Knowledge and attitude regarding the COVID-19 pandemic among undergraduate health science students of Nepal: An online survey

Objectives

This study aims to assess health science students' knowledge and attitude about COVID-19 epidemiology, management, and prevention; and the association of knowledge and attitude with various sociodemographic characteristics.

Methods

An online survey was done among 524 undergraduate health science students using a pre-tested questionnaire across 19 health science institutions in Nepal from 30 June to 11 August 2021. All subjects were enrolled in the study after informed consent. Outcomes were Knowledge level, attitude level, and predictors of knowledge level and attitude level. Bivariate analysis was done to determine the association between variables.

Results

Of 524 students, 42.9% were male, and 57.1% were female. More than half (54.6%) and the majority (85.1%) participants had good knowledge and attitude, respectively. Approximately three-fifths (59.4%) of the participants were from the B. P. Koirala Institute of Health Sciences (BPKIHS). Students in BPKIHS (odds ratio = 1.774; 95% confidence interval = 1.243-2.533), junior years (odds ratio = 8.892; 95% confidence interval = 5.814-13.599), age less than 23 years (odds ratio = 2.985; 95% confidence interval = 2.089-4.266) were more likely to have good knowledge. Students under 23 years (odds ratio = 24.160; 95% confidence interval: 9.570-60.992) and those in junior years (odds ratio = 4.460; 95% confidence interval = 3.753-5.300) were likely to have a good attitude level. Students in BPKIHS (odds ratio = 0.443; 95% confidence interval = 0.272-0.722) were less likely to have a good attitude.

Conclusions

Overall, health science students had adequate knowledge and a good attitude regarding COVID-19. However, students lacked knowledge regarding infectiousness, transmission, post-vaccination observation period, remdesivir use, convalescent plasma therapy, and awake-prone positioning. Knowledge and attitude scores were associated with age, stream, and study institution.

Prevalence and factors associated with depression, anxiety and stress symptoms among construction workers in Nepal

INTRODUCTION

The construction industry in Nepal, which employs a significant proportion of the population, ranks as one of the largest industries in the country. Construction work is physically demanding and can be risky due to the use of heavy machinery and the presence of intense physical labor. However, the physical and mental health of construction workers in Nepal is often neglected. This study aimed to assess psychological distress (depression, anxiety, and stress symptoms) and its association with socio-demographic, lifestyle, and occupational factors among construction workers in Kavre district, Nepal.

METHODS

We conducted a cross-sectional study from 1st October 2019 to 15th January 2020 among 402 construction workers in Banepa, and Panauti municipalities of Kavre district, Nepal. We collected data with face-to-face interviews using a structured questionnaire consisting of a) socio-demographic characteristics; b) lifestyle and occupational characteristics; and c) depression, anxiety and stress symptoms. We collected data using electronic forms in KoboToolbox and imported them into R version 3.6.2 for statistical analysis. We present parametric numerical variables as mean and standard deviation, and categorical variables as percentage and frequency. The confidence interval around proportion was estimated with the Clopper-Pearson method. We applied univariate and multivariable logistic regression to determine factors associated with depression symptoms, anxiety, and stress. The result of logistic regression was presented as crude odds ratio, adjusted odds ratio (AOR), and their 95% confidence interval (CI).

RESULTS

The prevalence of depression, anxiety and stress symptoms were 17.1% (95%CI: 13.6-21.2), 19.2% (95%CI: 15.5-23.4) and 16.4% (95%CI: 12.9-20.4), respectively. In multivariable logistic regression analysis, depression symptom was positively associated with poor sleep quality (AOR = 3.51; 95%CI: 1.5-8.19; p-value: 0.004); stress symptom was positively associated with Brahmin ethnicity (AOR = 3.76; 95%CI:1.34-10.58; p-value: 0.012) and current smoking (AOR = 2.0; 95%CI: 1.11-3.82 p-value: 0.022). But anxiety symptoms were not associated with any of the variables.

CONCLUSIONS

The prevalence of depression, anxiety, and stress symptoms were high among construction workers. Developing evidence-based and appropriate community-based mental health prevention programs among laborers and construction workers is recommended.

Management of health information of nepalese labour migrants

INTRODUCTION

The monitoring and improvement of the health of labour migrants (LMs) require sufficient health data to be recorded and managed. In this context, this study was conducted to explore the management of health information of Nepalese labour migrants (NLMs).

METHODS

This is an explorative qualitative study. Stakeholders involved directly or indirectly in maintaining the health profile of NLMs were first mapped, physically visited, and any documents or information were collected. Then, sixteen key informant interviews were conducted among these stakeholders related to labour migrants' health information management and challenges. A checklist extracted information from the interviews, and a thematic analysis was carried out to summarize the challenges.

RESULTS

Government agencies, non-governmental organizations, and government approved private medical centers are involved in generating and maintaining the health data of NLMs. The Foreign Employment Board (FEB) records deaths and disabilities of NLMs while at work abroad and these health records are also maintained in an online portal called Foreign Employment Information Management System (FEIMS) under the Department of Foreign Employment (DoFE). Health assessment of NLMs is a mandatory procedure before departure, which is done through the government-approved pre-departure private medical assessment centers. The health records from these assessment centers are first recorded in paper-based form and then entered into an online electronic form to be stored by the DoFE. The filled-up paper forms are sent to District Health Offices, which further report the data to the Department of Health Services (DoHS), Ministry of Health and Population (MoHP) and associated governmental infectious diseases centers. However, there is no formal health assessment of NLMs upon arrival to Nepal. Key informants raised various issues and concerns in maintaining health records of NLMs, which were grouped into three themes: lack of interest to develop a unified online system; need of competent human resources and equipment; and developing a set of health indicators for migrant health assessment.

CONCLUSION

The FEB and government-approved private assessment centers are the main stakeholders in keeping the health records of outgoing NLMs. The current migrant health record keeping procedure in Nepal is fragmented. The national Health Information Management Systems does not effectively capture and categorize the health record of NLMs. There is a need to effectively link national health information system with premigration health assessment centers; and potentially develop a migrant health information management system by systematically keeping health records electronically with relevant health indicators on departing and arriving NLMs.

Knowledge and practices of modern contraceptives among religious minority (Muslim) women: A cross-sectional study from Southern Nepal

BACKGROUND

Uptake of family planning (FP) services could prevent many unwanted pregnancies, and unsafe abortions and avert maternal deaths. However, women, especially from ethnic and religious minorities, have a low practice of contraceptives in Nepal. This study examined the knowledge and practices of modern contraceptive methods among Muslim women in Nepal.

METHODS

A cross-sectional study was conducted among 400 Muslim women in the Khajura Rural Municipality of Banke district. Data were collected using face to face structured interviews. Two outcome variables included i) knowledge of and ii) practices of contraceptives. Knowledge and practice scores were estimated using the list of questions. Using median as a cut-off point, scores were categorised into two categories for each outcome variable (e.g., good knowledge and poor knowledge). Independent variables were several sociodemographic factors. The study employed logistic regression analysis, and odds ratios (OR) were reported with 95% confidence intervals (CIs) at a significance level of p<0.05 (two-tailed).

RESULTS

Almost two-thirds (69.2%) of respondents had good knowledge of modern contraceptive methods, but only 47.3% practised these methods. Women of nuclear family (adjusted odds ratio (aOR) = 0.60; 95% CI: 0.38,0.95), and who work in agricultural sector (aOR = 0.38; 95% CI: 0.22, 0.64) were less likely to have good knowledge on modern contraceptives. Women with primary (aOR = 2.59; 95% CI: 1.43, 4.72), secondary and above education (aOR = 4.41; 95% CI:2.02,9.63), women with good knowledge of modern contraceptives (aOR = 2.73; 95% CI: 1.66, 4.51), who ever visited a health facility for FP counselling (aOR = 4.40; 95% CI: 2.58, 7.50) had higher odds of modern contraceptives practices.

CONCLUSION

Muslim women had low use of modern contraceptive methods despite having satisfactory knowledge about them. There is a need for more equitable and focused high-quality FP practices. Targeted interventions are needed to increase the knowledge and practices of contraceptives in the Muslim community. The study highlights the need to target FP interventions among socially disadvantaged women, those living in a nuclear family, and those with poor knowledge of modern contraceptives.

High coverage but low quality of maternal and newborn health services in the coverage cascade: who is benefitted and left behind in accessing better quality health services in Nepal?

BACKGROUND

Antenatal care (ANC) visits, institutional delivery, and postnatal care (PNC) visits are vital to improve the health of mothers and newborns. Despite improved access to these routine maternal and newborn health (MNH) services in Nepal, little is known about the cascade of health service coverage, particularly contact coverage, intervention-specific coverage, and quality-adjusted coverage of MNH services. This study examined the cascade of MNH services coverage, as well as social determinants associated with uptake of quality MNH services in Nepal.

