Low-income and middle-income countries are struggling with a growing epidemic of non-communicable diseases. To achieve the Sustainable Development Goals, their healthcare systems need to be strengthened and redesigned. The Starfield 4Cs of primary care—first-contact access, care coordination, comprehensiveness and continuity—offer practical, high-quality design options for non-communicable disease care in low-income and middle-income countries. We describe an integrated non-communicable disease intervention in rural Nepal using the 4C principles. We present 18 months of retrospective assessment of implementation for patients with type II diabetes, hypertension and chronic obstructive pulmonary disease. We assessed feasibility using facility and community follow-up as proxy measures, and assessed effectiveness using singular ‘at-goal’ metrics for each condition. The median follow-up for diabetes, hypertension and chronic obstructive pulmonary disease was 6, 6 and 7 facility visits, and 10, 10 and 11 community visits, respectively (0.9 monthly patient touch-points). Loss-to-follow-up rates were 16%, 19% and 22%, respectively. The median time between visits was approximately 2 months for facility visits and 1 month for community visits. ‘At-goal’ status for patients with chronic obstructive pulmonary disease improved from baseline to endline (p=0.01), but not for diabetes or hypertension. This is the first integrated non-communicable disease intervention, based on the 4C principles, in Nepal. Our experience demonstrates high rates of facility and community follow-up, with comparatively low lost-to-follow-up rates. The mixed effectiveness results suggest that while this intervention may be valuable, it may not be sufficient to impact outcomes. To achieve the Sustainable Development Goals, further implementation research is urgently needed to determine how to optimise non-communicable disease interventions.

Background Chhaupadi is a deeply rooted tradition and a centuries-old harmful religio-cultural practice. Chhaupadi is common in some parts of Karnali and Sudurpaschim Provinces of western Nepal, where women and girls are considered impure, unclean, and untouchable in the menstrual period or immediately following childbirth. In Chhaupadi practice, women and girls are isolated from a range of daily household chores, social events and forbidden from touching other people and objects. Chhaupadi tradition banishes women and girls into menstruation huts’, or Chhau huts or livestock sheds to live and sleep. These practices are guided by existing harmful beliefs and practices in western Nepal, resulting in poor menstrual hygiene and poor physical and mental health outcomes. This study examined the magnitude of Chhaupadi practice and reviewed the existing policies for Chhaupadi eradication in Nepal. Methods We used both quantitative survey and qualitative content analysis of the available policies. First, a quantitative cross-sectional survey assessed the prevalence of Chhaupadi among 221 adolescent girls in Mangalsen Municipality of Achham district. Second, the contents of prevailing policies on Chhaupadi eradication were analysed qualitatively using the policy cube framework. Results The current survey revealed that most adolescent girls (84%) practised Chhaupadi in their most recent menstruation. The Chhaupadi practice was high if the girls were aged 15–17 years, born to an illiterate mother, and belonged to a nuclear family. Out of the girls practising Chhaupadi, most (86%) reported social and household activities restrictions. The policy content analysis of identified higher-level policy documents (constitution, acts, and regulations) have provisioned financial resources, ensured independent monitoring mechanisms, and had judiciary remedial measures. However, middle (policies and plans) and lower-level (directives) documents lacked adequate budgetary commitment and independent monitoring mechanisms. Conclusion Chhaupadi remains prevalent in western Nepal and has several impacts to the health of adolescent girls. Existing policy mechanisms lack multilevel (individual, family, community, subnational and national) interventions, including financial and monitoring systems for Chhaupadi eradication. Eradicating Chhaupadi practice requires a robust multilevel implementation mechanism at the national and sub-national levels, including adequate financing and accountable systems up to the community level.

