation of non-crying neonates after birth can help transition to spontaneous breathing. In this study, we aim to assess the impact of intact versus clamped umbilical cord on spontaneous breathing after stimulation of non-crying neonates.Methods This is an observational study among non-crying neonates (n=3073) born in hospitals of Nepal. Non-crying neonates born vaginally at gestational age ≥34 weeks were observed for their response to stimulation with the cord intact or clamped. Obstetric characteristics of the neonates were analysed. Association of spontaneous breathing with cord management was assessed using logistic regression.Results Among non-crying neonates, 2563 received stimulation. Of these, a higher proportion of the neonates were breathing in the group with cord intact as compared with the group cord clamped (81.1% vs 68.9%, p

There are contrasting opinions of what global health (GH) curricula should contain and limited discussion on whose voices should shape it. In GH education, those with first-hand expertise of living and working in the contexts discussed in GH classrooms are often absent when designing curricula. To address this, we developed a new model of curriculum codesign called Virtual Roundtable for Collaborative Education Design (ViRCoED). This paper describes the rationale and outputs of the ViRCoED approach in designing a new section of the Global Health Bachelor of Science (BSc) curriculum at Imperial College London, with a focus on healthcare in the Syrian conflict. The team, importantly, involved partners with lived and/or professional experience of the conflict as well as alumni of the course and educators in all stages of design and delivery through to marking and project evaluation. The project experimented with disrupting power dynamics and extending ownership of the curriculum beyond traditional faculty by codesigning and codelivering module contents together with colleagues with direct expertise and experience of the Syrian context. An authentic approach was applied to assessment design using real-time syndromic healthcare data from the Aleppo and Idlib Governorates. We discuss the challenges involved in our collaborative partnership and describe how it may have enhanced the validity of our curriculum with students engaging in a richer representation of key health issues in the conflict. We observed an enhanced self-reflexivity in the students’ approach to quantitative data and its complex interpretation. The dialogic nature of this collaborative design was also a formative process for partners and an opportunity for GH educators to reflect on their own positionality. The project aims to challenge current standards and structures in GH curriculum development and gesture towards a GH education sector eventually led by those with lived experience and expertise to significantly enhance the validity of GH education.

Abstract Background About 5.8 million maternal deaths, neonatal deaths and stillbirths occur every year with 99% of them taking place in low- and middle-income countries. Two thirds of them could be prevented through cost-effective interventions during pregnancy, intrapartum and postpartum periods. Despite the availability of standards and guidelines for the care of mother and newborn, challenges remain in translating these standards into practice in health facilities. Although several quality improvement (QI) interventions have been systematically reviewed by the Cochrane Effective Practice and Organization of Care (EPOC) group, evidence lack on QI interventions for improving perinatal outcomes in health facilities. This systematic review will identify QI interventions implemented for maternal and neonatal care in health facilities and their impact on perinatal outcomes. Methods/design This review will look at studies of mothers, newborn and both who received inpatient care at health facilities. QI interventions targeted at health system level (macro), at healthcare organization (meso) and at health workers practice (micro) will be reviewed. Mortality of mothers and newborn and relevant health worker practices will be assessed. The MEDLINE, Embase, World Health Organization Global Health Library, Cochrane Library and trial registries electronic databases will be searched for relevant studies from the year 2000 onwards. Data will be extracted from the identified relevant literature using Epi review software. Risk of bias will be assessed in the studies using the Cochrane risk of bias tool for randomized and observational studies. Standard data synthesis and analysis will be used for the review, and the data will be analysed using EPPI Reviewer 4. Discussion This review will inform the global agenda for evidence-based health care by (1) providing a basis for operational guidelines for implementing clinical standards of perinatal care, (2) identify research priorities for generating evidence for QI interventions and (3) QI intervention options with lessons learnt for implementation based on the level of needed resources. Systematic review registration PROSPERO registration number CRD42018106075