METHODS

We conducted a secondary analysis of data derived from the Nepal Demographic and Health Survey (NDHS) 2016, taking 1978 women aged 15-49 years who had a live birth in the 2 years preceding the survey. Three outcome variables were (i) four or more (4⁺) ANC visits, (ii) institutional delivery, and (iii) first PNC visit for mothers and newborns within 48 h of childbirth. We applied a cascade of health services coverage, including contact coverage, intervention-specific and quality-adjusted coverage, using a list of specific intervention components for each outcome variable. Several social determinants of health were included as independent variables to identify determinants of uptake of quality MNH services. We generated a quality score for each outcome variable and dichotomised the scores into two categories of "poor" and "optimal" quality, considering > 0.8 as a cut-off point. Binomial logistic regression was conducted and odds ratios (OR) were reported with 95% confidence intervals (CIs) at the significance level of p < 0.05 (two-tailed).

RESULTS

Contact coverage was higher than intervention-specific coverage and quality-adjusted coverage across all MNH services. Women with advantaged ethnicities or who had access to bank accounts had higher odds of receiving optimal quality MNH services, while women who speak the Maithili language and who had high birth order (≥ 4) had lower odds of receiving optimal quality ANC services. Women who received better quality ANC services had higher odds of receiving optimal quality institutional delivery. Women received poor quality PNC services if they were from remote provinces, had higher birth order and perceived problems when not having access to female providers.

CONCLUSIONS

Women experiencing ethnic and social disadvantages, and from remote provinces received poor quality MNH services. The quality-adjusted coverage can be estimated using household survey data, such as demographic and health surveys, especially in countries with limited routine data. Policies and programs should focus on increasing quality of MNH services and targeting disadvantaged populations and those living in remote areas. Ensuring access to female health providers and improving the quality of earlier maternity visits could improve the quality of health care during the pregnancy-delivery-postnatal period.

Health problems of nepalese labor migrants: A scoping review

Labor migrants (LMs) often work in precarious work environments and are exposed to various health risks. There is a lack of information on the health of international Nepalese LMs (NLMs). This scoping study was conducted to assess the health problems of international NLMs based on the six-stage scoping review process of Arksey and O'Malley. A literature review and stakeholders consultation related to NLMs' health information were conducted. A total of 455 studies were identified of which 38 studies were potentially relevant based on title and/or abstract screening, and a total of 16 studies were finally included and assessed. The literature showed that the health problems incurred by NLMs are mainly mental health problems; accidents, injuries, and infectious diseases. The Foreign Employment Board is the main public stakeholder which records deaths and disabilities of NLMs. The record showed that there were a total of 3,752,811 labor permits approval, a total of 7467 deaths, and a total of 1512 disabilities among NLMs during the 11 years from 2008-2018. There is a need to have a better investigation of causes of death and disability among NLMs to assign scientific causes of death. Predeparture orientation on mental health coping strategies, labor rights, health-care accessibility options in destination countries, traffic safety, and infectious diseases should be instituted.

Prevalence and determinants of non-communicable disease risk factors among adult population of Kathmandu

BACKGROUND

According to WHO, the deaths due to NCDs in Nepal have soared from 60% of all deaths in 2014 to 66% in 2018. The study assessed the prevalence and determinants of non-communicable disease risk factors among adult population of Kathmandu.

MATERIALS AND METHODS

A community based cross-sectional study was conducted from September 2019 to February 2020 among 18-69 years adults residing in municipalities of Kathmandu district. Multi-stage random sampling technique was used to select 245 subjects who were interviewed using WHO NCD STEPS instrument. Chi-square test and logistic regression analysis were done to explore the determinants of NCD risk factors.

RESULTS

The prevalence of current smoking, alcohol consumption, low intake of fruits and vegetables and low physical activity was found to be 22%, 31%, 93.9% and 10.2% respectively. More than half (52.2%) of the participants were overweight or obese and the prevalence of raised blood pressure was 27.8%. Smoking was associated significantly with male gender (AOR = 2.37, CI: 1.20-5.13) and respondents with no formal schooling (AOR: 4.33, CI: 1.50-12.48). Similarly, the odds of alcohol consumption were higher among male gender (AOR: 2.78, CI: 1.47-5.26), people who were employed (AOR: 2.30, CI: 1.13-4.82), and those who belonged to Chhetri (AOR: 2.83, CI: 1.19-6.72), Janajati (AOR: 6.18, CI: 2.74-13.90), Dalit and Madhesi, (AOR: 7.51, CI: 2.13-26.35) ethnic groups. Furthermore, respondents who were aged 30-44 years (AOR: 5.15, CI: 1.91-13.85) and 45-59 years (AOR: 4.54 CI: 1.63-12.66), who were in marital union (AOR: 3.39, CI: 1.25-9.13), and who belonged to Janajati (AOR: 3.37, CI: 1.61-7.04), Dalit and Madhesi (AOR: 4.62, CI: 1.26-16.86) ethnic groups were more likely to be associated with overweight or obesity. Additionally, the odds of raised blood pressure were higher among people who were of older age (AOR: 6.91, CI: 1.67-28.63) and those who belonged to Janajati ethnic group (AOR: 3.60, CI: 1.46-8.87) after multivariate analysis.

CONCLUSION

The findings of the study highlighted high prevalence of behavioral and metabolic risk factors, which varied on different socio-demographic grounds. Thus, population specific health promotion interventions centered on public health interests is recommended to reduce risk factors of NCDs.

Maternal Near Miss Analysis in Three Hospitals of Nepal: An Assessment Using Three Delays Model

BACKGROUND

Maternal Near Miss cases have similarities with those dying from such complications and so present an important opportunity to improve practice. This study was conducted to assess the prevalence of Maternal Near Miss events and identify the delays experienced.

METHODS

This was a facility-based cross-sectional study conducted in three tertiary referral hospitals from three provinces of Nepal. All the women surviving a near miss event during six months data collection period were included in the study.

RESULTS

There were 67 near miss cases, 7 maternal deaths, and 9158 live births in the study hospitals during the data collection period. This resulted in Maternal Near Miss ratio of 7.31/1000 live births and facility-based Maternal Mortality Ratio of 76/100,000 live births. Severe obstetric haemorrhage (54%) was the most frequent clinical cause of near miss, followed by hypertensive disorders (43%). At least one type of delay was experienced by 85% women. First delay occurred in 63% (42 of 67) cases, second delay occurred in 52% (33 of 62) cases and third delay occurred in 55% (37 of 67) cases.

CONCLUSIONS

This study found out that all three delays were common among women experiencing maternal near miss event. Raising awareness regarding dangers signs, improving referral system and strengthening ability of health workers can help in reducing these delays.

Basic emergency obstetric and newborn care service availability and readiness in Nepal: Analysis of the 2015 Nepal Health Facility Survey

Background

Achieving maternal and newborn related Sustainable Development Goals targets is challenging for Nepal, mainly due to poor quality of maternity services. In this context, we aim to assess the Basic Emergency Obstetric and Newborn Care (BEmONC) service availability and readiness in health facilities in Nepal by analyzing data from Nepal Health Facility Survey (NHFS), 2015.

Methods

We utilized cross-sectional data from the nationally representative NHFS, 2015. Service availability was measured by seven signal functions of BEmONC, and service readiness by the availability and functioning of supportive items categorized into three domains: staff and guidelines, diagnostic equipment, and basic medicine and commodities. We used the World Health Organization’s service availability and readiness indicators to estimate the readiness scores. We performed a multiple linear regression to identify important factors in the readiness of the health facilities to provide BEmONC services.

Results

The BEmONC service readiness score was significantly higher in public hospitals compared with private hospitals and peripheral public health facilities. Significant factors associated with service readiness score were the facility type (14.69 points higher in public hospitals, P<0.001), number of service delivery staff (2.49 points increase per each additional delivery staff, P<0.001), the service hours (4.89 points higher in facilities offering 24-hour services, P = 0.01) and status of periodic review of maternal and newborn deaths (4.88 points higher in facilities that conducted periodic review, P = 0.043).

Conclusions

These findings suggest that BEmONC services in Nepal could be improved by increasing the number of service delivery staff, expanding service hours to 24-hours a day, and conducting periodic review of maternal and newborn deaths at health facilities, mainly in the peripheral public health facilities. The private hospitals need to be encouraged for BEmONC service readiness.