BackgroundChronic obstructive pulmonary disease accounts for a significant portion of the world’s morbidity and mortality, and disproportionately affects low/middle-income countries. Chronic obstructive pulmonary disease management in low-resource settings is suboptimal with diagnostics, medications and high-quality, evidence-based care largely unavailable or unaffordable for most people. In early 2016, we aimed to improve the quality of chronic obstructive pulmonary disease management at Bayalpata Hospital in rural Achham, Nepal. Given that quality improvement infrastructure is limited in our setting, we also aimed to model the use of an electronic health record system for quality improvement, and to build local quality improvement capacity.DesignUsing international chronic obstructive pulmonary disease guidelines, the quality improvement team designed a locally adapted chronic obstructive pulmonary disease protocol which was subsequently converted into an electronic health record template. Over several Plan-Do-Study-Act cycles, the team rolled out a multifaceted intervention including educational sessions, reminders, as well as audits and feedback.ResultsThe rate of oral corticosteroid prescriptions for acute exacerbations of chronic obstructive pulmonary disease increased from 14% at baseline to >60% by month 7, with the mean monthly rate maintained above this level for the remainder of the initiative. The process measure of chronic obstructive pulmonary disease template completion rate increased from 44% at baseline to >60% by month 2 and remained between 50% and 70% for the remainder of the initiative.ConclusionThis case study demonstrates the feasibility of robust quality improvement programmes in rural settings and the essential role of capacity building in ensuring sustainability. It also highlights how individual quality improvement initiatives can catalyse systems-level improvements, which in turn create a stronger foundation for continuous quality improvement and healthcare system strengthening.

Introduction: The government of Nepal has implemented Safe Motherhood programs throughout the country to decrease the perinatal morbidity and mortality. Safe motherhood service includes normal vaginal delivery, Caesarian Section (CS) and perinatal management.  CS rates are a major public concern.  Currently 18.6% of all births occur by CS, ranging from 6 to 27.2% in different parts of the world. Methods:  Retrospectively collected data from Electronic Health Record (EHR) of deliveries from May 1,2016 to October 31,2020 were used. We have analyzed demographic profiles like age, geographical location. Similarly, gestational age, caste, gravida, parity, various indications of CS, maternal, fetal and neonatal outcomes were also recorded. Results: A total of 4168 deliveries were conducted over four and half years with 3694 (88.6%) vaginal deliveries and 474 (11.4%) CS. There was constant maintenance of CS rate from 5-15% over four and half years, 11% in 2016 to 12% in 2019.  Fetal distress was the commonest indication of overall CS followed by Non-progress of labor. The women from Bhimeshwor municipality were 156 (32.9%). The most CS was done in the age group of 20-24 years, which was 192 (40.5%). Neonatal Death was 3/1000 births. There was one maternal mortality due to PPH and late presenation. Conclusion: Different from the other evidences, we found that our CS rate was within the limit of WHO’s recommendation for lower resource setting. Following strict guidelines and with dedicated care, it’s possible to maintain recommended CS rate with less neonatal and maternal morbidities even in lower resource setting where there are no NICU, ICU facilities and Electronic Fetal Monitoring (EFM).

Background: Chhaupadi practice, which is characterized by banishment of women during menstruation from their usual residence due to supposed impurity. The Chhaupadi custom is also known as ‘chhue’or ‘bahirhunu’ in Dadeldhura,Baitadi and Darchula,as Chhaupadi in Acham, and as ‘chaukulla’or ‘chhaukudi’in Bajhang district.The aim of the study was to find out Socio demographic factors associated with Chhaupadi practices among adolescence girls of Mangalsen Municipality, Acham Nepal. Methods: The community based descriptive cross-sectional study using face to face interview was carried out in Mangalsen Municipality, Acham Nepal. 221 adolescence girls (10-19) years were selected by simple random sampling. The total duration of data collection was one month from 2074/01/07 to 2074/02/08. Data were collected using self-designed semi structured questionnaire. Collected data were manually checked then entered into IBM SPSS version 20.0 for Window. We used Pearsons chi-square test is used to investigate the effect of Socio-demographic variable on Chhaupadi practices during last menstruation period of adolescent. Results: Among 221 adolescent girls, there were 84.2 %(186) of the respondents were kept in Chhaupadi or slept at Chhau goth during entire last time menstrual period, Socio-demographic characteristics such as age (χ2=8.997, 0.001), mother educational level(χ2= 6.80, p=0.033), occupational status of respondent’s mother (χ2=4.20, p=0.04) ,type of family(χ2=5.20, p=0.022) were found to be significantly associated with Chhaupadi practice . Conclusions: Majority of the adolescent girls are still practicing Chhaupadi during menstrual period. Chhaupadi practice continues to exits in community because of illetracy,traditional belief system.To abolish Chhaupadi practice awareness and education at community level is required.