Program managers routinely design and implement specialised maternal and newborn health trainings for health workers in low- and middle-income countries to provide better-coordinated care across the continuum of care. However, in these countries details on the availability of different training packages, skills covered in those training packages and the gaps in their implementation are patchy. This paper presents an assessment of maternal and newborn health training packages to describe differences in training contents and implementation approaches used for a range of training packages in Ethiopia and Nepal. We conducted a mixed-methods study. The quantitative assessment was conducted using a comprehensive assessment questionnaire based on validated WHO guidelines and developed jointly with global maternal and newborn health experts. The qualitative assessment was conducted through key informant interviews with national stakeholders involved in implementing these training packages and working with the Ministries of Health in both countries. Our quantitative analysis revealed several key gaps in the technical content of maternal and newborn health training packages in both countries. Our qualitative results from key informant interviews provided additional insights by highlighting several issues with trainings related to quality, skill retention, logistics, and management. Taken together, our findings suggest four key areas of improvement: first, training materials should be updated based on the content gaps identified and should be aligned with each other. Second, trainings should address actual health worker performance gaps using a variety of innovative approaches such as blended and self-directed learning. Third, post-training supervision and ongoing mentoring need to be strengthened. Lastly, functional training information systems are required to support planning efforts in both countries.

IntroductionFamily planning methods are used to promote safer sexual practices, reduce unintended pregnancies and unsafe abortion, and control population. Young people aged 15-24 years belong to a key reproductive age group. However, little is known about their engagement with the family planning services in Nepal. Our study aimed to identify the perceptions of and barriers to the use of family planning among youth in Nepal.MethodsA qualitative explorative study was done among adolescents and young people aged 15-24 years from the Hattimuda village in eastern Nepal. Six focus group discussions and 25 in-depth interviews were conducted with both male and female participants in the community using a maximum variation sampling method. Data were analyzed using a thematic framework approach.ResultsMany individuals were aware that family planning measures postpone pregnancy. However, some young participants were not fully aware of the available family planning services. Some married couples who preferred 'birth spacing' received negative judgments from their family members for not starting a family. The perceived barriers to the use of family planning included lack of knowledge about family planning use, fear of side effects of modern family planning methods, lack of access/affordability due to familial and religious beliefs/myths/misconceptions. On an individual level, some couples' timid nature also negatively influenced the uptake of family planning measures.ConclusionWomen predominantly take the responsibility for using family planning measures in male-dominated decision-making societies. Moreover, young men feel that the current family planning programs have very little space for men to engage even if they were willing to participate. Communication in the community and in between the couples seem to be influenced by the presence of strong societal and cultural norms and practices. These practices seem to affect family planning related teaching at schools as well. This research shows that both young men and women are keen on getting involved with initiatives and campaigns for supporting local governments in strengthening the family planning programs in Nepal.

The COVID-19 pandemic has not only affected health systems but also has had deep socio-economic effects. The lockdown enforced in Nepal, had people running out of means to make ends meet, the public in fear of an unknown disease, and challenges for leaders to deliver better. Local governments of Nepal, established under the federal system, have the closest ties to the community. They have powers entrusted by the constitution to enact laws according to the needs of the community. During the 83 days of lockdown, the local governments came through for their inhabitants by managing quarantines and isolation centers, taking care of diagnostics, providing food and rations, and arranging facilities to bring back their locals stranded in other cities. The local governments improved awareness and helped maintain the lockdown. These undertakings by the local governments of Nepal highlight the importance of a community-based approach to dealing with pandemics.

ObjectiveTo identify the prevalence, risk factors and health impacts associated with small for gestational age (SGA) births in Nepal.MethodsA cross-sectional study was conducted in 12 public hospitals in Nepal from 1 July 2017 to 29 August 2018. A total of 60 695 babies delivered in these hospitals during the study period were eligible for inclusion. Clinical information of mothers and newborns was collected by data collectors using a data retrieval form. A semistructured interview was conducted at the time of discharge to gather sociodemographic information from women who provided the consent (n=50 392). Babies weighing less than the 10th percentile for their gestational age were classified as SGA. Demographic, obstetric and neonatal characteristics of study participants were analysed for associations with SGA. The association between SGA and likelihood of babies requiring resuscitation or resulting in stillbirth and neonatal death was also explored.ResultsThe prevalence of SGA births across the 12 hospitals observed in Nepal was 11.9%. After multiple variable adjustment, several factors were found to be associated with SGA births, including whether mothers were illiterate compared with those completing secondary and higher education (adjusted OR (AOR)=1.73; 95% CI 1.09 to 2.76), use of polluted fuel compared with use of clean fuel for cooking (AOR=1.51; 95% CI 1.16 to 1.97), first antenatal care (ANC) visit occurring during the third trimester compared with first trimester (AOR=1.82; 95% CI 1.27 to 2.61) and multiple deliveries compared with single delivery (AOR=3.07; 95% CI 1.46 to 6.46). SGA was significantly associated with stillbirth (AOR=7.30; 95% CI 6.26 to 8.52) and neonatal mortality (AOR=5.34; 95% CI 4.65 to 6.12).ConclusionsLow literacy status of mothers, use of polluted fuel for cooking, time of first ANC visit and multiple deliveries are associated with SGA births. Interventions encouraging pregnant women to attend ANC visits early can reduce the burden of SGA births.