Intersectional (in) equities in contact coverage of maternal and newborn health services in Nepal: insights from a nationwide cross-sectional household survey

Background

Persistent inequities in coverage of maternal and newborn health (MNH) services continue to pose a major challenge to the health-care system in Nepal. This paper uses a novel composite indicator of intersectional (dis) advantages to examine how different (in) equity markers intersect to create (in) equities in contact coverage of MNH services across the continuum of care (CoC) in Nepal.

Methods

A secondary analysis was conducted among 1978 women aged 15–49 years who had a live birth in the two years preceding the survey. Data were derived from the Nepal Demographic and Health Survey (NDHS) 2016. The three outcome variables included were 1) at least four antenatal care (4ANC) visits, 2) institutional delivery, and 3) postnatal care (PNC) consult for newborns and mothers within 48 h of childbirth. Independent variables were wealth status, education, ethnicity, languages, residence, and marginalisation status. Intersectional (dis) advantages were created using three socioeconomic variables (wealth status, level of education and ethnicity of women). Binomial logistic regression analysis was employed to identify the patterns of (in) equities in contact coverage of MNH services across the CoC.

Results

The contact coverage of 4ANC visits, institutional delivery, and PNC visit was 72, 64, and 51% respectively. Relative to women with triple disadvantage, the odds of contact coverage of 4ANC visits was more than five-fold higher (Adjusted Odds Ratio (aOR) = 5.51; 95% CI: 2.85, 10.64) among women with triple forms of advantages (literate and advantaged ethnicity and higher wealth status). Women with triple advantages were seven-fold more likely to give birth in a health institution (aOR = 7.32; 95% CI: 3.66, 14.63). They were also four times more likely (aOR = 4.18; 95% CI: 2.40, 7.28) to receive PNC visit compared to their triple disadvantaged counterparts.

Conclusions

The contact coverage of routine MNH visits was low among women with social disadvantages and lowest among women with multiple forms of socioeconomic disadvantages. Tracking health service coverage among women with multiple forms of (dis) advantage can provide crucial information for designing contextual and targeted approaches to actions towards universal coverage of MNH services and improving health equity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11142-8.

Factors associated with low back pain among construction workers in Nepal: A cross-sectional study

BACKGROUND

Low back pain (LBP) is the commonest cause of disability throughout the world. This study aimed to determine the prevalence and factors associated with LBP among the construction workers in Nepal.

METHODS

A community-based cross-sectional study was conducted among the construction workers working in Banepa and Panauti municipalities of Kavre district, from September 2019 to February 2020. Data was collected purposively by face-to-face interview from 402 eligible participants from the both municipalities using semi-structured questionnaire. Mobile-based data collection was done using KoboCollect. Data were exported to and analysed using R-programming software (R-3.6.2). Univariate and multivariate logistic regressions were performed. All tests were two tailed and performed at 95% confidence interval (CI).

RESULT

One-year prevalence of LBP among construction workers were 52.0% (95%CI: 47.0-57.0). The higher odds of LBP was reported among females [adjusted odds ratio (aOR) = 2.42; 95%CI: 1.12-5.23], those living below poverty-line (aOR = 2.35; 95%CI: 1.32-4.19), participants with more than five years of work experience (aOR = 1.66; 95%CI: 1.01-2.73) and those with intermediate sleep quality (aOR = 2.06; CI: 1.03-4.11). About 80.0% of construction workers with LBP never seek healthcare services due to: a) time constraints (90.9%), b) financial constraints (18.1%) and c) fear of losing wages on seeking healthcare services (40.9%). The majority of the participants (94.8% among those without LBP and 72.3% among those with LBP) did nothing to prevent or manage LBP.

CONCLUSION

The prevalence of LBP in the past one year was high among construction workers where majority of workers never did anything to prevent or manage LBP. Therefore, the public health professionals should set up the health promotion, education, and interventions aimed at increasing awareness on preventive techniques and predisposing factors of LBP.

Who are dying and why? A case series study of maternal deaths in Nepal

OBJECTIVES

To identify delays and associated factors for maternal deaths in Nepal.

DESIGN

A cross-sectional case series study of maternal deaths. An integrated verbal and social autopsy tool was used to collect quantitative and qualitative information regarding three delays. We recorded death accounts and conducted social autopsy by means of community Focus Group Discussions for each maternal death; and analysed data by framework analysis.

SETTING

Sixty-two maternal deaths in six districts in three provinces of Nepal.

RESULTS

Nearly half of the deceased women (45.2%) were primiparous and one-third had no formal education. About 40% were from Terai/Madhesi and 30.6% from lower caste. The most common place of death was private hospitals (41.9%), followed by public hospitals (29.1%). Nearly three-fourth cases were referred to higher health facilities and median time (IQR) of stay at the lower health facility was 120 (60-180) hours. Nearly half of deaths (43.5%) were attributable to more than one delay while first and third delay each contributed equally (25.8%). Lack of perceived need; perceived cost and low status; traditional beliefs and practices; physically inaccessible facilities and lack of service readiness and quality care were important factors in maternal deaths.

CONCLUSIONS

The first and third delays were the equal contributors of maternal deaths. Interventions related to birth preparedness, economic support and family planning need to be focused on poor and marginalised communities. Community management of quick transportation, early diagnosis of pregnancy risks, accommodation facilities near the referral hospitals and dedicated skilled manpower with adequate medicines, equipment and blood supplies in referral hospitals are needed for further reduction of maternal deaths in Nepal.

Policies and actions to reduce maternal mortality in Nepal: perspectives of key informants

Nepal made impressive progress in reducing maternal mortality until 2015. Since then, progress has stagnated, coinciding with Nepal’s transition to a federation with significant devolution in health management. In this context, we conducted key informant interviews (KII) to solicit perspectives on policies responsible for the reduction in maternal mortality, reasons for the stagnation in maternal mortality, and interventions needed for a faster decline in maternal mortality. We conducted 36 KIIs and analysed transcripts using standard framework analysis methods. The key informants identified three policies as the most important for maternal mortality reduction in Nepal: the Safe Motherhood Policy, Skilled Birth Attendant Policy, and Safe Abortion Policy. They opined that policies were adequate, but implementation was weak and ineffective, and strategies needed to be tailored to the local context. A range of health system factors, including poor quality of care, were identified by key informants as underlying the stagnation in Nepal’s maternal mortality ratio, as well as a few demand-side aspects. According to key informants, to reduce maternal deaths further Nepal needs to ensure that the current family planning, birth preparedness, financial incentives, free delivery services, abortion care, and community post-partum care programmes reach marginalised and vulnerable communities. Facilities offering comprehensive emergency obstetric care need to be accessible, and in hill and mountain areas, access could be supported by establishing maternity waiting homes. Social accountability can be strengthened through social audits, role models, and empowerment of health and management committees.

How Does Public Knowledge, Attitudes, and Behaviors Correlate in Relation to COVID-19? A Community-Based Cross-Sectional Study in Nepal

Background: The COVID-19 pandemic has created a global health emergency requiring an effective public health response including citizen's roles in preventing spread and controlling the pandemic. Little is known about public knowledge, beliefs and behaviors in-relation to the pandemic in Nepal. This study aims to assess knowledge, attitude and practices (KAP) toward COVID-19 among the general public and to identify associated factors. Methods: A cross-sectional survey was conducted between May-June 2020 with a sample of 645, recruited from 26 hospitals across Nepal. We conducted telephone interviews using a semi-structured questionnaire related to KAP regarding COVID-19. T-test and one-way ANOVA was conducted to determine group differences for socio-demographic variables. Linear regression and correlational analysis were performed to identify associated factors and measure strength and direction of relationships. Results: Overall mean scores for knowledge, attitude and practice were 11.6 (SD 4.5), 2.7 (SD 1.8), and 9.9 (SD 1.93) respectively, but differed by socio-demographic characteristics. Positive but weak linear correlations were observed between knowledge-practice (r = 0.19, p < 0.01) and attitude-practice (r = 0.08, p < 0.05). The relationship between knowledge and education was fairly strong (r = 0.34, p < 0.01). Province, place of residence, ecological area, age, gender and caste/ethnicity were also significantly associated with KAP score of participants. Conclusion: The study found varying degrees of correlation between Knowledge, Attitude and Practice that may increase as the pandemic evolves in Nepal. Knowledge and level of education had positive associations with attitude and adherence to precautionary measures. The findings suggest a need for targeted community awareness interventions for the most vulnerable populations, men, those with no school education, the elderly and people living in rural areas.

