Comparative Study between Operative versus Non-operative Treatment for Base of Fifth Metatarsal Fractures in Young Adults

Background The treatment of displaced base of fifth metatarsal fracture remains controversial regarding the conservative and operative treatment. Objective To investigate the therapeutic effect of operative and non-operative treatment for base of fifth metatarsal fractures. Method This was retrospective comparative study performed in Civil Service Hospital, Kathmandu, Nepal from December 2014 to November 2019. Patients were randomly divided into two groups by computer generated technique. Group1 included 17 patients who underwent open reduction and internal fixation using tension band wiring, whereas group 2 included 17 patients who underwent non-operative treatment with boot cast. Result The AOFAS and VAS-FA scores at 3 months in operative and non-operative groups were 89.34±2.14 versus 86.94±2.22 (p < 0.05) and 5.58±0.87 versus 3.58±0.93 (p < 0.05). Similarly, AOFAS and VAS-FA at 12 months after treatment were 90.94±2.43 versus 90.17±1.55 (p > 0.05) and 0.64±0.280.94±0.39 (p > 0.05) in operative and non-operative groups respectively. The average time to bear full weight and return to work were 6.82±1.13 versus 7.08±1.24 weeks (p > 0.05) and 8.76±1.20 versus 10.35±1.41 weeks ( p < 0.05) respectively. The mean of VAS score at 3months of treatment is 5.58±0.87 for non-operative group and 3.58±0.93 for operative group (p <0.05). Conclusion Operative intervention has been preferred over the non-operative treatment in young adults or athletes with more than 3 mm displaced fifth metatarsal base fracture to achieve anatomical reduction of fracture, hasten the recovery and rehabilitation and to decrease the complications associated with non-operative treatment.

Diagnostic and Treatment Delays among the Tuberculosis Patients in the Urban Area of Western Nepal

Background Diagnosis and treatment of tuberculosis is vital for health system to identify, treat patients as early as possible and to reduce frequency of new cases of a disease among the contacts of known cases. Objective To determine the diagnostic and treatment delay in the urban population of the western, Nepal and factors associated to it. Method An institutional based cross-sectional study was conducted in urban area of Western Nepal. Category I 142 TB patients aged over 15 years visiting DOTs centre during period of three months were included in study. Interview schedule was designed to elicit information on socio- demographic characteristics and history of symptoms. Diagnostic and treatment delay was calculated, chi square test was applied to find associations and non - parametric tests (Mann Whitney U test and Kruskal Wallis H test) for evaluating group differences. Result Out of 142 TB clients, mean age was 38.12 years. Majority (58%) were males. Around 44% belong to upper, 30% middle and 26% lower economic class. Study showed median diagnostic delay 34 days (Q3 =68 Days, Q1 =19 Days), treatment delay less than a day (Q3 =1 Day, Q1 =0 Day) and total delay 33.50 days (Q3 =71 Days, Q1 =19 Days). Smear positive patients had significantly higher risk of diagnostic delay compared to negative (OR=2.18. P=0.035). However, no significant associations found between socio-economic/demographic classes with delay. Median delays was more amongst married (Q3 =86 Days, Median =72 days, Q1=24 Days compared to single/separated (Q3 =74 Days, Median =57 days, Q1 =15 Days) and other socio-demographic variables had no significant differences. Conclusion Delay in diagnosis and treatment in Urban region of Western, Nepal was shorter compared to other places in Nepal and neighboring countries. Shorter delay for smear negative pulmonary tuberculosis raises doubt that cases are not examined according to the national TB control programs manual.

State of midwives in Nepal: HRH to improve maternal and neonatal health and survival

Improving health and survival of mothers and newborns depends on the delivery of evidence-based cost effective interventions through a skilled care provider. Evidence suggests that midwives are compassionate skilled care providers to mothers, and ensuring these skilled human resources is a key to progress towards Millennium Development Goals 4 and 5. With this in mind, this article analyses the state of midwifery in Nepal and what strategies are needed to ensuretheir accessibility and availability. In Nepal, as a result of community mobilization through Female Community Health Volunteers for birth preparedness and complication readiness, there has been a demand for skilled care at birth. However the supply of skilled birth attendants has been inadequate both in terms of number as well as quality of care.

Developing community-based intervention strategies and package to save newborns in Nepal