Background: Mental health needs of victims of domestic and family violence are often overlooked. A booklet was designed to help women update their knowledge and skills in effective coping with domestic and family violence and support them in developing effective stress reduction and problem management techniques. In addition, this booklet is believed to serve as a reference for further use. This paper describes the development process and validation of the information booklet. This booklet was used during an intervention trial conducted in Nepal to educate abused pregnant women. Methods: This methodological study involved three stages: bibliographical survey, development of the booklet, and validation by specialists in the relevant fields and representatives of the target audiences. A total of eight experts, currently working in the field of domestic violence and/or midwifery, and 15 representatives of the target participants were involved in the validation process. A minimum Content Validity Index of 0.78 was considered for content validation, and minimum agreement of 75% for face validation. Results: The booklet presented a global Content Validity Index of 0.92. The overall level of agreement within the target participants was 86.3%, which was higher than the minimum recommended level. Both subject experts and participants positively evaluated the adequacy, coverage and readability of contents of the booklet. Conclusions: The booklet was validated using content and face validity. This validated booklet is expected to be an effective tool for communication that would help pregnant women cope better with domestic and family violence and adopt strategies to remain emotionally healthy. Keywords: Booklet; development; domestic violence; validation studies.

Abstract Objectives This cross-sectional study was conducted to describe the socio-demographic characteristics, assess the utilization of HIV testing and counselling services, and to explore the reasons for the non-utilization of HIV testing and counselling services among the key populations at the Bhutanese refugee camps in eastern Nepal. Results The HIV testing and counselling services are utilized by less than a third (29%) of the key population among the Bhutanese Refugees. The prime source of information about the HIV testing and counselling sites has been health workers followed by peer/outreach educators and neighbors. Common self-reported barriers for utilization of HIV testing and counselling services by the Bhutanese refugees were self-perceived stigma about HIV, the fear of being discriminated and the lack of knowledge about HIV testing and counselling services. There is a need to analyze the gap between availability and utilization through more qualitative approaches in order to identify interventions to increase the uptake of the HIV testing and counselling services.

Abstract Background Menstrual hygiene management (MHM) is an essential aspect of hygiene for women and adolescent girls between menarche and menopause. Despite being an important issue concerning women and girls in the menstruating age group MHM is often overlooked in post-disaster responses. Further, there is limited evidence of menstrual hygiene management in humanitarian settings. This study aims to describe the experiences and perceptions of women and adolescent girls on menstrual hygiene management in post-earthquake Nepal. Methods A mixed methods study was carried out among the earthquake affected women and adolescent girls in three villages of Sindhupalchowk district of Nepal. Data was collected using a semi-structured questionnaire that captured experiences and perceptions of respondents on menstrual hygiene management in the aftermath of the Nepal earthquake. Quantitative data were triangulated with in-depth interview regarding respondent’s personal experiences of menstrual hygiene management. Results Menstrual hygiene was rated as the sixth highest overall need and perceived as an immediate need by 18.8% of the respondents. There were 42.8% women & girls who menstruated within first week of the earthquake. Reusable sanitary cloth were used by about 66.7% of the respondents before the earthquake and remained a popular method (76.1%) post-earthquake. None of the respondents reported receiving menstrual adsorbents as relief materials in the first month following the earthquake. Disposable pads (77.8%) were preferred by respondents as they were perceived to be clean and convenient to use. Most respondents (73.5%) felt that reusable sanitary pads were a sustainable choice. Women who were in the age group of 15-34 years (OR = 3.14; CI = (1.07-9.20), did not go to school (OR = 9.68; CI = 2.16-43.33), married (OR = 2.99; CI = 1.22-7.31) and previously used reusable sanitary cloth (OR = 5.82; CI = 2.33-14.55) were more likely to use the reusable sanitary cloth. Conclusions In the immediate aftermath of the earthquake, women and girls completely depended on the use of locally available resources as adsorbents during menstruation. Immediate relief activities by humanitarian agencies, lacked MHM activities. Understanding the previous practice and using local resources, the reusable sanitary cloth is a way to address the menstrual hygiene needs in the post-disaster situations in Nepal.

