Pathways to mental health care in Nepal: a 14-center nationwide study

BACKGROUND

Pathways to care studies are feasible and tested means of finding the actual routes taken by patients before reaching proper care. In view of the predominance of nonprofessional service providers and the lack of previous large studies on pathways in Nepal, this multicenter study is needed. The aim of the study was to trace the various pathways and carers involved in mental health care; assess clinical variables such as the duration of untreated illness, clinical presentation and treatment; and compare geographically and culturally diverse landscapes.

METHODS

This was a cross-sectional, convenience sampling study performed at 14 centers where new cases were being taken. The World Health Organization Study of the Pathways-to-Care Schedule was applied. The Nepali version of the encounter form was used. The data were collected between 17 September and 16 October 2020 and were analyzed using the Statistical Package for the Social Sciences (SPSS). Additionally, perspectives from local investigators were collected and discussed.

RESULTS

Most of the first carers were native/religious faith healers (28.2%), followed by psychiatrists (26%). The median duration for the first psychiatric consultation was 3 weeks. The duration of untreated illness was 30.72 ± 80.34 (median: 4) weeks, and the time taken for this journey was 94.99 ± 274.58 (median: 30) min. The longest delay from the onset of illness to psychiatric care was for epilepsy {90.0 ± 199.0 (median: 25.5)} weeks, followed by neurotic illness {22.89 ± 73.45 (median: 2)} and psychotic illness {10.54 ± 18.28 (median: 2)} weeks. Overall, most patients with severe mental illnesses (SMIs) had their first contact with faithhealers (49%), then met with medical doctors (13%) or psychiatrists (28%). Marked differences in clinical presentation surfaced when hilly centers were compared with the Terai belt.

CONCLUSIONS

Faith healers, general practitioners and hospital doctors are major carers, and the means of educating them for proper referral can be considered. The investigators see several hindrances and opportunities in the studied pathways. The employment of more mental health professionals and better mental health advocacy, public awareness programs and school education are suggested strategies to improve proper mental health care.

Menopausal Health Status of Nepalese Women

INTRODUCTION

Menopause is an unavoidable and sometimes problematic condition in which women may suffer from a number of health problems. Knowledge of the major symptoms associated with menopause helps reduce the burden and stress associated with the condition. In this context, a study was conducted to establish baseline data regarding menopausal health problems among Nepalese women.

METHODS

A descriptive cross-sectional study was conducted among 2000 women aged over 40 years to identify their knowledge, attitude and practice related to menopausal health problems. Data was collected by interviewing the women and doing physical examination. Analysis was done using descriptive statistics and SPSS software was used for data analysis.

RESULTS

A cohort of 2073 women (ages 40-60 years) participated in the research, among them 2000 yielded complete response. The study revealed that 820 (41%) women had reached menopause. The average age of menopause was 48.7 years. Majority of the women 1183 (59.2%) in the study did not know about menopausal health problems. Abnormal bleeding 353 (17.65%), sweating 315 (15.75%), hot flushes 299 (14.95%), joint/muscle pain 285 (14.25%) were the most common menopausal symptoms known by the women. Joint pain 736 (36.8%), hot flushes 584 (29.2%), irregular bleeding 582 (29.1%) were the most common experienced symptoms of menopause and only 586 (29.3%) consulted the health workers to alleviate menopausal symptoms. Moreover, most of the women 926 (46.3%) accepted menopause as a part of life.

CONCLUSIONS

The research has tried to establish the baseline of menopausal health problems in the Nepalese women. The average age of menopause was 48.7 years. Majority did not know about menopausal health problems. Further researches with nationally representative sample are recommended to further explore the menopausal health problems of Nepalese women.

