Bipin Adhikari

Community engagement and population coverage in mass anti-malarial administrations: a systematic literature review

BackgroundMass anti-malarial administration has been proposed as a key component of the malaria elimination strategy in South East Asia. The success of this approach depends on the local malaria epidemiology, nature of the anti-malarial regimen and population coverage. Community engagement is used to promote population coverage but little research has systematically analysed its impact. This systematic review examines population coverage and community engagement in programmes of mass anti-malarial drug administration.MethodsThis review builds on a previous review that identified 3049 articles describing mass anti-malarial administrations published between 1913 and 2011. Further search and application of a set of criteria conducted in the current review resulted in 51 articles that were retained for analysis. These 51 papers described the population coverage and/or community engagement in mass anti-malarial administrations. Population coverage was quantitatively assessed and a thematic analysis was conducted on the community engagement activities.ResultsThe studies were conducted in 26 countries: in diverse healthcare and social contexts where various anti-malarial regimens under varied study designs were administered. Twenty-eight articles reported only population coverage; 12 described only community engagement activities; and 11 community engagement and population coverage. Average population coverage was 83% but methods of calculating coverage were frequently unclear or inconsistent. Community engagement activities included providing health education and incentives, using community structures (e.g. existing hierarchies or health infrastructure), mobilizing human resources, and collaborating with government at some level (e.g. ministries of health). Community engagement was often a process involving various activities throughout the duration of the intervention.ConclusionThe mean population coverage was over 80% but incomplete reporting of calculation methods limits conclusions and comparisons between studies. Various community engagement activities and approaches were described, but many articles contained limited or no details. Other factors relevant to population coverage, such as the social, cultural and study context were scarcely reported. Further research is needed to understand the factors that influence population coverage and adherence in mass anti-malarial administrations and the role community engagement activities and approaches play in satisfactory participation.

Rebuilding Earthquake Struck Nepal through Community Engagement

Nepal underwent two major earthquakes during 2015 which claimed 9,000 deaths, left more than 23,000 injured, displaced about 2 million people and destroyed about 1,000 health facilities. Emerging health issues and disease outbreaks soon after the earthquakes were major priorities. However, preventive measures such as health education, health promotion and trainings embedded in community engagement remained largely unimplemented. Establishing community preparedness by delivering knowledge about the disasters, preparing contingency plans and conducting disaster drills can be promising in Nepal where geographical inaccessibility invariably impedes the on time management during disasters. The steps that could be taken in Nepal without additional resources include identifying community leaders and volunteers who could participate in health promotion initiatives, training of thus identified community volunteers, formation of community task force, devolvement of responsibilities with continual support (trainings and resources) and supervision of the community task force.

Factors affecting perceived stigma in leprosy affected persons in western Nepal.

Background There are various factors which construct the perception of stigma in both leprosy affected persons and unaffected persons. The main purpose of this study was to determine the level of perceived stigma and the risk factors contributing to it among leprosy affected person attending the Green Pastures Hospital, Pokhara municipality of western Nepal. Methods A cross-sectional study was conducted among 135 people affected by leprosy at Green Pastures Hospital and Rehabilitation Centre. Persons above the age of 18 were interviewed using a set of questionnaire form and Explanatory Model Interview Catalogue (EMIC). In addition, two sets of focused group discussions each containing 10 participants from the ward were conducted with the objectives of answering the frequently affected EMIC items. Results Among 135 leprosy affected persons, the median score of perceived stigma was 10 while it ranged from 0–34. Higher perceived stigma score was found in illiterate persons (p = 0.008), participants whose incomes were self-described as inadequate (p = 0.014) and who had changed their occupation due to leprosy (p = 0.018). Patients who lacked information on leprosy (p = 0.025), knowledge about the causes (p = 0.02) and transmission of leprosy (p = 0.046) and those who had perception that leprosy is a severe disease (p<0.001) and is difficult to treat (p<0.001) had higher perceived stigma score. Participants with disfigurement or deformities (p = 0.014), ulcers (p = 0.022) and odorous ulcers (p = 0.043) had higher perceived stigma score. Conclusion The factors associated with higher stigma were illiteracy, perceived economical inadequacy, change of occupation due to leprosy, lack of knowledge about leprosy, perception of leprosy as a severe disease and difficult to treat. Similarly, visible deformities and ulcers were associated with higher stigma. There is an urgent need of stigma reduction strategies focused on health education and health awareness programs in addition to the necessary rehabilitation support.