Abstract Background A little more than 1/3rd of the rural households in Nepal have improved latrine facility. The government of Nepal is working towards making an open defecation free area all over Nepal. There is no data found in literature searches regarding the status of latrines and its utilisation in Nepal. This study aims to estimate the coverage and utilisation of latrine and its associated factors in a rural community of Nepal. Methods We conducted a cross sectional study in March 2015–September 2015 among 625 households in Hattimuda Village, Morang district in Eastern Nepal using semi-structured pre-tested questionnaire with observational checklists. Results Out of 623 households, 473 (76.9%) have latrine facilities. There is an increase in latrine coverage in Hattimuda by 37% (38.9% in 2011 to 75.9% in 2016). Majority of the latrines (89.9%) were functional, however 32.3% needs maintenance. The extent of latrine utilisation among those households with a toilet at home was satisfactory (94.3%). Presence of child below 5 years of age at home (OR 2.37, 95% CI 0.05–0.46), functional latrine (OR 27.37, 95% CI 6.84–109.45), frequency of cleaning (OR 3.66, 95% CI 1.09–12.29) and latrine constructed with self-initiation (OR 4.21, 95% CI 1.06–16.66) are factors significantly associated with the utilisation of the latrine. Conclusions While the coverage needs to be increased, appropriate interventions to increase the utilisation of latrine needs to be in place so that the village moves closer to open defecation free (ODF) status. As other studies are not found from Nepal, the findings from this study can be used a reference for other rural areas of Nepal.

Abstract Background Health literacy has been linked to health outcomes across population groups around the world. Nepal, a low income country, experiences the double burden of highly prevalent communicable as well as non-communicable diseases. The World Health Organization (WHO) has positioned health literacy as a key mechanism to meet the health-related Sustainable Development Goal (SDG3). However, there is little known about the status of health literacy in developing countries such as Nepal. This paper aims to review the potential of health literacy to address SDG3 in Nepal. Methods A rapid review was conducted using the knowledge to action evidence summary approach. Articles included in the review were those reporting on barriers to health care engagements in Nepal published in English language between January 2000 and December 2015. Results Barriers for healthcare engagement included knowledge and education as strong factors, followed by culture, gender roles, quality of service and cost of services. These barriers influence the Nepalese community to access and engage with services, and make and enact healthcare decisions, not only at the individual level but at the family level. These factors are directly linked to health literacy. Health literacy is a pivotal determinant of understanding, accessing and using health information and health services, it is important that the health literacy needs of the people be addressed. Conclusion Locally identified and developed health literacy interventions may provide opportunities for systematic improvements in health to address impediments to healthcare in Nepal. Further research on health literacy and implementation of health literacy interventions may help reduce inequalities and increase the responsiveness of health systems which could potentially facilitate Nepal to meet the sustainable development goals. While there is currently little in place for health literacy to impact on the SDG3, this paper generates insights into health literacy’s potential role.

INTRODUCTION:Open defecation is ongoing in Nepal despite the rise in efforts for increasing latrine coverage and its use. Understanding the reasons for open defecation would complement the ongoing efforts to achieve the 'open defecation free' status in Nepal. This study aimed at exploring different motivations of people who practice open defecation in a village in Nepal. METHODS:This study was conducted among the people from the Hattimudha village in Morang district of eastern Nepal, who practiced open defecation. Maximum variation sampling method was used to recruit participants for 20 in-depth interviews and 2 focus group discussions. We adopted a content analysis approach to analyze the data. RESULTS:We categorized different reasons for open defecation as motivation by choice and motivation by compulsion. Open defecation by choice as is expressed as a medium for socializing, a habit and an enjoyable outdoor activity that complies with spiritual and religious norms. Open defecation by compulsion include reasons such as not having a latrine at home or having an alternative use for the latrine structures. Despite having a private latrine at home or access to a public latrine, people were compelled to practice open defecation due to constraints of norms restricting latrine use and hygiene issues in general. For women the issues with privacy and issues refraining women to use the same latrine as men compelled women to look for open defecation places. CONCLUSION:Open defecation is either a voluntary choice or a compulsion. This choice is closely linked with personal preferences, cultural and traditional norms with special concerns for privacy for women and girls in different communities. The ongoing campaigns to promote latrine construction and its use needs to carefully consider these factors in order to reduce the open defecation practices and increase the use of sanitary latrines.