A Cross-Sectional Survey of Contraceptive Use and Birth Spacing Among Multiparous Women in Eastern Nepal

Despite the known benefits of the use of contraceptives, notably birth spacing, the use of contraceptives in Nepal has remained stagnant since 2006. The purpose of this article is to assess the knowledge and use of contraceptives, and to ascertain preceding interbirth spacing in an eastern plain district of Nepal. A cross-sectional survey was completed on 406 multiparous women aged 18 to 49 years to collect data via structured questionnaires in Jhapa district of Nepal. The majority of the participants (96.1%) had knowledge of at least one modern contraceptive: injectable and oral contraceptives were the most common. Female sterilization was the most commonly used method of contraception. The median birth spacing was 41.5 months, and the majority of participants (79.1%) had preceding interbirth spacing greater than 24 months. The average preferred birth spacing was 51.3 months, and about half of the participants said that 60 months was the appropriate birth spacing. Though knowledge of contraceptives use is almost universal in this population, the use is still low. The preferred birth spacing is longer than the actual birth spacing, signifying an unmet need of contraception.

Social determinants of health affecting utilisation of routine maternity services in Nepal: a narrative review of the evidence

Nepal has one of the highest maternal and neonatal mortality rates among low- and middle-income countries. Nepal's health system focuses on life-saving interventions provided during the antenatal to postpartum period. However, the inequality in the uptake of maternity services is of major concern. This study aimed to synthesise evidence from the literature regarding the social determinants of health on the use of maternity services in Nepal. We conducted a structured narrative review of studies published from 1994 to 2016. We searched five databases: PubMed; CINAHL; EMBASE; ProQuest and Global Index Medicus using search terms covering four domains: access and use; equity determinants; routine maternity services and Nepal. The findings of the studies were summarised using the World Health Organization's Social Determinants of Health framework. A total of 59 studies were reviewed. A range of socio-structural and intermediary-level determinants was identified, either as facilitating factors, or as barriers, to the uptake of maternity services. These determinants were higher socioeconomic status; education; privileged ethnicities such as Brahmins/Chhetris, people following the Hindu religion; accessible geography; access to transportation; family support; women's autonomy and empowerment; and a birth preparedness plan. Findings indicate the need for health and non-health sector interventions, including education linked to job opportunities; mainstreaming of marginalised communities in economic activities and provision of skilled providers, equipment and medicines. Interventions to improve maternal health should be viewed using a broad 'social determinants of health' framework.

Implications of methodological differences in measuring the rates of exclusive breastfeeding in Nepal: findings from literature review and cohort study

Background

Correct measurement and continuous monitoring of exclusive breastfeeding are essential to promote exclusive breastfeeding. Measuring exclusive breastfeeding is a complex issue as rates can vary according to the definition, measurement period, questions asked, and infant’s age. This article reviewed the methodology of reporting exclusive breastfeeding in Nepal, and compared exclusive breastfeeding rates using data from a cohort study undertaken in western Nepal.

Methods

A literature review was first conducted on studies published during 2000–2014. In our cohort study, 735 mother-infant pairs were recruited within the first month postpartum and followed up during the fourth and sixth months.

Results

The majority of studies in Nepal, including national surveys, used the World Health Organization (WHO) recommended definition (only breastmilk with the exception of medicine and vitamin syrup), and the most common measurement period was a 24-h recall. Our data demonstrated that the exclusive breastfeeding rate during the sixth month was 8.9% using the recall-since-birth method but was 18.7% using the 24-h recall method. Substantial differences in rates were also found during the first (66.3% vs 83.9%) and fourth months (39.2% vs 61.1%).

Conclusion

We found that recent studies reporting exclusive breastfeeding in Nepal varied considerably in methodology. The most commonly used measurement, the 24-h recall, leads to over-estimation of the prevalence of exclusive breastfeeding when compared to the recall-since-birth method. A common standard of reporting exclusive breastfeeding is clearly needed for evidence-based decision making.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-1180-9) contains supplementary material, which is available to authorized users.

Birth Spacing of Pregnant Women in Nepal: A Community-Based Study

BACKGROUND

Optimal birth spacing has health advantages for both mother and child. In developing countries, shorter birth intervals are common and associated with social, cultural, and economic factors, as well as a lack of family planning. This study investigated the first birth interval after marriage and preceding interbirth interval in Nepal.

METHODS

A community-based prospective cohort study was conducted in the Kaski district of Nepal. Information on birth spacing, demographic, and obstetric characteristics was obtained from 701 pregnant women using a structured questionnaire. Logistic regression analyses were performed to ascertain factors associated with short birth spacing.

RESULTS

About 39% of primiparous women gave their first child birth within 1 year of marriage and 23% of multiparous women had short preceding interbirth intervals (<24 months). The average birth spacing among the multiparous group was 44.9 (SD 21.8) months. Overall, short birth spacing appeared to be inversely associated with advancing maternal age. For the multiparous group, Janajati and lower caste women, and those whose newborn was female, were more likely to have short birth spacing.

CONCLUSION

The preceding interbirth interval was relatively long in the Kaski district of Nepal and tended to be associated with maternal age, caste, and sex of newborn infant. Optimal birth spacing programs should target Janajati and lower caste women, along with promotion of gender equality in society.

NGOs, Foreign Aid, and Development in Nepal

The number of non-governmental organizations (NGOs) working in Nepal has grown significantly since the 1990s due to a range of factors. A total of 39,759 NGOs and 189 international non-governmental organizations were registered in Nepal between 1977 and 2014 in various sectors, including health, agriculture, poverty alleviation, and good governance. Despite thousands of NGOs and significant amounts of foreign aid, Nepal remains one of the poorest countries in South Asia. The case of Nepal indicates that aid and donor support alone are insufficient for sustained development.

The supplemental use of infant formula in the context of universal breastfeeding practices in Western Nepal

Background

While the initiation of breastfeeding is universal in Nepal, little has been reported on formula feeding practices. This study aimed to report the prevalence of, and factors associated with, the use of infant formula as supplementary feeds in the Western region of Nepal.

Methods

A community-based cohort study was conducted to collect infant feeding information among 735 postpartum mothers using structured questionnaires. Complete formula feeding data were collected from 711 women in the first, fourth and sixth month postpartum. Factors independently associated with formula feeding were investigated using multiple logistic regression.

Results

All mothers were breastfeeding their infants at the time of recruitment. The prevalence of formula feeding was 7.5 % in the first month and 17 % in the sixth month. About a quarter of mothers (23.8 %) reported providing infant formula at least once during the first six months of life. Infant formula was used commonly as top-up food. Stepwise logistic regression showed that infants born to families residing in urban areas (adjusted odds ratio (aOR): 2.14; 95 % confidence interval (CI): 1.37 to 3.33), mothers with higher education (aOR: 2.08; 95 % CI: 1.14 to 3.80), and infants born by caesarean section (aOR: 1.96; 95 % CI: 1.21 to 3.18) were at greater risk of formula feeding.

Conclusion

The current findings indicate that health workers should support mothers to initiate and continue exclusive breastfeeding particularly after caesarean deliveries. Furthermore, urban health programs in Nepal should incorporate breastfeeding programs which discourage the unnecessary use of formula feeding. The marketing of formula milk should be monitored more vigilantly especially in the aftermath of the April 2015 earthquakes or other natural disasters.

Epidemiology of road traffic injuries in Nepal, 2001-2013: systematic review and secondary data analysis

OBJECTIVE

To investigate the epidemiology of road traffic injury (RTI) in Nepal for the period 2001-2013.

METHODS

2 approaches, secondary data analysis and systematic literature review, were adopted. RTI data were retrieved from traffic police records and analysed for the incidence of RTI. Electronic databases were searched for published articles that described the epidemiology of RTI in Nepal.

RESULTS

A total of 95,902 crashes, 100,499 injuries and 14,512 deaths were recorded by the traffic police over the 12-year period, 2001-2013. The mortality rate increased from 4/100,000 population in 2001-2002 to 7/100,000 population in 2011-2012. There were relatively more reported crashes yet fewer deaths in Kathmandu valley than the rest of the country. Of the 20 articles related to RTI, only 11 articles met the eligibility criteria, but these were mainly descriptive case series or cross-sectional hospital-based studies. The majority of RTI were reported to occur among motorcyclists and pedestrians, in males, and in the age group 20-40 years. The common sites of injury were lower and upper extremities. Only 3 articles mentioned possible causes of accidents that include pedestrian road behaviour, alcohol consumption and improper bus driving.

CONCLUSIONS

Nepal suffers a heavy burden of RTI, with higher fatalities on highways out of Kathmandu valley caused by bus crashes in hilly districts. The majority of published studies on RTI are descriptive and hospital based, indicating the need for more thorough investigation of causes of RTI and systematic recording of crashes for the development of effective interventions.

Adverse obstetric symptoms and rural-urban difference in cesarean delivery in Rupandehi district, Western Nepal: a cohort study

BACKGROUND

The burden of maternal morbidity is high in developing countries including Nepal. This study investigated obstetric complications and rural-urban difference in cesarean delivery rate in Western Nepal.