Effectiveness of Intrathecal Morphine for Analgesia following Elective Caesarean Section

Aims: This study evaluates the effectiveness of usage of 0.2 mg intrathecal morphine as post-operative analgesia and its effect on activity of mother after elective cesarean section. Methods: This hospital based prospective, randomized, double-blinded and placebo controlled study was carried out at Nagarik Community Teaching Hospital, Bhaktapur between 2012 January to 2014 November after the approval was taken from the hospital authority and the written informed consent from the participating patients. Fifty women of ASA I or II physical status undergoing cesarean section under sub-arachnoid block was randomized into two groups – P group (placebo group, n = 25) and M group (Treatment group, n = 25). P Group received hyperbaric bupivacaine 2.3ml, 0.5% bupivacaine (11.5 mg) and M Group received morphine 0.2 ml (0.2 mg) plus bupivacaine 2.3ml, 0.5% (11.5 mg) intrathecally. All subjects received 8 mg ondansetron intravenously 30 minutes before surgery to prevent possible drug-induced pruritus and post-operative nausea and vomiting. 1000 mg rectal acetaminophen suppository was given at the end of the surgery. Pain, nausea and pruritus during the first 24 hours using visual analog scale were recorded by a trained nurse or attending doctor who was not involved in the study. Results: Duration of complete analgesia and the time to request for additional analgesics was longer in M Group than in P Group. Similarly, the active movement is earlier in M Group than in P Group. There were no significant differences in adverse effects between the groups. Conclusions: Addition of morphine 0.2 mg to heavy bupivacaine intrathecally reduced post-operative pain and analgesic requirements without any significant difference in adverse effects. 

Near-miss Obstetric Events in a Tertiary Care Teaching Hospital in Nepal: An Audit

Aims: This study aims to determine the frequency of near-miss obstetric events and analyze its nature such as reasons for near-miss, organ dysfunction associated and critical management required among pregnant women managed over a 3-year period in a Tertiary Care Teaching Hospital in Nepal. Methods: This hospital based prospective, descriptive study was done from August 2011 to February 2015. Case eligibility was defined by WHO Near-Miss Guidelines. Medical records of the patients and the interview with the patient, accompanying family members and health workers from referral centres were used to generate the data which were filled in the pre-designed questionnaire. The data generated and analyzed included age and gestation weeks, parity, mode of intervention, associated organ dysfunctions, reasons for near-miss and critical intervention accompanied to manage the near-miss cases. Results were presented in mean ± SD and percentages, wherever applicable. Results: There were 4617 deliveries with 28 near-miss cases. The major factors contributing near-miss events were obstetric haemorrhage followed by hypertensive disorder. Three fourth (n=21) of cases required blood transfusion and almost all cases (n=26) required ICU management. Coagulation disorder was observed in majority of cases (n=23) followed by cardiovascular, respiratory and uterine atony. Conclusions: In this study, maternal near-miss event was mainly attributable to obstetric haemorrhage followed by hypertension and sepsis. Major organ-system disorders observed were coagulation disorder, cardiovascular, respiratory and uterine disorders. Almost all the cases were managed in ICU and majority of them required blood transfusion. 

Condom Tamponade in the Management of Massive Obstetric Hemorrhage: An Experience at a Teaching Hospital

Aims:This study evaluates the effectiveness of condom tamponade in the management of massive obstetric hemorrhage. Methods: This hospital based prospective descriptive study was done in the department of obstetrics and gynecology of KIST Medical College Teaching Hospital, Lalitpur, Nepal from January 2013 to December 2013. During the study period, patients with obstetric hemorrhage(>500ml blood loss) were identified and the details of the patient and their treatment were acquired. Data analysis was done by descriptive statistics using mean, median and frequency cross tabulations. The decision for condom tamponade was made when active continuous hemorrhage persisted despite of initial conservative measures. Results: Among 39 patients of obstetric hemorrhage out of 1522 deliveries, eight were managed by condom tamponade which includes 6 postpartum hemorrhage cases, 1 incomplete abortion case and 1 antepartum case managed prophylactically in anticipation of postpartum hemorrhage. Conclusions: Despite of the small study sample, the study concludes the use of condom tamponade as an effective means of controlling massive obstetrical hemorrhage due to uterine atony (both in post partum and post abortion cases). It is safe, easily available, inexpensive, minimally invasive, does not require anesthesia, easy to use and can be performed by any level of health personnel with some training. DOI: http://dx.doi.org/10.3126/njog.v9i1.11187 NJOG 2014 Jan-Jun; 2(1):41-47