A National Equity Initiative to Address Noncommunicable Diseases and Injuries: Findings and Recommendation from the Nepal NCDI Poverty Commission

We aimed to assess the burden of NCDIs across socioeconomic groups, their economic impact, existing health service readiness and availability, current policy frameworks and national investment, and planned programmatic initiatives in Nepal through a comprehensive literature review. Secondary data from Global Burden of Disease estimates from GBD 2015 and National Living Standard Survey 2011 were used to estimate the burden of NCDI and present the relationship of NCDI burden with socioeconomic status. The Commission used these data to define priority NCDI conditions and recommend potential cost-effective, poverty-averting, and equity-promoting health system interventions. NCDIs disproportionately affect the health and well-being of poorer populations in Nepal and cause significant impoverishment. The Commission found a high diversity of NCDIs in Nepal, with approximately 60% of the morbidity and mortality caused by NCDIs without primary quantified behavioral or metabolic risk factors, and nearly half of all NCDI-related DALYs occurring in Nepalese younger than 40 years. The Commission prioritized an expanded set of twenty-five NCDI conditions and recommended introduction or scale-up of twenty-three evidence-based health sector interventions. Implementation of these interventions would avert an estimated 9680 premature deaths per annum by 2030 and would cost approximately $8.76 per capita. The Commission modelled potential financing mechanisms, including increased excise taxation on tobacco, alcohol, and sugar-sweetened beverages, which would provide significant revenue for NCDI-related expenditures. Overall, the Commission's conclusions are expected to be a valuable contribution to equitable NCDI planning in Nepal and similar resource-constrained settings globally.

Evaluation of Knowledge, Attitude, Practice and Hospital Experience Regarding COVID-19 among Post-partum Mothers at a Tertiary Care Center: A Cross-sectional Study

Background Pregnant and breastfeeding women are more susceptible to viral infection and in the year 2020 they have to face the COVID-19 pandemic. Since, no successful treatment and vaccine has been developed so far, efforts to enhance the knowledge, attitudes, and practice of the public, especially the high-risk groups like pregnancy and postpartum period are crucial to manage COVID-19 pandemic. Objective To analyze the knowledge, attitude, practice and hospital experience regarding COVID-19 among post-partum mothers at a tertiary care center of Nepal Method The data collection was based on direct interview after receiving written consent from the research participants, using a semi-structured questionnaire. The questionnaire consisted of 4 major domains- knowledge (8 questions), attitude (6 questions), practice (5 questions) and experience (5 questions). Standard descriptive statistics were used for the data, mean and standard deviation for continuous variables whereas frequencies and percentages for categorical variables. Result A total of 203 post-partum women participated in the study. Almost all the participants had heard about COVID-19 (96.6%). A majority of them were aware about how COVID-19 gets transmitted and its preventive measures. Most of the participants (88.2%) knew that COVID-19 has effects on pregnancy. Almost all of participants (97%) wore mask during hospital stay. All of the women washed their hands with soap water or alcohol based sanitizer. A majority of the mothers (79.3%) wore mask while breastfeeding their baby. Conclusion The post-partum mothers have good knowledge, attitude, practice and experiences regarding the COVID-19 pandemic.

Access to Drugs and Out of Pocket Expenditure in Primary Health Facilities

BACKGROUND

The Government of Nepal promulgated health as a human right via Interim constitution and implemented Free Health Service Program in 2008 as a commitment to universalize basic health care services. So, the aim of this study was to understand reported access to medicine and health care services received by outpatients in public primary facilities.

METHODS

The study followed cross sectional study design. Two hundred and thirty-four For data 234 out patients were interviewed on the day of the field visit in March and October 2014 across 28 primary health facilities of seven purposively selected districts representing three ecological belts and five development regions of the country.

RESULTS

Our study revealed that the average number of medicines prescribed per patient was 2.65 per case in primary public health facilities, of which 91.2% were dispensed. Around 86.6% dispensed medicines were appropriately labeled and 84% of outpatients had proper knowledge of dosage and timing of medicine use. Around 55.6% of outpatients purchased some or all prescribed medicines from nearby private facilities which were not available in public facilities. Around 40% of them travelled more than half an hour to reach the facility.

CONCLUSIONS

The gap in medicines prescribed and dispensed, Out of Pocket expenditure coupled with opportunity cost of travelling, appear as hurdles in access to basic health care services. So increasing free medicines list in public primary facilities with all round the year availability might answer major part of the problem.