In Nepal, the proportion of under 5 deaths that are neonatal (0-28 days) has been increasing in the last decade, due to faster declines in infant and child mortality than in neonatal mortality. This trend is likely due to a focus on maternal and child survival programs that did not adequately address newborn health needs. Policy and actions to save newborn lives resulted from increased attention to newborn deaths in 2001, culminating in the endorsement of the National Neonatal Health Strategy in 2004, a milestone that established newborn health and survival as a national priority. Operationalization of the National Neonatal Health Strategy took place in 2007 with the development of the Community-Based Newborn Care Package (CB-NCP). This paper describes how national stakeholders used global, regional and in-country research and policies to develop the CB-NCP, thus outlining key ingredients to make newborn health programming a reality in Nepal. A technical working group was constituted to review existing evidence on interventions to improve newborn survival, develop a tool to prioritize neonatal interventions, and conduct program learning visits to identify key components appropriate to the Nepal context that should be included in the Community Based Integrated Newborn Care Package. The group identified interventions based on the evidence of impact on newborn survival, potential mechanisms within the existing health system to deliver the interventions, and linkages with existing programs and different tiers of the health system. Not only was Nepal one of the first countries in south-east Asia where government adopted a national strategy to reduce neonatal deaths, but it was also one of the first to endorse a package of neonatal interventions for pilot testing and scaling up through existing community-based health systems that provide basic health services throughout the country. CB-NCP was designed to be gradually scaled up throughout the country by integration with Safe Motherhood and Child survival programs that are currently operating at scale. Under Ministry of health and Population leadership, a network of academia, professional bodies and partners developed a common vision for improving newborn health and survival, and launched district-level pilot programs to demonstrate and learn how newborn health interventions could be effectively and efficiently delivered and scaled up in Nepal.

Fitting Community Based Newborn Care Package into the health systems of Nepal

Community-based strategies for delivering effective newborn interventions are an essential step to avert newborn death, in settings where the health facilities are unable to effectively deliver the interventions and reach their population. Effective implementation of community-based interventions as a large scale program and within the existing health system depends on the appropriate design and planning, monitoring and support systems. This article provides an overview of implementation design of Community-Based Newborn Care Package (CB-NCP) program, its setup within the health system, and early results of the implementation from one of the pilot districts. The evaluation of CB-NCP in one of the pilot districts shows significant improvement in antenatal, intrapartum and post natal care. The implementation design of the CB-NCP has six different health system management functions: i) district planning and orientation, ii) training/human resource development, iii) monitoring and evaluation, iv) logistics and supply chain management, v) communication strategy, and vi) pay for performance. The CB-NCP program embraced the existing system of monitoring with some additional components for the pilot phase to test implementation feasibility, and aligns with existing safe motherhood and child health programs. Though CB-NCP interventions are proven independently in different local and global contexts, they are piloted in 10 districts as a "package" within the national health system settings of Nepal.

State of maternal, newborn and child health programmes in Nepal: what may a continuum of care model mean for more effective and efficient service delivery?

The cost-effective interventions exist across the continuum of maternal to child survival at each level of the health system that can contribute to achieve the Millennium Development Goals 4 and 5. However, implementation inefficiency, low coverage and equity gaps along this continuum remain a serious challenge to Nepal's efforts to achieve these goals. This paper proposes a continuum of care model; discusses the readiness of policy and programs to provide high impact interventions across the continuum; identifies existing gaps in MNCHN programs; and recommends policy and program actions to improve coverage, equity, effectiveness and efficiency along the continuum of MNCHN service delivery in Nepal. The literature review includes systematic desk review, followed by discussions and deliberations amongst a group of professionals and MNCH experts in Nepal. Within the government health system in Nepal, a continuum of care approach is feasible, as policies and plans exist to ensure an integrated approach across the maternal to child care continuum. However, health programs largely remain vertically oriented. Achieving integration across the maternal to child continuum of care remains a challenge at each level of health system. An integrated system of program management for maternal, newborn and child health would be a feasible solution to enable an efficient and effective delivery of intervention packages. A collaborative and partnership approach to strengthen health systems, building managerial capacity, improving governance and engaging the private and civil sectors remains vital to achieve effective coverage and improve equity across the continuum of care.

Community participation and mobilization in community-based maternal, newborn and child health programmes in Nepal

A number of studies on community mobilization for maternal and newborn health have demonstrated that community participation is of profound importance in the delivery of community based survival interventions for mother, newborn and children and a cost effective way to reduce mortality. However, the lessons learnt from the efficacy trials have not been tested within the health systems. Nepal is well known for its public health programmes and wide successes in campaign based interventions as a result of active involvement of volunteers and organizations based in the community. This paper analyzes the degree of community participation and mobilization in community-based maternal, newborn and child health programmes and its potential implication in acceleration towards achieving Millennium Development Goals 4 and 5. The study is based on analysis of the existing national community based maternal, neonatal and child health programmes in terms of degree of community mobilization and participation for ownership and sustainability of programmes. Furthermore, a qualitative assessment was carried out to assess the level of engagement of community structures in community based maternal, newborn and child health programme. None of the national community based maternal, newborn and child health programmes used the community action cycle approach and there was minimal level of involvement of community networks. The mother's groups had been least engaged in identifying and solving the maternal, newborn and child health problems and Female community health volunteer were engaged in delivering messages at household level and not through the mother's groups. Though the Community Action Cycle was studied in Nepal and it was found effective to achieve the objectives, getting its lessons into practice to design community health programs were lacking. The mother's groups need to be revitalized to ensure their active participation in identifying, analyzing and agreeing on steps to solve the problems related to maternal, neonatal and child health so that care seeking and utilization of health services will be further enhanced. The national strategies need to explore the possibilities of incorporating the community action cycle frame into its programmes, test the frame and ensure its implementation in the National community based programs in order to improve health outcomes of mother, newborn and children.