Elements of effective community engagement: lessons from a targeted malaria elimination study in Lao PDR (Laos)

ABSTRACT Background: Mass drug (antimalarial) administration (MDA) is currently under study in Southeast Asia as part of a package of interventions referred to as targeted malaria elimination (TME). This intervention relies on effective community engagement that promotes uptake and adherence in target communities (above 80%). Objective: Based on the experienced of designing and implementing the community engagement for TME in Laos, in this article we aim to present the elements of effective community engagement for mass antimalarial administration. Methods: The design and implementation of community engagement, which took place from September 2015 to August 2016 was recorded as field notes, meeting minutes and photographs. These data underwent qualitative content analysis. Results: The community engagement strategy that accompanied TME in Laos was successful in terms of contributing to high levels of participation in mass anti-malarial administration (above 85%). Based on the experience of designing and implementing the community engagement, five key elements were identified: (1) stakeholder and authority engagement, which proceeded from national level, to regional/district and local level; (2) local human resources, particularly the recruitment of local volunteers who were integral to the design and implementation of activities in the study villages; (3) formative research, to rapidly gain insight into the local social and economic context; (4) responsiveness whereby the approach was adapted according to the needs of the community and their responses to the various study components; and (5) sharing control/leadership with the community in terms of decisions on the organization of TME activities. Conclusions: The community engagement that accompanied TME in Laos had to deal with challenges of implementing a complex study in remote and linguistically isolated villages. Despite these challenges, the study recorded high population coverage. Lessons learnt from this experience are useful for studies and intervention programs in diverse contexts.

Earthquakes, Fuel Crisis, Power Outages, and Health Care in Nepal: Implications for the Future

Earthquakes are a major natural calamity with pervasive effects on human life and nature. Similar effects are mimicked by man-made disasters such as fuel crises and power outages in developing countries. Natural and man-made disasters can cause intangible human suffering and often leave scars of lifelong psychosocial damage. Lessons from these disasters are frequently not implemented. The main objective of this study was to review the effects of the 2015 earthquakes, fuel crisis, and power outages on the health services of Nepal and formulate recommendations for the future. The impacts of earthquakes on health can be divided into immediate, intermediate, and long-term effects. Power outages and fuel crises have health hazards at all stages. It is imperative to understand the temporal effects of earthquakes, because the major needs soon after the earthquake (emergency care) are vastly different from long-term needs such as rehabilitation and psychosocial support. In Nepal, the inadequate and nearly nonexistent specialized health care at the peripheral level claimed many lives during the earthquakes and left many people disproportionately injured. Preemptive strategies such as mobile critical care units at primary health centers, intensive care training for health workers, and alternative plans for emergency care must be prioritized. Similarly, infrastructural damage led to poor sanitation, and alternative plans for temporary settlements (water supply, food, settlements logistics, space for temporary settlements) must be in place where the danger of disease outbreak is imminent. While much of these strategies are implementable and are often set as priorities, long-term effects of earthquakes such as physical and psychosocial supports are often overlooked. The burden of psychosocial stresses, including depression and physical disabilities, needs to be prioritized by facilitating human resources for mental health care and rehabilitation. In addition, inclusion of mental health and rehabilitation facilities in government health care services of Nepal needs to be prioritized. Similarly, power outages and fuel crises affect health care disproportionately. In the current context where permanent solutions may not be possible, mitigating health hazards, especially cold chain maintenance for essential medicines and continuation of life-saving procedures, are mandatory and policies to regulate all health care services must be undertaken. (Disaster Med Public Health Preparedness. 2017;11:625-632).