METHODS

A community-based cohort study was conducted in the Rupandehi district of Western Nepal during January-October, 2014, by interviewing 735 mothers within one month postpartum. The prevalence of obstetric complications was reported via frequency distribution, while factors associated with cesarean delivery were assessed using logistic regression analysis.

RESULTS

The prevalence of adverse obstetric symptoms during antenatal, intranatal and postnatal periods were 19.7%, 27.8% and 21.6%, respectively. In total, 81 (11.0%) mothers reported having stillbirths. The cesarean delivery rate was 14.1% overall but was four times higher in the urban (23.0%) than in the rural areas (5.8%). Prolonged labor (19.0%) and heavy bleeding (16.7%) were common among rural women. Logistic regression analysis confirmed that cesarean section was more likely for mothers residing in urban areas than in rural areas (adjusted odds ratio 3.41; 95 % confidence interval 2.01 to 5.78).

CONCLUSIONS

About one in five mothers reported some adverse obstetric symptoms. Obstetric problems were more common in the rural areas, whereas cesarean delivery rate was much higher in the urban areas. Further investigations are required to determine whether these cesarean sections are medically warranted or provider induced.

Postpartum Breastfeeding Promotion and Duration of Exclusive Breastfeeding in Western Nepal

BACKGROUND

Encouragement and skills provided to mothers during the postpartum period have been found to be successful in increasing exclusive breastfeeding rates. However, evidence from developing countries is limited. This study aimed to ascertain whether education and skill support provided by health workers during the postpartum period were associated with increased duration of exclusive breastfeeding in Western Nepal.

METHODS

A community-based prospective cohort study was conducted between January and October 2014, in the Rupandehi district of Nepal. Information on breastfeeding promotion provided by health workers after birth was collected from 649 mothers. The association between breastfeeding promotion and exclusive breastfeeding was investigated using multivariable Cox regression analysis.

RESULTS

Of the 649 mothers, 35 percent received all eight types of breastfeeding promotion advice, and 60 percent received six or more such types of advice. Breastfeeding promotion, such as "breastfeeding on demand" (hazard ratio [HR] 0.74 [95% CI 0.59-0.92]) and "not to provide pacifier or teats" (HR 0.82 [95% CI 0.68-0.97]), were significantly associated with a lower risk of exclusive breastfeeding cessation. The dose-response relationship was also significant for the number of advices received (HR 0.94 [95% CI 0.90-0.97]).

CONCLUSIONS

This study provides evidence that breastfeeding education and support immediately after childbirth could increase the duration of breastfeeding. The results suggest further attention to breastfeeding promotion in all maternity hospitals and birthing centers through skilled birth attendants.

Incidence of low birthweight in central Nepal: a community-based prospective cohort study

Many deliveries in low income countries still take place at home and the newborns are often not weighed. This community-based study ascertained the incidence of low birthweight (LBW) and compared the birthweight between home- and facility-born neonates in central Nepal. A total of 701 pregnant women from the Kaski district were recruited and interviewed. Birthweights of newborns were measured by pan balance in health facility settings immediately after birth, or by local community health volunteers using colour-coded spring balance within 48 h of home birth. Household follow up of participants were undertaken less than 45 days after delivery to record the weight of their infants. Of the 639 postpartum women who took part in the follow up interview, information on birthweight was available from 605 singleton births. Among them, 65 (10.7 %) were born at home. Overall, the mean birthweight was 3,059 (SD 464) g and incidence of LBW was 16.5 % (95 % CI 13.5-19.5 %). However, the home-born infants reported significantly lower (p = 0.009) mean birthweight (2,920, SD 435 g) than their facility-born counterparts (3,078, SD 461 g). This difference in birthweight remained significant (p = 0.03) after adjustment for maternal and socio-demographic characteristics. Incidence of LBW in central Nepal was quite high. Home-born babies appeared to have lower birthweight and thus their inclusion could provide an accurate estimate of the LBW rate.

Under-utilization of antenatal care services in Timor-Leste: results from Demographic and Health Survey 2009-2010

Background

Timor-Leste is a young country in the Asia-Pacific region with a high maternal mortality rate of 557 per 100,000 live births. As most maternal deaths can be prevented by providing quality antenatal care (ANC) and skilled assistance during childbirth, understanding the barriers to the utilization of ANC services can enhance program implementation. This study aimed to investigate the prevalence and factors associated with the under-utilization of ANC services in Timor-Leste.

Methods

Timor-Leste Demographic and Health Survey (TDHS) 2009–2010 was a nationally representative multi-stage cross-sectional study involving 11,463 households and 9,828 childbirths. Information on last born child was recorded for 5,895 mother-child pairs. Factors influencing under-utilization of ANC were assessed using hierarchical logistic regression analysis.

Results

Only 3311 (55.2, 95 % confidence interval (CI) 53.1 to 57.3 %) made the recommended four ANC visits, while 2584 (44.8; 95 % CI 42.7 to 46.9 %) of them reported attending three or less ANC services. Significant factors positively associated with the under-utilization of ANC were low wealth status (odds ratio (OR) 2.09; 95 % CI 1.68 to 2.60), no maternal education (OR 1.54; 95 % CI 1.30 to 1.82) or primary maternal education (OR 1.21; 95 % CI 1.04 to 1.41), no paternal education (OR 1.34; 95 % CI 1.13 to 1.60), and having a big problem in permission to visit health facility (OR 1.65; 95 % CI 1.39 to 1.96).

Conclusions

Despite the apparently good progress made in re-establishing the healthcare infrastructure, 45 % of mothers remained in need of a focused intervention to increase their use of ANC services. Further prenatal care program should pay attention to women with low wealth status and those and their partners who are uneducated. Moreover, women should be encouraged to make decision on their own health.

Prevalence and factors associated with prelacteal feeding in Western Nepal

BACKGROUND

Newborn infants are often given prelacteal feeds in Nepal despite government policies encouraging exclusive breastfeeding for the first six months of life.

AIM

This study investigated the prevalence, reasons, types and factors associated with prelacteal feeding in the south-western region of Nepal.

METHODS

Information on prelacteal feeding was obtained from 735 recently delivered women who were recruited for a prospective community-based cohort study conducted during 2014 in the Rupandehi district of Nepal. Factors associated with prelacteal feeding were assessed using logistic regression analysis.

FINDINGS

A total of 225 (30.6%) mothers reported giving prelacteal feeds to their infants. The most popular prelacteal food was formula milk (41.7%), followed by cow or buffalo milk (26.6%), and sugar/glucose water (12.4%). Caesarean delivery (17.3%), cultural preference (16.4%) and being tired after childbirth (10.6%) were the most commonly cited reasons. Almost half (48%) of the mothers were advised by their mother/mother-in-law on prelacteal feeding method. Higher parity (adjusted odds ratio (OR) 2.05; 95% confidence interval (CI) 1.18-3.54), low birthweight (OR 1.97; 95% CI 1.23-3.16), caesarean delivery (OR 3.70; 95% CI 2.37-5.80) and wealthy status (OR 2.49; 95% CI 1.52-4.06) were associated with prelacteal feeding.

CONCLUSION

Nearly one-third of the infants in this study were given prelacteal feeds. Future breastfeeding promotion programmes should focus on the mothers with low birthweight infants, of high parity, from a wealthy family and those who had caesarean delivery.

Defining and Developing a Global Public Health Course for Public Health Graduates

Global public health is increasingly being seen as a speciality field within the university education of public health. However, the exact meaning of global public health is still unclear, resulting in varied curricula and teaching units among universities. The contextual differences between high- and low- and middle-income countries, and the process of globalization need to be taken into account while developing any global public health course. Global public health and public health are not separable and global public health often appears as an extension of public health in the era of globalization and interdependence. Though global public health is readily understood as health of global population, it is mainly practiced as health problems and their solutions set within low- and middle-income countries. Additional specialist competencies relevant to the context of low- and middle-income countries are needed to work in this field. Although there can be a long list of competencies relevant to this broad topic, available literature suggests that knowledge and skills related with ethics and vulnerable groups/issues; globalization and its impact on health; disease burden; culture, society, and politics; and management are important.