Electroconvulsive Therapy in First Episode Schizophrenia – Experiences from Nepal

Introduction: Little is known regarding efficacy and effectiveness of electroconvulsive therapy (ECT) in young, first episode schizophrenia. Present study was done to evaluate short term and long term efficacy and effectiveness of ECT in patients with first episode schizophrenia. Materials and methods: This is a prospective study where forty five patients were evaluated at medical college in Nepal.12 patients received ECT as compared to 33 non-receivers. Patients were evaluated at admission, at discharge, 1st month, 6th month and at 12th month after discharge from the hospital. Evaluations were done using Brief Psychiatric Research Scale (BPRS), Global Assessment of Function (GAF). Results: The mean duration of hospitalization was25.42 days among ECT receivers as compared to 34.75 days among non-receivers. Patients who received ECT showed significant improvement in BPRS at discharge (p=0.001), 1st month (p=0.001, 6th month (p=0.001) and at 12th month (p=0.001). Similarly there was significant improvement in GAF at discharge (p=0.001), 6th month (p=0.053) and at 12th month (p=0.003). Conclusion: Though used infrequently, ECT in young first episode schizophrenia give significant overall improvement and wellbeing with very minimal side-effects. ECT also shortens duration of hospitalization with early discharge and improvement in psychosocial wellbeing. DOI: http://dx.doi.org/10.3126/jpan.v3i1.11350 J Psychiatrists’ Association of Nepal Vol .3, No.1, 2014: 35-40

Kala azar in Nepal: estimating the effects of socioeconomic factors on disease incidence

BACKGROUND

The incidence of Kala Azar (KA), a neglected tropical infectious disease, describes the pattern of disease, but is not principally concerned with explaining its causes. The transmission of the infectious diseases is determined by the complex interactions between environmental and socioeconomic factors. Environmental factors are predicted to have a significant impact on disease transmission; moreover, socioeconomic factors modify the magnitude and direction of these impacts. A number of studies have examined possible determinants of KA in endemic countries of the world; however, most of them appear to have used either qualitative approaches or subjective speculations. None of the studies indicates in quantitative terms the potential effects of poverty-alleviation programs on the incidence of KA.

MATERIALS AND METHODS

Data related to characteristics of community were collected from primary as well as secondary sources. Underlying socioeconomic determinants on KA incidence were estimated by exploiting a linear multiple regression.

RESULTS

The multivariate analysis has confirmed that burden of KA is disproportionately borne by vulnerable and marginalized groups. KA is most entrenched in the poorest communities. Elimination of KA is directly related to poverty alleviation because if the poverty incidence reduces by 10 percent, it will lead to reduction of KA incidence by 16 percent. The strategy for disease control or elimination should shift from traditional disease-centered approaches to a holistic approach that can break the links between poverty and KA.

CONCLUSIONS

To achieve the target of elimination of KA in Nepal by 2015, the poverty incidence should be reduced from existing poverty 27 percent to at least 16 percent in KA endemic areas. The association between poverty and KA reflects causality running in both directions: poverty multiplies KA incidence and KA pushes poor into marginal poor or further poverty.

Experiencing stigma: Nepalese perspectives

BACKGROUND

Experiencing stigma by patients with mental illness in their day to day lives has substantial importance in treatment, compliance and quality of life. There is dearth of information and researches in experiences/ perceptions and coping of stigma in Nepal.

AIMS

The objective of this study was to find out experiences/ perceptions and coping of stigma and stigmatizations among patients with mental illness.

MATERIALS AND METHODS

This is a retrospective, cross sectional study of patients admitted in psychiatry ward. Patients were assessed using self-report questionnaire which focused on beliefs about discrimination against mental illness, rejection experiences, and ways of coping with stigma. Patient's socio demographic profiles were also assessed.

RESULTS

Fifty three patients completed questionnaire concerning various constructs of stigma. There were 29 male patients and 24 female patients. Majority (N=45; 84.9%) were of Hindu religion but there were mixed numbers regarding caste. Most of the patients were aware of the stigma associated with mental illness. There were experiences of rejection by family members and colleagues (N=23; 43.4%) and health care professional (N=16; 30.2%). There were strong perceptions of stigmatization felt by patients in different social circumstances. Though maintaining secrecy and avoidance/withdrawal of stigma provoking scenario were not experienced much, there was a strong sense of advocacy whenever there was any negative view of mental illness. Some of the questionnaire items in "perception", "rejection" and "coping" showed statistical significance (p=0.001).