Introduction: Self-prescription of medicines are common especially in low income countries. Paracetamol is a common medicine that is self-prescribed also among university students. Incorrect use of paracetamol can lead to ill effects on health including liver failure. There is scarce evidence of the use of paracetamol by self-medication in Nepal. The objective of this study is to evaluate the paracetamol use by self-prescription among the undergraduate students of BPKIHS. Methods: A cross-sectional study was conducted among 570 undergraduate students of BPKIHS from February 2016 till July 2016. Pretested semi-structured, self-administered questionnaire was used to collect information regarding socio-demographic characteristics, paracetamol use and perception regarding paracetamol use. Systematic random sampling was done from a list of all medical dental and nursing students to select the study sample. Results: Most (86%) students are in the category of 20-24 years. Female students are slightly more than male. Majority of the students are from Nepal. More than half of the students are from medical stream. Self-prescription of paracetamol is seen among 90.1% of the students in our study. Correct dose of paracetamol was mentioned by less than half (49.3%) of the students. Self-prescription of paracetamol is considered beneficial by all participants of this study. Conclusions: Self-prescription of paracetamol by health sciences students of B P Koirala Institute of Health Sciences is high, while the knowledge of correct dose of paracetamol for adults is low. There is a need to further explore this gap and possibly conduct further studies for other medicines as well. Keywords: Paracetamol; Self-prescription; health sciences students; undergraduate students. | PubMed

Background: Injuries are a problem worldwide in all occupations. Welders are exposed to many hazards at work resulting in a variety of health problems including injuries at work. This study was conducted to find out the prevalence and factors associated with injuries among welders in Dharan city of eastern Nepal. Methods: A cross sectional study was conducted among 86 welders in Dharan city. Occurrence of injury in past 2 weeks and past 12 months were recorded. Data regarding sociodemographic along with occupational characteristics was collected using semi structured questionnaire. Data analysis was done using SPSS version 17. Results: All the welders in this study were male with almost half of the welders under the age of 25 years and about a fifth (21.1%) of the welders having received some form of welding training. In the past 12 months, 21.1% of the welders suffered from work related injuries. More than 95% welders used at least one personal protective equipment in this study. More injuries were seen among welders with age ?35 years, working experience ? 5 years, not received training and not using of PPE at work. However, these factors were not found to be statistically significant. Conclusions: Work related injuries are high among welders of Dharan. Further research is required to explore the relationship between age, literacy, training and use of personal protective equipment with the occurrence of injuries among the welders. Keywords: Injury; Nepal; welders; work-related injuries.

Background: Snake bite among children is an important public health problem in many tropical and subtropical countries. Limited studies are found on snake-bite in Nepal using the WHO snake-bite management guidelines. This study assessed the clinico-epidemiological profile and their outcome in snake-bite among children using the WHO Guidelines for treatment of snake bite. Methods: This is a descriptive study among 75 children less than 14 years of age admitted in Emergency Room (ER) of Lumbini Zonal Hospital from 2011-2012 with the history of poisonous snake bite. Results: More than half (56%) of the cases were males and 3/5th (58%) were above 10 years of age. About 40% of the patients were brought to ER within 6-12 hrs of snake bite. Common site of snake-bite was lower limbs (32%) followed by upper limbs (29%). Abdominal Pain (44%) was observed as most common sign/symptom of snake-bite poisoning after local pain followed by ptosis (17.3%). The case fatality rate (CFR) was 16.0%. Conclusion: Use of WHO treatment guideline for snakebite case management among children showed low CFR. However further studies need to done to compare the treatment outcomes between WHO guideline and the National Guidelines among snakebite cases among children. Journal of Nobel College of Medicine Vol.4(1) 2015: 21-25

