Research Papers

In our work, we recognize and appreciate the importance of disseminating and sharing knowledge.

**Mental Health

*Reproductive, Maternal, & Child Health (RMNCH)

Community Health

Collaborative care model for depression in rural Nepal: a mixed-methods implementation research study

Abstract:

Introduction: Despite carrying a disproportionately high burden of depression, patients in low-income countries lack access to effective care. The collaborative care model (CoCM) has robust evidence for clinical effectiveness in improving mental health outcomes. However, evidence from real-world implementation of CoCM is necessary to inform its expansion in low-resource settings.

Conclusion: Using the COM-B framework, we successfully adapted and implemented CoCM in rural Nepal, and found that it enhanced providers’ positive perceptions of and engagement in delivering mental healthcare. We observed clinical improvement of depression comparable to controlled trials in high-resource settings. We recommend using implementation research to adapt and evaluate CoCM in other resource-constrained settings to help expand access to high-quality mental healthcare.

Rimal P, Choudhury N Agrawal P, et al. Collaborative care model for depression in rural Nepal: a mixed-methods implementation research study. BMJ Open 2021;11:e048481.doi:10.1136/bmjopen-2020-048481

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Cross-cultural adaptation of motivational interviewing for use in rural Nepal

Abstract:

Background: Motivational Interviewing (MI) has a robust evidence base in facilitating behavior change for several health conditions. MI focuses on the individual and assumes patient autonomy. Cross-cultural adaptation can face several challenges in settings where individualism and autonomy may not be as prominent. Sociocultural factors such as gender, class, caste hinder individual decision-making. Key informant perspectives are an essential aspect of cross-cultural adaptation of new interventions. Here, we share our experience of translating and adapting MI concepts to the local language and culture in rural Nepal, where families and communities play a central role in influencing a person’s behaviors.

Conclusions: MI carries several cultural assumptions, particularly around individual freedom and autonomy. MI adaptation thus faces challenges in cultures where such assumptions may not hold. However, cross-cultural adaptation with key informant perspectives can lead to creative strategies that recognize both the patient’s autonomy and their role as a member of a complex social fabric to facilitate behavior change.

Rimal, P., Khadka, S., Bogati, B. et al. Cross-cultural adaptation of motivational interviewing for use in rural Nepal. BMC Psychol9,52 (2021). https://doi.org/10.1186/s40359-021-00557-y

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Treatment recommendations made by a consultant psychiatrist to improve the quality of care in a collaborative mental health intervention in rural Nepal

Abstract:

Background: The Collaborative Care Model (CoCM) for mental healthcare, where a consulting psychiatrist supports primary care and behavioral health workers, has the potential to address the large unmet burden of mental illness worldwide. A core component of this model is that the psychiatrist reviews treatment plans for a panel of patients and provides specific clinical recommendations to improve the quality of care. Very few studies have reported data on such recommendations. This study reviews and classifies the recommendations made by consulting psychiatrists in a rural primary care clinic in Nepal.

Conclusions: In this CoCM study, the majority of treatment plans did not require significant change. The recommendations highlight the challenge that non-specialists face in making an accurate mental health diagnosis, the relative neglect of non-pharmacological interventions, and the risk of inappropriate medications. These results can inform interventions to better support non-specialists in rural areas.

Rimal P, Maru D, Chwastiak L, Agrawal P, Rao D, Swar S, Citrin D, Acharya B. Treatment recommendations made by a consultant psychiatrist to improve the quality of care in a collaborative mental health intervention in rural Nepal. BMC Psychiatry. 2020 Feb 5;20(1):46. doi: 10.1186/s12888-020-2464-1. PMID: 32024490; PMCID: PMC7003398.

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Delivering Collaborative Care in Rural Settings: Integrating Remote Teleconsultation and Local Supervision in Rural Nepal

Abstract:

The collaborative care model can deliver high-quality mental health care. In rural regions, clinical supervision is conducted remotely rather than in person. The authors implemented a remote teleconsultation model in rural Nepal, where the consulting psychiatrist is over 30 hours away. This column describes strategies for several challenges: poor mental health competencies and high turnover among primary care providers; need for urgent consultations; psychiatrist discomfort with lack of direct patient contact; unreliable electricity, technological tools, documentation, and delivery of treatment recommendations; on-site clinicians’ low motivation to accept psychiatrist recommendations; and mismatch between the psychiatrist’s recommendations and the site’s capacity to implement them.