Global leadership against antimicrobial resistance ought to include developing countries.

www.thelancet.com/infection Vol 16 July 2016 775 the need to improve the overall health of its people to reduce antibiotic use, through strategies such as mass vaccination and health education. It is high time for policy makers and stakeholders to act and make a global plan to control antimicrobial resistance, which should include developing countries. The present situation is a threat to the entire world as a resistance pattern developing in a remote location soon spreads across borders. To achieve global leadership in antimicrobial resistance, funding for research and collaboration with existing antimicrobial resistance initiatives in LMICs are mandatory steps.

Why do people participate in mass anti-malarial administration? Findings from a qualitative study in Nong District, Savannakhet Province, Lao PDR (Laos)

BackgroundAs a part of targeted malaria elimination (TME) in the Greater Mekong Sub-region (GMS), mass drug administration (MDA) with anti-malarials was conducted in four villages in Nong District, Savannakhet Province, Lao PDR (Laos). A high proportion of the target population participated in the MDA, with over 87% agreeing to take the anti-malarial. Drawing on qualitative data collected alongside the MDA, this article explores the factors that led to this high population coverage.MethodsQualitative data collection methods included observations, which were recorded in field notes, focus group discussions (FGDs), and semi-structured interviews (SSIs). Data were collected on local context, MDA-related knowledge, attitudes and perceptions. FGDs and SSIs were audio-recorded, transcribed and translated to English. All transcriptions and field notes underwent qualitative content analysis using QSR NVivo.ResultsRespondents recognized malaria as a health concern and described the need for a malaria control program. The risk of malaria including asymptomatic infection was explained in terms of participants’ work in forest and fields, and poor hygiene. During the MDA rounds, there was an improvement in knowledge on the concept of asymptomatic malaria, the rationale of MDA and the blood test. In all four villages, poverty affected access to healthcare and the provision of free care by TME was highly appreciated. TME was jointly undertaken by research staff and local volunteers. Authorities were involved in all TME activities. Lao Theung communities were cohesive and community members tended to follow each other’s behaviour closely including participation in MDA. Factors such as understanding the concept and rationale of the study, free health care, collaboration with the village volunteers, support from authorities and cohesive communities contributed in building trust and high population coverage in MDA.ConclusionFuture malaria control programmes can become successful in achieving the high coverage in MDAs drawing from the success of TME in Laos. A high population coverage in TME was a combination of various factors that included the community engagement to promote the concept and rationale of MDA for asymptomatic malaria in addition to their baseline understanding of malaria as a health concern, provision of free primary health care, partnering of the research with local volunteers and authorities, building social relationship with community members and the cohesive nature of the communities boosted the trust and participation in MDA.

Hidden Costs of Hospital Based Delivery from Two Tertiary Hospitals in Western Nepal.