Background: In the past 20 years HIV/AIDS has become an increasing global phenomenon. The rising trend of morbidity and mortality has not only changed the demography but also poses a huge socio-economic burden on well-being of households, communities and country. In Nepal as the epidemic is maturing. However, the epidemic has never been maintained in the general population through heterosexual transmission in Nepal, rather it is driven by the infections among higher risk populations and their sexual partners. Objectives: To assess the knowledge about HIV/AIDS among household level. Material and Methods: A household based survey was conducted in all the nine wards of Chandbela VDC. Interview was conducted using pre-tested semi structured questionnaire which included socio demographic profile and characteristics to assess awareness on HIV/AIDS. The data was analyzed to calculate percentages and proportions. Results: Out of total population (7034), 50.39% were male and 49.60% were female. Majority of the males and females were literate i.e. 73.58% and 51.37% respectively. Out of 1274 households, 946(74.25%) households were below poverty line, where 19.34% of people did agriculture for living and 3.3% were migrant worker. Most of the people 73.2% were aware and had heard about HIV/AIDS from various medium like 24.53% from radio, 15.19% from friends However, 16.8% of the people never heard of HIV/AIDS. According to 33% of people unsafe sexual practice could transmit HIV/AIDS and 28.83% of people thought avoiding unsafe sexual Practice can prevent from acquiring HIV/AIDS. Of the total respondents, 61.6% of the people believed that even a healthy looking person can have HIV/AIDS. Attitude towards HIV/AIDS patients of majority of population (55.93%) was to avoid any kind of relation or contact with patient. Conclusion: Although majority of the population were literate, were aware of and had heard about HIV/AIDS, the attitude towards the patient was not positive. DOI: http://dx.doi.org/10.3126/jonmc.v3i1.12235 Journal of Nobel Medical College Vol. 3, No.1 Issue 6, 2014, Page: 35-39

Background: Appropriate use of the available electronic resources is important for decision making in health. The use of electronic resources in health care is universal. The study measures the eHealth literacy skills among the medical and dental interns of the B P Koirala Institute of Health Sciences (BPKIHS), Nepal. Methods: Self administered electronic Health Literacy Scale (eHEALS) was used to collect data from 125 medical and dental interns at BPKIHS. The interns represent immediate past medical student and soon to be professional doctor. Results: A quarter of interns are not sure about the usefulness of internet resources for health. The interns have limited knowledge about right resources in the internet. They are not equipped to tell useful resources from the not-useful ones in the internet. Conclusions: There is a need to pay attention to the eHealth Literacy needs of the interns. Further research may be needed to generate evidence on what interventions may be specific to meet the ehealth literacy needs of the medical and dental interns. Keywords: e-Health Literacy; electronic resources in health; health information technology; health literacy in Nepal; health literacy of intern.

Introduction: The management of Obstetrics and Gynaecological Emergency is directed at the preservation of life, health, sexual function and the perpetuation of fertility. Main aim of the study was to access the burden of Surgical Emergency in Obstetrics and Gynaecology and their course of management at BPKIHS. Methods: A total of 314 women presenting at the emergency admission room of Obstetrics and Gynaecology Department of BPKIHS over two years, who required surgical intervention were included in this hospital based descriptive study. Clinical assessment and routine laboratory investigations were performed in all cases. All patients who presented with shock were resuscitated and surgery was done at earliest possible time. Results: The age of patients ranged from 15- 55 years with approximately 43% in the 25-34 years category. Ninety two percent of them were married. Among the unmarried, 64% came with problems related to unsafe abortion. About 61% of females presenting as acute surgical abdomen had ruptured ectopic pregnancy, 7.64% had twisted ovarian cyst, and 6.26% had haemoperitoneum and pyoperitoneum following vaginal hysterectomies, total abdominal hysterectomies and caesarean section. Almost half (47.8%) of the cases underwent salphingectomy. Conclusions:Women present with wide range of complaints and conditions in the admission room of Obstetrics and Gynecology department of BPKIHS. Skilled clinicians, immediate investigation facilities and experienced specialty Obstetrical and Gynaecological surgeons are the main backbone of the emergency case management and saving lives. Study indicates there is need of some prospective study to establish the causes of rising trend in Ectopic Pregnancies. Keywords: ectopic pregnancy; emergency; gynaecological; obstetrics.