Non Medical Interventions for Childhood Diarrhoea Control:Way Forward in Nepal

Background Diarrhoeal diseases remain a major cause of mortality of children aged under-five years in the developing countries including Nepal. The transmission of diarrhoea mostly caused by biological agents and is facilitated by the behavioural, social and environmental factors. More recently, the concept of prevention altering these factors is getting momentum. Objective To recommend the most effective non medical intervention that can prevent and control childhood diarrhoeal disease in Nepal. Methods Litrature review was conducted to analyse the successful interventions in developing countries. Peer review articles were accessed from “Science direct”, “Google Scholar”, and “Pubmed”. Interventions focussing on social and environmental determinants of diarrhoea were included. Results Four interventions (with primary focus in social and environmental determinants of diarrhoeal disease) were purposively selected, summarized and discussed. Saniya programme (Burkina Faso 1995 to 1998) is considered successful in modifying the risk behaviours. Intensive hand washing programme (Pakistan 2002 to 2003), a cluster randomized controlled trail, was not sustainable as the results did not last long once the free supply of soap was stopped. School Led Total Sanitation (Nepal 2006) is a participatory, community centred program whose focus is on local ownership. This program approach is effective and feasible for scaling up in Nepal. Global Public Private Partnership for Hand washing with Soap (Ghana 2002) was based on the marketing researches and hence yielded effective results. Conclusion Combination of School Led Total Sanitation and Global Public Private Partnership for hand washing with soap suits Nepal. These interventions focus on creating demand, changing behaviour and thereby, improving the sanitation status. DOI: http://dx.doi.org/10.3126/kumj.v11i3.12517 Kathmandu Univ Med J 2013; 43(3):256-261

Low compliance with iron-folate supplementation among postpartum mothers of Nepal: an analysis of Nepal Demographic and Health Survey 2011

One in five maternal deaths are directly attributable to anaemia in the world. The World Health Organization recommends iron supplementation from the second trimester of pregnancy to 45 days after delivery. The aim of this study was to determine the compliance rate of iron-folate consumption and the factors associated with iron-folate consumption among post-natal mothers in Nepal. This study utilised the data of Nepal Demographic and Health Survey (NDHS) 2011. The NDHS 2011 is a cross sectional and nationally representative survey. Of the 4,148 respondents, only 20.7% consumed iron throughout the post-natal period for 45 days. Mothers who had higher and secondary education [adjusted Odd ratio (aOR) 3.101; 95% CI (2.268-4.240)]; had attended four or more antenatal care visits [aOR 9.406; 95% CI (5.552-15.938)]; lived in Far-western development region [aOR 1.822; 95% CI (1.387-2.395)]; delivered in health facility [aOR 1.335; 95% CI (1.057-1.687)]; and attended postnatal care [aOR 2.348; 95% CI (1.859-2.965)] were more likely to take iron for 45 days of postpartum. Intervention to increase the compliance with the postpartum iron-folate supplementation are required to avoid adverse pregnancy outcomes associated with poor iron status with especial focus on the mothers who delivered at homes and did not attend post-natal check up.

Factors associated with early initiation of breastfeeding among Nepalese mothers: further analysis of Nepal Demographic and Health Survey, 2011

Background

Timely initiation of breastfeeding has been reported to reduce neonatal mortality by 19.1%. The World Health Organisation recommends early initiation of breastfeeding i.e. breastfeeding a newborn within the first hour of life. Knowledge on the rate and the determinants of early initiation of breastfeeding may help health program managers to design and implement effective breastfeeding promotion programs. The aim of this study was to determine the rate and the determinants of early initiation of breastfeeding in Nepal.

Methods

This study used the data from Nepal Demographic and Health Survey (NDHS) 2011 which is a nationally representative sample study. Chi square test and multiple logistic regression analysis were used to examine the factors associated with early initiation of breastfeeding (within one hour of birth).

Results

Of 4079 mothers, 66.4% initiated breastfeeding within one hour of delivery. Mothers with higher education (Odds Ratio (OR) 2.56; 95% CI : 1.26, 5.21), mothers of disadvantaged Janjati ethnicity (OR 1.43; 95% CI : 1.04, 1.94), mothers who were involved in agriculture occupation (OR 1.51; 95% CI : 1.16, 1.97), mothers who delivered in a health facility (OR 1.67; 95% CI : 1.25, 2.23), whose children were large at birth (OR 1.46; 95% CI : 1.07, 1.99) were more likely to initiate breastfeeding within the first hour of child birth.

Conclusions

Results suggest that two thirds of children in Nepal were breastfed within the first hour after birth. Although there was a higher prevalence of early initiation of breastfeeding among mothers who delivered in health facilities compared to mothers who delivered at home, universal practice of early initiation of breastfeeding should be a routine practice. The findings suggest the need of breastfeeding promotion programs among the mothers who are less educated, and not working. Such breastfeeding promotion programmes could be implemented via Nepal’s extensive network of community-based workers.

The role of obstetric knowledge in utilization of delivery service in Nepal

Birth Preparedness and Complication Readiness (BP/CR) program has been promoted in Nepal to equip pregnant women with obstetric knowledge so as to motivate them to seek professional care. Using a prospective design of 701 pregnant women of more than 5 months gestation in a central hills district of Nepal, we evaluated if having obstetric knowledge could make a difference in maternal delivery behaviour. The results suggested that BP/CR program was effective in raising women's obstetric knowledge, which was significantly associated with facility delivery according to logistic regression analysis. In particular, women who acknowledged that unexpected problems could occur during pregnancy and childbirth were more likely (odds ratio [OR] 5.83, 95% confidence interval [CI] 2.95-11.52) to deliver at a health facility than others unaware of the possible consequences. Similarly, women who knew any antepartum danger sign (OR 2.16, 95% CI: 1.17-3.98), any intrapartum danger sign (OR 3.80, 95% CI: 2.07-6.96) and any postpartum danger sign (OR 3.47 95% CI: 1.93-6.25), tended to deliver at a health facility. Convincing and counselling the pregnant women of the health consequences of pregnancy and childbirth would increase their utilization of delivery service.

A community-based prospective cohort study of exclusive breastfeeding in central Nepal

BACKGROUND

Existing information on breastfeeding in low income countries such as Nepal has been largely derived from cross-sectional demographic health surveys. This study investigated exclusive breastfeeding rates, and compared the duration of exclusive breastfeeding between rural and urban mothers in central Nepal using an alternate cohort methodology.

METHODS

A community-based prospective cohort study was conducted among 639 recently delivered mothers representative of the Kaski district of Nepal. Breastfeeding information was obtained at birth (n = 639), 4 weeks (n = 639), 12 weeks (n = 615; 96.2%) and 22 weeks (n = 515; 80.6%) through repeated interviews using validated questionnaires. Risk of cessation of exclusive breastfeeding was assessed by Cox regression analysis.

RESULTS

The great majority of women received breastfeeding information (74%) and were encouraged to breastfeed by health personnel or family members (81%). Although nearly all mothers (98%) breastfed up to six months, the reported exclusive breastfeeding rate declined rapidly from 90.9% at birth to 29.7% at 22 weeks. Urban women experienced significantly shorter (p = 0.02) exclusive breastfeeding duration (mean 104.5, 95% CI 95.8 to 113.1 days) and were more likely to cease exclusive breastfeeding (hazard ratio (HR) 1.28, 95% CI 1.03 to 1.60) than their rural counterparts (mean 144.7, 95% CI 132.3 to 157.1 days). Breastfeeding problem (HR 2.07, 95% CI 1.66 to 2.57) and caesarean delivery (HR 1.88, 95% CI 1.36 to 2.62) were also significantly associated with exclusive breastfeeding cessation.

CONCLUSIONS

Despite the almost universal practice of breastfeeding, the reported exclusive breastfeeding rates declined substantially over time. Exclusive breastfeeding up to six months was more common in rural than urban areas of central Nepal. Urban mothers also exclusively breastfed shorter than rural mothers.

Institutionalising of public health

Though public health situation in Nepal is under-developed, the public health education and workforce has not been prioritised. Nepal should institutionalise public health education by means of accrediting public health courses, registration of public health graduates in a data bank and increasing job opportunities for public health graduates in various institutions at government sector.

Infant feeding information, attitudes and practices: a longitudinal survey in central Nepal

Background

Infant feeding is governed by environmental as well as cultural factors. Breastfeeding knowledge and attitudes are known to be associated with breastfeeding duration. This study investigated breastfeeding information, attitudes and supplementary feeding in the central hills district of Nepal.

Methods

A community-based prospective cohort study of 701 pregnant women was conducted. Information on breastfeeding attitudes, feeding practices and supplementary feeding was sought from the cohort at 4 weeks, 12 weeks and 22 weeks postpartum through repeated interviews using validated questionnaires.

Results

Average duration of intended breastfeeding was 28 months (SD 7.9) and average target time to introduce solid foods was 6.1 months (SD 1.2). About 80% of women reported their husband, mother/mother-in-law preferred breastfeeding. Eleven percent of the cohort said that breastfeeding was not enjoyable. At 12 weeks and 22 weeks after birth, about a quarter (24.8%) and half (52.8%) of the infants were introduced cow/buffalo milk, respectively, while only 6.3% and 13.4% of them were given infant formula. Overall, any breastfeeding rate remained high at over 98% throughout the follow up period.