Swar, S., Rimal, P., Gauchan, B., Maru, D., Yang, Y., & Acharya, B. (2019). Delivering Collaborative Care in Rural Settings: Integrating Remote Teleconsultation and Local Supervision in Rural Nepal. Psychiatric services (Washington, D.C.), 70(1), 78–81. https://doi.org/10.1176/appi.ps.201800273

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A Type II hybrid effectiveness-implementation study of an integrated CHW intervention to address maternal healthcare in rural Nepal

Skilled care during pregnancy, childbirth, and postpartum is essential to prevent adverse maternal health outcomes, yet utilization of care remains low in many resource-limited countries, including Nepal. Community health workers (CHWs) can mitigate health system challenges and geographical barriers to achieving universal health coverage. Gaps remain, however, in understanding whether evidence-based interventions delivered by CHWs, closely aligned with WHO recommendations, are effective in Nepal’s context. We conducted a type II hybrid effectiveness-implementation, mixed-methods study in two rural districts in Nepal to evaluate the effectiveness and the implementation of an evidence-based integrated maternal and child health intervention delivered by CHWs, using a mobile application. The intervention was implemented stepwise over four years (2014–2018), with 65 CHWs enrolling 30,785 families. We performed a mixed-effects Poisson regression to assess institutional birth rate (IBR) pre-and post-intervention. We used the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework to evaluate the implementation during and after the study completion. There was an average 30% increase in IBR post-intervention, adjusting for confounding variables (p<0.0001). Study enrollment showed 35% of families identified as dalit, janjati, or other castes. About 78–89% of postpartum women received at least one CHW-counseled home visit within 60 days of childbirth. Ten (53% of planned) municipalities adopted the intervention during the study period. Implementation fidelity, measured by median counseled home visits, improved with intervention time. The intervention was institutionalized beyond the study period and expanded to four additional hubs, albeit with adjustments in management and supervision. Mechanisms of intervention impact include increased knowledge, timely referrals, and longitudinal CHW interaction. Full-time, supervised, and trained CHWs delivering evidence-based integrated care appears to be effective in improving maternal healthcare in rural Nepal. This study contributes to the growing body of evidence on the role of community health workers in achieving universal health coverage.

Tiwari A, Thapa A, Choudhury N, Khatri R, Sapkota S, Wu W-J, et al. (2023) A Type II hybrid effectiveness-implementation study of an integrated CHW intervention to address maternal healthcare in rural Nepal. PLOS Glob Public Health 3(1): e0001512. https://doi.org/10.1371/journal.pgph.0001512

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Building a Global Evidence Base to Guide Policy and Implementation for Group Antenatal Care in Low‐ and Middle‐Income Countries

Abstract:

Evidence from high-income countries suggests that group antenatal care, an alternative service delivery model, may be an effective strategy for improving both the provision and experience of care. Until recently, published research about group antenatal care did not represent findings from low- and middle-income countries, which have health priorities, system challenges, and opportunities that are different than those in high-income countries. Because high-quality evidence is limited, the World Health Organization recommends group antenatal care be implemented only in the context of rigorous research. In 2016 the Global Group Antenatal Care Collaborative was formed as a platform for group antenatal care researchers working in low- and middle-income countries to share experiences and shape future research to accelerate the development of a robust global evidence base reflecting implementation and outcomes specific to low- and middle-income countries. This article presents a brief history of the Collaborative’s work to date, proposes a common definition and key principles for group antenatal care, and recommends an evaluation and reporting framework for group antenatal care research.

Grenier, L., Lori, J.R., Darney, B.G., Noguchi, L.M., Maru, S., Klima, C., Lundeen, T., Walker, D., Patil, C.L., Suhowatsky, S. and Musange, S. (2020), Building a Global Evidence Base to Guide Policy and Implementation for Group Antenatal Care in Low- and Middle-Income Countries: Key Principles and Research Framework Recommendations from the Global Group Antenatal Care Collaborative. Journal of Midwifery & Women’s Health, 65: 694-699. https://doi.org/10.1111/jmwh.13143

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Community-based postpartum contraceptive counselling in rural Nepal: a mixed-methods evaluation

Abstract:

Unmet need for postpartum contraception in rural Nepal remains high and expanding access to sexual and reproductive healthcare is essential to achieving universal healthcare. We evaluated the impact of an integrated intervention that employed community health workers aided by mobile technology to deliver patient-centred, home-based antenatal and postnatal counselling on postpartum modern contraceptive use. This was a pre-post-intervention study in seven village wards in a single municipality in rural Nepal. The primary outcome was modern contraceptive use among recently postpartum women. We performed a multivariable logistic regression to examine contraceptive use among postpartum women pre- and one-year post-intervention. We conducted qualitative interviews to explore the implementation process. There were 445 postpartum women in the pre-intervention group and 508 in the post-intervention group. Modern contraceptive use increased from 29% pre-intervention to 46% post-intervention (p < 0.0001). Adjusting for age, caste, and household expenditure, time since delivery and sex of child in the index pregnancy, postpartum women one-year post-intervention had twice the odds (OR 2.3; CI 1.7, 3.1; p < 0.0001) of using a modern contraceptive method as compared to pre-intervention. Factors at the individual, family, and systems level influenced women’s contraceptive decisions. The intervention contributed to increasing contraceptive use through knowledge transfer, demand generation, referrals to healthcare facilities, and follow-up. A community-based, patient-centred contraceptive counselling intervention supported by mobile technology and integrated into longitudinal care delivered by community health workers appears to be an effective strategy for improving uptake of modern contraception among postpartum women in rural Nepal.

Wan-Ju Wu, Aparna Tiwari, Nandini Choudhury, Indira Basnett, Rita
Bhatt, David Citrin, Scott Halliday, Lal Kunwar, Duncan Maru, Isha Nirola, Sachit Pandey, Hari Jung Rayamazi, Sabitri Sapkota, Sita Saud, Aradhana Thapa, Alisa Goldberg & Sheela Maru (2020) Community-based postpartum contraceptive counselling in rural Nepal: a
mixed-methods evaluation, Sexual and Reproductive Health Matters, 28:2, 1765646, DOI: 10.1080/26410397.2020.1765646

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Measuring fidelity, feasibility, costs: an implementation evaluation of a cluster-controlled trial of group antenatal care in rural Nepal

Abstract:

Background: Access to high-quality antenatal care services has been shown to be beneficial for maternal and child health. In 2016, the WHO published evidence-based recommendations for antenatal care that aim to improve utilization, quality of care, and the patient experience. Prior research in Nepal has shown that a lack of social support, birth planning, and resources are barriers to accessing services in rural communities. The success of CenteringPregnancy and participatory action women’s groups suggests that group care models may both improve access to care and the quality of care delivered through women’s empowerment and the creation of social networks. We present a group antenatal care model in rural Nepal, designed and implemented by the healthcare delivery organization Nyaya Health Nepal, as well as an assessment of implementation outcomes.

Conclusion: Group antenatal care provided in collaboration with local government clinics has the potential to provide accessible and high quality antenatal care to women in rural Nepal. The intervention is a feasible and affordable alternative to individual antenatal care. Our experience has shown that adaptation from prior models was important for the program to be successful in the local context within the national healthcare system.

Harsha Bangura, A., Nirola, I., Thapa, P. et al. Measuring fidelity, feasibility, costs: an implementation evaluation of a cluster-controlled trial of group antenatal care in rural Nepal. Reprod Health 17, 5 (2020). https://doi.org/10.1186/s12978-019-0840-4

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The power of peers: an effectiveness evaluation of a cluster-controlled trial of group antenatal care in rural Nepal

Abstract:

Background: Reducing the maternal mortality ratio to less than 70 per 100,000 live births globally is one of the Sustainable Development Goals. Approximately 830 women die from pregnancy- or childbirth-related complications every day. Almost 99% of these deaths occur in developing countries. Increasing antenatal care quality and completion, and institutional delivery are key strategies to reduce maternal mortality, however there are many implementation challenges in rural and resource-limited settings. In Nepal, 43% of deliveries do not take place in an institution and 31% of women have insufficient antenatal care. Context-specific and evidence-based strategies are needed to improve antenatal care completion and institutional birth. We present an assessment of effectiveness outcomes for an adaptation of a group antenatal care model delivered by community health workers and midwives in close collaboration with government staff in rural Nepal.

Conclusion: While there was no significant change in institutional birth and antenatal care completion at the population level between groups, there was an increase of these outcomes in both groups. This may be secondary to the primary importance of community health worker involvement in both of these groups. Knowledge of key pregnancy danger signs was significantly improved in the home visit plus group antenatal care cohort compared with the home visit care only group. This initial study of Nyaya Health Nepal’s adapted group care model demonstrates the potential for impacting women’s antenatal care experience and should be studied over a longer period as an intervention embedded within a community health worker program.