CONCLUSION

People with mental illness experience stigma during their course of illness and treatment and it is an important determinant for the relapse of symptoms and non-compliance to treatment. Despite experiencing stigma, patients were generally treated fairly by other people. Patients develop various mechanisms to cope with stigma, mostly secrecy and avoidance. Advocacy and anti-stigma campaign along with positive attitudes of health professionals play important role in decreasing stigmatizing experiences in patients.

Mental Health Services in New Nepal – Observations, Objections and Outlooks for the Future

It has been over a decade since the government of Nepal adopted the National Mental Health Policy (NMHP) in 1997. This article analyses the current provision of fragmented mental health services in Nepal through case scenarios from Jumla innorthwest and Janakpur in southeast Nepal, criticises the proposed mental health Act, discusses the reasons why the NMHP has not been implemented and suggests future models of delivering mental health services in the wider community. Absence of a mental health section within the department of health, insuffi cient budget, chronic shortage of trained manpower, and unplanned growth of private medical institutions appear to be the issues deserving urgent attention. Setting up specialist psychiatric facilities in all developmental regions or future states, developing community mental health programmes and integration of mental health into general health care are the ways forward to meet the needs and expectations of the new federal Nepal. Key Words: community mental health, national mental health policy, Nepal, psychiatry

Mental health services in New Nepal--observations, objections and outlooks for the future

It has been over a decade since the government of Nepal adopted the National Mental Health Policy (NMHP) in 1997. This article analyses the current provision of fragmented mental health services in Nepal through case scenarios from Jumla in northwest and Janakpur in southeast Nepal, criticises the proposed mental health Act, discusses the reasons why the NMHP has not been implemented and suggests future models of delivering mental health services in the wider community. Absence of a mental health section within the department of health, insufficient budget, chronic shortage of trained manpower, and unplanned growth of private medical institutions appear to be the issues deserving urgent attention. Setting up specialist psychiatric facilities in all developmental regions or future states, developing community mental health programmes and integration of mental health into general health care are the ways forward to meet the needs and expectations of the new federal Nepal.

An open, randomized, comparative study of efficacy and safety of risperidone and haloperidol in schizophrenia

OBJECTIVES

In the last decade there have been numerous randomized controlled trials comparing the efficacy and safety of second generation antipsychotics and conventional antipsychotics in the treatment of schizophrenia, but most of them have been conducted in the western population. This study compared the efficacy and safety of risperidone versus haloperidol in the Nepalese context, in order to add on to the very few literatures available on this topic in the South East Asia region and compare them.

METHODS

Patients with the diagnosis of schizophrenia were randomly assigned to receive risperidone 4-6 milligrams (mg) per day and haloperidol 10-20 mg per day, and were followed up for 6 weeks. Assessment were done on the day of the diagnostic interview and days 7, 14, 28 and 42 (end point). During the assessment periods Positive and Negative Syndrome Scale (PANSS) was administered to monitor the progress in psychopathology and Udvalg for Kliniske Undersogelser (UKU) side effects rating scale was applied to rate the treatment emergent adverse effects.

RESULTS

Both risperidone and haloperidol were associated with substantial baseline- to- endpoint reduction in symptom severity. After one week of treatment, the improvement in schizophrenia with risperidone was significantly better than haloperidol in terms of PANSS- total Score (-45.4 versus -29.5), negative subscale score (-14.3 versus -6.68) and general psychopathology subscale score (-20.9 versus -13.7). At the end point of the study, the benefit was maintained in total score (-52.1 versus -43.1), though the negative subscale score still showed tendency for greater improvement in psychopathology with risperidone. The side effects profile did not show significant differences except in extrapyramidal symptoms. Thirty-eight percent of risperidone treated patients had to resort to anti-parkinsonian treatment compared to 78% in haloperidol treatment group.

CONCLUSION

Similar to the studies in the western countries, Asia and Indian subcontinent, both risperidone and haloperidol were effective in the reduction of psychopathological symptoms in this group of Nepalese population with the diagnosis of schizophrenia. However, risperidone was quicker and better then haloperidol and risperidone had a better safety profile. This is important, because extrapyramidal side effects of neuroleptics are responsible for non-compliance and increased cost in terms of us of anti-parkinsonian medication.