Conclusions

Breastfeeding attitudes were encouraging in this population. Breastfeeding was almost universal. Use of infant formula was quite low, whereas cow or buffalo milk appeared to be popular supplementary foods.

Initiation of Breastfeeding and Factors Associated with Prelacteal Feeds in Central Nepal

BACKGROUND

Prelacteal feeds and delayed initiation of breastfeeding may lead to undernutrition of the infant but are still prevalent in many countries.

OBJECTIVE

A prospective cohort community-based study was conducted in central Nepal to ascertain the rate of early breastfeeding initiation and factors associated with the introduction of prelacteal feeds.

METHODS

Breastfeeding information was collected from 639 women who recently gave birth in the Kaski district of central Nepal. Backward stepwise logistic regression analysis was performed to determine factors associated with the use of prelacteal feeds.

RESULTS

The incidence of prelacteal feeds was 9.1%, with infant formula being the most common prelacteal food. Approximately 67% and 90% of mothers breastfed within 1 hour and 4 hours of delivery, respectively. Women who reside in urban areas (odds ratio [OR] = 2.68; 95% confidence interval [CI], 1.35-5.39), first-time mothers (OR = 2.15; 95% CI, 1.15-4.02), and those who underwent cesarean section (OR = 10.10; 95% CI, 5.47-18.67) were more likely to give prelacteal feeds to their infants.

CONCLUSION

The early initiation of breastfeeding with colostrum as the first feed was common in the study area. The introduction of prelacteal feeds was associated with urban residency, first-time motherhood, and cesarean delivery.

Public health education in South Asia: a basis for structuring a master degree course

Countries in South Asian Association for Regional Cooperation (SAARC) lack enough public health workforces to address their poor public health situation. Recently, there have been efforts to develop capacity building in public health in these countries by producing competent public health workforce through public health institutes and schools. Considering the wide nature of public health, the public health education and curricula should be linked with skills, knowledge, and competencies needed for public health practice and professionalism. The 3 domains of public health practice and the 10 essential public health services provide an operational framework to explore this link between public health practice and public health education. This framework incorporates five core areas of public health education. A master degree course in public health can be structured by incorporating these core areas as basic and reinforcing one of these areas as an elective followed by a dissertation work.

Social determinants of poor knowledge on HIV among Nepalese males: findings from national survey 2011

Since the first case detection in Nepal in 1988, the number of cases of Human Immunodeficiency Virus (HIV) are increasing. Limited studies exist concerning the knowledge on HIV among the Nepalese men. This study aimed to examine the social determinants of poor knowledge on HIV among Nepalese men aged 15-49 years based on Nepal Demographic and Health Survey (NDHS), 2011. This study is based on the secondary data of NDHS 2011. HIV knowledge was assessed by using structured qustionnaire. A Chi square test followed by logistic regression was performed to find the association of social determinants with outcome variables. Of the 3,991 participants, 1,217 (30.5%) had comprehensive knowledge and the majority (69.5%) had poor knowledge on HIV. More than half (54.6%) reported that mosquito bite can transmit HIV and 26.5% reported that sharing food can transmit HIV. Respondents who were uneducated [aOR 10.782; 95% CI (6.673-17.421)], were manual workers [aOR 1.442; 95% CI (1.152-1.804)], were poor [aOR 1.847; 95% CI (1.350-2.570)]; lived in the the Eastern region [aOR 2.203(1.738-2.793)], or in the Mountain [aOR 1.542; 95% CI (1.132-1.864)]; did not read newspaper/magazine at all [aOR 1.454; 95% CI (1.142-1.851)] and did not listen to the radio at all [aOR 1.354; 95% CI (1.046-1.752)] were likely to have poor knowledge of HIV. HIV prevention programs should include men incorporating appropriate educatoinal intervention to increase their knowledge.

Utilization of maternal and child health services in western rural Nepal: a cross-sectional community-based study

BACKGROUND

Considering the commitment and investment of Nepal to reduce maternal and child mortality, understanding service utilization and factors associated with a child and maternal health services is important.

OBJECTIVES

This study was examined the factors associated with utilization of maternal and child health services in Kapilvastu District of Nepal.

MATERIALS AND METHODS

A cross-sectional study was conducted in 2010 by interviewing 190 mothers having children of aged 12-23 months using the standardized questionnaire.

RESULTS

Immunization status (97.4%) and vitamin A supplementation (98.4%) was high. However, initiation of breastfeeding within an hour of birth was low (45.3%) and 63.2% had practiced exclusive breastfeeding. Majority (69.5%) of respondents delivered their child at home and 39.5% sought assistance from health workers. The mothers who did not have any education, mothers from Dalit/Janjati and the Terai origin were less likely to deliver at the health facility and to seek the assistance of health workers during childbirth.

CONCLUSION

The immunization program coverage was high, whereas maternal health service utilization remained poor. Interventions that focus on mothers from Dalit/Janjati group and with lower education are likely to increase utilization of maternal health services.

Need factors for utilisation of institutional delivery services in Nepal: an analysis from Nepal Demographic and Health Survey, 2011

OBJECTIVE

This study aims to assess the role of need factors with respect to the utilisation of institutional delivery services in Nepal.

DESIGN

An analytic study was conducted using a subset of 4079 ever married women from the 2011 Nepal Demographic and Health Survey, which utilised two-stage cluster sampling. Logistic regression with complex sample analysis was performed to evaluate the effects of antenatal care visits and birth preparedness activities on facility delivery.

OUTCOME MEASURES

Facility delivery.

RESULTS

Overall facility delivery rate was low at 36.9% (95% CI 33.5% to 40.2%, SE 1.69). Only half (50.1%) of the women made four or more antenatal care visits while 62.9% (95% CI 59.9% to 65.8%, SE 1.51) did not indicate any of the four birth preparation activities. After adjusting for external, predisposing and enabling factors, women who made more than four antenatal care visits were five times more likely to deliver at a health facility when compared to those who paid no visit (adjusted OR 4.94, 95% CI 3.14 to 7.76). Similarly, the likelihood for facility delivery increased by 3.4-fold among women who prepared for at least two of the four activities compared to their counterparts who made no preparation (adjusted OR 3.41, 95% CI 2.01 to 5.58).

CONCLUSIONS

The perceived need, as expressed by the frequency of antenatal care visits and birth preparedness activities, plays an important role in institutional delivery service utilisation for Nepali women. These findings have implications for behavioural interventions to change their intention to deliver at a health facility.

Poor thermal care practices among home births in Nepal: further analysis of Nepal Demographic and Health Survey 2011

Introduction

Hypothermia is a major factor associated with neonatal mortality in low and middle income countries. Thermal care protection of newborn through a series of measures taken at birth and during the initial days of life is recommended to reduce the hypothermia and associated neonatal mortality. This study aimed to identify the prevalence of and the factors associated with receiving ‘optimum thermal care’ among home born newborns of Nepal.

Methods

Data from the Nepal Demographic and Health Surveys (NDHS) 2011 were used for this study. Women who reported a home birth for their most recent childbirth was included in the study. Factors associated with optimum thermal care were examined using Chi-square test followed by logistic regression.

Results

A total of 2464 newborns were included in the study. A total of 57.6 % were dried before the placenta was delivered; 60.3% were wrapped; 24.5% had not bathing during the first 24 hours, and 63.9% were breastfed within one hour of birth. Overall, only 248 (10.7%; 95% CI (8.8 %, 12.9%)) newborns received optimum thermal care. Newborns whose mothers had achieved higher education (OR 2.810; 95% CI (1.132, 6.976)), attended four or more antenatal care visits (OR 2.563; 95% CI (1.309, 5.017)), and those whose birth were attended by skilled attendants (OR 2.178; 95% CI (1.428, 3.323)) were likely to receive optimum thermal care.

Conclusion

The current study showed that only one in ten newborns in Nepal received optimum thermal care. Future newborn survival programs should focus on those mothers who are uneducated; who do not attend the recommended four or more attend antenatal care visits; and those who deliver without the assistance of skilled birth attendants to reduce the risk of neonatal hypothermia in Nepal.

Factors associated with the utilisation of postnatal care services among the mothers of Nepal: analysis of Nepal demographic and health survey 2011

Background

Postnatal care is essential to save the life of the mother and newborn. Knowledge on the determinants of postnatal care assists the policy makers to design, justify and implement appropriate interventions. The current study aimed to analyse the factors associated with utilisation of postnatal care services by mothers in Nepal based on the data from Nepal Demographic and Health Survey (NDHS) 2011.