Thapa, P., Bangura, A.H., Nirola, I. et al. The power of peers: an effectiveness evaluation of a cluster-controlled trial of group antenatal care in rural Nepal. Reprod Health 16, 150 (2019). https://doi.org/10.1186/s12978-019-0820-8

 

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An integrated community health worker intervention in rural Nepal: a type 2 hybrid effectiveness-implementation study protocol

Abstract:

Background: Community health workers are an important cadre in low-income countries where human resources for health and health care infrastructure are limited. As local women, they are uniquely positioned to understand and successfully navigate barriers to health care access. Recent case studies of large community health worker programs have highlighted the importance of training, both initial and ongoing, and accountability through structured management, salaries, and ongoing monitoring and evaluation. A gap in the evidence regarding whether such community health worker systems can change health outcomes, as well as be sustainably adopted at scale, remains. In this study, we plan to evaluate a community health worker system delivering an evidence-based integrated reproductive, maternal, newborn, and child health intervention as it is scaled up in rural Nepal.

Discussion: This is the first hybrid effectiveness-implementation study of an integrated reproductive, maternal, newborn, and child health intervention in rural Nepal that we are aware of. As Nepal takes steps towards achieving the Sustainable Development Goals, the data from this three-year study will be useful in the detailed planning of a professionalized community health worker cadre delivering evidence-based reproductive, maternal, newborn, and child health interventions to the country’s rural population.

Maru, S., Nirola, I., Thapa, A., Thapa, P., Kunwar, L., Wu, W. J., Halliday, S., Citrin, D., Schwarz, R., Basnett, I., Kc, N., Karki, K., Chaudhari, P., & Maru, D. (2018). An integrated community health worker intervention in rural Nepal: a type 2 hybrid effectiveness-implementation study protocol. Implementation science : IS, 13(1), 53. https://doi.org/10.1186/s13012-018-0741-x

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Costing Analysis of a Pilot Community Health Worker Program in Rural Nepal

Abstract:

Community health workers (CHWs) are essential to primary health care systems and are a cost-effective strategy to achieve the Sustainable Development Goals (SDGs). Nepal is strongly committed to universal health coverage and the SDGs. In 2017, the Nepal Ministry of Health and Population partnered with the nongovernmental organization Nyaya Health Nepal to pilot a program aligned with the 2018 World Health Organization guidelines for CHWs. The program includes CHWs who: (1) receive regular financial compensation; (2) meet a minimum education level; (3) are well supervised; (4) are continuously trained; (5) are integrated into local primary health care systems; (6) use mobile health tools; (7) have consistent supply chain; (8) live in the communities they serve; and (9) provide service without point-of-care user fees. The pilot model has previously demonstrated improved institutional birth rate, antenatal care completion, and postpartum contraception utilization. Here, we performed a retrospective costing analysis from July 16, 2017, to July 15, 2018, in a catchment area population of 60,000. The average per capita annual cost is US$3.05 (range: US$1.94 to US$4.70 across 24 villages) of which 74% is personnel cost. Service delivery and administrative costs and per beneficiary costs for all services are also described. To address the current discourse among Nepali policymakers at the local and federal levels, we also present 3 alternative implementation scenarios that policymakers may consider. Given the Government of Nepal’s commitment to increase health care spending (US$51.00 per capita) to 7.0% of the 2030 gross domestic product, paired with recent health care systems decentralization leading to expanded fiscal space in municipalities, this CHW program provides a feasible opportunity to make progress toward achieving universal health coverage and the health-related SDGs. This costing analysis offers insights and practical considerations for policymakers and locally elected officials for deploying a CHW cadre as a mechanism to achieve the SDG targets.

Nepal, P., Schwarz, R., Citrin, D., Thapa, A., Acharya, B., Acharya, Y., Aryal, A., Baum, A., Bhandari, V., Bhatt, L., Bhattarai, D., Choudhury, N., Dangal, B., Dhimal, M., Dhungana, S. K., Gauchan, B., Halliday, S., Kalaunee, S. P., Kunwar, L. B., Maru, D., … Maru, S. (2020). Costing Analysis of a Pilot Community Health Worker Program in Rural Nepal. Global health, science and practice, 8(2), 239–255. https://doi.org/10.9745/GHSP-D-19-00393

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