Introduction Hospital based delivery has been an expensive experience for poor households because of hidden costs which are usually unaccounted in hospital costs. The main aim of this study was to estimate the hidden costs of hospital based delivery and determine the factors associated with the hidden costs. Methods A hospital based cross-sectional study was conducted among 384 post-partum mothers with their husbands/house heads during the discharge time in Manipal Teaching Hospital and Western Regional Hospital, Pokhara, Nepal. A face to face interview with each respondent was conducted using a structured questionnaire. Hidden costs were calculated based on the price rate of the market during the time of the study. Results The total hidden costs for normal delivery and C-section delivery were 243.4 USD (US Dollar) and 321.6 USD respectively. Of the total maternity care expenditures; higher mean expenditures were found for food & drinking (53.07%), clothes (9.8%) and transport (7.3%). For postpartum women with their husband or house head, the total mean opportunity cost of “days of work loss” were 84.1 USD and 81.9 USD for normal delivery and C-section respectively. Factors such as literate mother (p = 0.007), employed house head (p = 0.011), monthly family income more than 25,000 NRs (Nepalese Rupees) (p = 0.014), private hospital as a place of delivery (p = 0.0001), C-section as a mode of delivery (p = 0.0001), longer duration (>5days) of stay in hospital (p = 0.0001), longer distance (>15km) from house to hospital (p = 0.0001) and longer travel time (>240 minutes) from house to hospital (p = 0.007) showed a significant association with the higher hidden costs (>25000 NRs). Conclusion Experiences of hidden costs on hospital based delivery and opportunity costs of days of work loss were found high. Several socio-demographic factors, delivery related factors (place and mode of delivery, length of stay, distance from hospital and travel time) were associated with hidden costs. Hidden costs can be a critical factor for many poor and remote households who attend the hospital for delivery. Current remuneration (10–15 USD for normal delivery, 30 USD for complicated delivery and 70 USD for caesarean section delivery) for maternity incentive needs to account the hidden costs by increasing it to 250 USD for normal delivery and 350 USD for C-section. Decentralization of the obstetric care to remote and under-privileged population might reduce the economic burden of pregnant women and can facilitate their attendance at the health care centers.

Organ and human trafficking in Nepal.

I was baff led to read, in Sophie Cousins’ World Report (Feb 27, p 833), the stories of people in Nepal who were made vulnerable because of the earthquake and poverty to sell their organs, particularly their kidneys. A substantial proportion of kidney donors (315 [70%] of 452) were unrelated to the recipient, and 94% of kidney transplantations were done in India, which has become an international hub for kidney trade. Only few scientifi c publications have so far reported this illegal human organ traffi cking, particularly because of the intricacies of tracking these cases. Additionally, frequent news and media reports on such trafficking, particularly between Nepal and India, have failed to ask the Nepalese Government to take action against it. Similarly, human traffi cking has been reported in Nepal. A systematic review in 2012 showed a shocking scenario of human traffi cking in Nepal that has been well rooted over the past decades. Apparently, action against these illegal human and organ traffi cking seems trivial. The solution to this problem is defi nitely not straightforward. Among many factors, impunity and poverty are the main contributors to human and organ traffi cking. Although legal loopholes seem to be the facilitating factor for organ and human traffi cking, a substantial number of people from remote and impoverished communities are often the victims and are mostly allured by fi nancial incentives. However, it is arguable if poverty alone could have been the only factor provoking people to sell their organs. More research on these issues is required. Although poverty reduction through sustainable development programmes could reverse these vulnerabilities in the long run, strong legal action s from both countries are required immediately. I declare no competing interests.

Ceftazidime-avibactam in ceftazidime-resistant infections

One of the important causes of the development of resistance to β-lactam drugs is their overuse. β-lactamase inhibitors have been combined with many β-lactam drugs to resume their efficacy since the emergence of multidrugresistant organisms. Yahuda Carmeli and colleagues recommended the combination of ceftazidimeavibactam as a potential alternative to carbapenems for the treatment of multidrug-resistant Gram-negative bacteria. However, for bacteria producing metallo-β-lactamase, carbapenems are still the last-resort drug. Discovery of new inhibitors that are active against diff erent types of β-lactamases, including metallo-βlactamases, is still a great challenge. High-income countries should limit the use of these last-resort drugs for the future. In the study by Carmeli and colleagues, ceftazidime-avibactam and carbapenems were both in effective in 9% of participants. Patients included in their study were those with complicated cases of urinary tract infection and intra-abdominal infection, which were resistant to ceftazidime. Additionally, the complete antibiotic profile of the organisms was not reported in the study. If these cases were resistant to β-lactam drugs only, non-β-lactam antibiotics and some other β-lactam– β-lactamase inhibitor combinations might have potential. Additionally, ceftazidime-avibactam and carbapenems are very expen sive drugs. On average, the cost of carbapenem treatment is US