Methods

This study utilised the data from NDHS 2011. The association between utilisation of at least one postnatal care visit (within 6 weeks of delivery) and immediate postnatal care (within 24 hours of delivery) with selected factors was examined by using Chi-square test (χ²), followed by multiple logistic regression.

Result

Of the 4079 mothers, 43.2% reported attending postnatal care within the first six weeks of birth, while 40.9% reported attending immediate postnatal care. Mothers who were from urban areas, from rich families, who were educated, whose partners were educated, who delivered in a health facility, who had attended a four or more antenatal visits, and whose delivery was attended by a skilled attendant were more likely to report attending at least one postnatal care visit. On the other hand, mothers who reported agricultural occupation, and whose partners performed agricultural occupation were less likely to have attended at least one postnatal care visit. Similarly, mothers who were from the urban areas, from rich families, who were educated, whose partners were educated, who had attended four or more antenatal visits, who delivered in a health facility and had delivered in the presence of a skilled birth attendant were more likely to report attending immediate postnatal care. Mothers who reported agricultural occupation, and whose partners performed agricultural occupation were less likely to attend immediate postnatal care.

Conclusion

The majority of postnatal mothers in Nepal did not seek postnatal care. Increasing utilisation of the recommended four or more antenatal visits, delivery at health facility and increasing awareness and access to services through community-based programs especially for the rural, poor, and less educated mothers may increase postnatal care attendance in Nepal.

Women's perception of quality of maternity services: a longitudinal survey in Nepal

Background

In the context of maternity service, the mother’s assessment of quality is central because emotional, cultural and respectful supports are vital during labour and the delivery process. This study compared client-perceived quality of maternity services between birth centres, public and private hospitals in a central hills district of Nepal.

Methods

A cohort of 701 pregnant women of 5 months or more gestational age were recruited and interviewed, followed by another interview within 45 days of delivery. Perception of quality was measured by a 20-item scale with three sub-scales: health facility, health care delivery, and interpersonal aspects. Perceived quality scores were analysed by ANOVA with post-hoc comparisons and multiple linear regression.

Results

Within the health facility sub-scale, birth centre was rated lowest on items ‘adequacy of medical equipment’, ‘health staff suited to women’s health’ and ‘adequacy of health staff’, whereas public hospital was rated the lowest with respect to ‘adequacy of room’, ‘adequacy of water’, ‘environment clean’, ‘privacy’ and ‘adequacy of information’. Mean scores of total quality and sub-scales health facility and health care delivery for women attending private hospital were higher (p < 0.001) than those using birth centre or public hospital. Mean score of the sub-scale interpersonal aspects for public hospital users was lower (p < 0.001) than those delivered at private hospital and birth centre. However, perception on interpersonal aspects by women using public hospital improved significantly after delivery (p < 0.001).

Conclusions

Overall, perception of quality differed significantly by types of health facility used for delivery. They rated lowest the supplies and equipment in birth centres and the amenities and interpersonal aspects in the public hospital. Accordingly, attention to these aspects is needed to improve the quality.

Factors associated with small size at birth in Nepal: further analysis of Nepal Demographic and Health Survey 2011

Background

The global Low Birth Weight (LBW) rate is reported to be 15.5% with more than 95% of these LBW infants being from developing countries. LBW is a major factor associated with neonatal deaths in developing countries. The determinants of low birth weight in Nepal have rarely been studied. This study aimed to identify the factors associated with small size at birth among under-five children.

Methods

Data from the 2011 Nepal Demographic and Health Survey (NDHS) were used. The association between small size at birth and explanatory variables were analysed using Chi-square tests (χ²) followed by logistic regression. Complex Sample Analysis was used to adjust for study design and sampling.

Results

A total of 5240 mother- singleton under five child pairs were included in the analysis, of which 936 (16.0%) children were reported as small size at birth. Of 1922 infants whose birth weight was recorded, 235 (11.5%) infants had low birth weight (<2500 grams). The mean birth weight was 3030 grams (standard deviation: 648.249 grams).

The mothers who had no antenatal visits were more likely (odds ratio (OR) 1.315; 95% confidence interval (CI) (1.042-1.661)) to have small size infants than those who had attended four or more antenatal visits. Mothers who lived in the Far-western development region were more likely to have (OR 1.698; 95% CI (1.228-2.349)) small size infants as compared to mothers from the Eastern development region. Female infants were more likely (OR 1.530; 95% CI (1.245-1.880)) to be at risk of being small than males.

Conclusion

One in every six infants was reported to be small at birth. Attendance of antenatal care programs appeared to have a significant impact on birth size. Adequate antenatal care visits combined with counselling and nutritional supplementation should be a focus to reduce adverse birth outcomes such as small size at birth, especially in the geographically and economically disadvantaged areas such as Far-western region of Nepal.

Obstetric complications and cesarean delivery in Nepal

OBJECTIVE

To determine the incidence of obstetric complications, the stillbirth rate, and the factors associated with cesarean delivery in central Nepal.

METHODS

A community-based prospective cohort study was undertaken in the Kaski district during 2011-2012. In total, 701 women who were at least 5 months pregnant were recruited and interviewed. Participants were followed-up and interviewed again within 45 days after delivery.

RESULTS

Of the 658 women who remained in the cohort after 43 were lost to follow-up, 12 (1.8%) had stillbirths. Cesareans accounted for 13.3% of the total deliveries. Age, urban residency, college-level education, and particularly presence of intrapartum symptoms significantly increased the likelihood of cesarean delivery. Prepartum, intrapartum, and postpartum symptoms were reported by 21.1%, 24.4%, and 10.2% of women, respectively. Common danger signs included prolonged labor, severe abdominal pain, swollen hand and body, and heavy bleeding.

CONCLUSION

Obstetric complications and stillbirth rates were relatively high in central Nepal. Cesarean delivery appeared to meet obstetric need and was performed with medical indication, particularly after the onset of labor.

Bypassing birth centres for childbirth: an analysis of data from a community-based prospective cohort study in Nepal

BACKGROUND

In Nepal, women residing in rural areas tend to bypass local birth centres and deliver at urban hospitals, despite the availability of obstetric care in these centres. This study investigated the incidence of bypassing, characteristics of bypassers and their reasons for bypassing the birth centres.

METHODS

A prospective cohort study was undertaken in the Kaski district of central Nepal. The 353 pregnant women of 5 months or more gestation recruited from the community had access to local birth centres. They were interviewed at baseline using a structured questionnaire, and were followed up within 45 days post-partum. Comparisons were made between women who delivered at birth centres and those who gave birth at hospital. Logistic regression analysis was performed to determine the factors affecting the risk of bypassing.

RESULTS

Of the final sample of 258 participants who delivered in a health facility, 181 women (70.2%) bypassed their nearest birth centres to deliver at hospitals. Bypassers tended to be wealthy and have intrapartum complications, but the likelihood of bypassing apparently decreased by higher parity and frequent (four or more) antenatal care visits. Availability of operating facility, adequacy of medical supplies and equipment and competent health staff at the facility were the main reasons for their bypassing decision.

CONCLUSIONS

The risk of bypassing for childbirth was high in central Nepal. Provision of quality and reliable emergency obstetric services together with well trained and competent staff at birth centres are recommended to reduce bypassing and pressure on the public hospital system.

Determinants of facility delivery after implementation of safer mother programme in Nepal: a prospective cohort study

BACKGROUND

There are several barriers for pregnant women to deliver in a health care facility. This prospective cohort study investigated factors affecting facility delivery and reasons for unplanned place of delivery after implementation of the safer mother programme in Nepal.

METHODS

Baseline interviews using a validated questionnaire were conducted on a sample of 700 pregnant women representative of the Kaski district in central Nepal. Follow-up interviews of the cohort were then conducted within 45 days postpartum. Stepwise logistic regression analysis was performed to determine factors associated with the facility delivery outcome.

RESULTS

Of the 644 pregnant women whose delivery location had been identified, 547 (85%) gave birth in a health care facility. Women were more likely to deliver in a health facility if they were educated especially with higher secondary or above qualification (adjusted odds ratio (OR) 12.39, 95% confidence interval (CI) 5.09 to 30.17), attended 4 or more antenatal care visits (OR 2.15, 95% CI 1.25 to 3.69), and lived within 30 minutes to the facility (OR 11.61, 95% CI 5.77 to 24.04). For the 97 women who delivered at home, 72 (74.2%) were unplanned, mainly due to quick precipitation of labour making it impossible to reach a health facility.

CONCLUSIONS

It appeared that facility delivery occurs more frequent among educated women and those who live nearby, even though maternity services are now freely available in Nepal. Because of the difficult terrain and transportation problem in rural areas, interventions that make maternity service physically accessible during antenatal period are needed to increase the utilisation of health facility for child birth.