Suresh Tamang

The Lancet Commission on Global Surgery (LCoGS) recommends using specialist surgical workforce density as one of 6 core indicators for monitoring universal access to safe, affordable surgical and anaesthesia care. Using Nepal as a case study, we explored the capacity of a generalist workforce (led by a family physician or MD general practitioner and non-physician anaesthetist) to enable effective surgical delivery through task-shifting. Using a multiple-methods approach, we retrospectively mapped essential surgical care and the enabling environment for surgery in 39 hospitals in 25 remote districts in Nepal and compared it with LCoGS indicators. All 25 districts performed surgery, 21 performed Caesarean section (CS), and 5 met at least 50% of district CS needs. Generalist surgical teams performed CS, the essential major operation at the district level, and very few laparotomies, but no operative orthopaedics. The density of specialist Surgeon/Anaesthesiologist/Obstetrician (SAO) was...

Background: Mid-level health workers are deployed in a large proportion with the expectation of similar patient outcomes as with physicians. Mid-level practitioners are Health Assistants and Auxiliary Health Workers who provide clinical care at remote locations. National Health Training Center has been providing 60 days in-service Mid-level Practicum training since 2009 AD for the mid-level practitioners with the aim to enhance quality of patient care in Nepal. Methods: An observational study conducted using retrospective data from onsite follow-up assessment of 180 Mid-level Practitioner from 18 districts of Nepal between July 2015 to June 2019. The retention of competency onsite follow-up was calculated as percentage of assessment score at the end of Mid-level Practicum training. Percentage retention of competency and association of retention with factors were analyzed using independent t-test. Results: Majority of participants were male (85.6%), and working in a Health Post (84.4%). Average clinical competency retention in each domain at their work place was 68.79% in knowledge, 73.80% in patient encounter skill, 82.84% in clinical decision-making skill and 87.58% in clinical procedure skill. Higher age groups, longer years of experience and participants from Terai region found to be associated with lower retention of knowledge. A better enabling environment and higher case load retained higher patient encounter skill. Conclusions: The competency retention among Mid-level Practicum trained mid-level health workers was found to be higher. Factors found associated with competency retention were age, geographic region, years of experience, case load and enabling environment.

BACKGROUND Nepal has made significant strides in maternal and neonatal mortality over the last three decades. However, poor quality of care can threaten the gains, as maternal and newborn services are particularly sensitive to quality of care. Our study aimed to understand current gaps in the process and the outcome dimensions of the quality of antenatal care (ANC), particularly at the sub-national level. We assessed these dimensions of the quality of ANC in 17 primary, public hospitals across Nepal. We also assessed the variation in the antenatal care process across the patients' socio-economic gradient. METHODS We used a convergent mixed methods approach, whereby we triangulated qualitative and quantitative data. In the quantitative component, we observed interactions between providers (17 hospitals from all seven provinces) and 198 women seeking ANC, and recorded the tasks the providers performed, using the Service Provision Assessments protocol available from the Demographic...

Background: Medical equipment plays a crucial role in the provision of quality healthcare services, despite this more than 50% of equipment in developing countries are non-functioning due to a lack of appropriate human resources to maintain. To address this problem some government hospitals of Nepal have deployed a mid-level technical cadre called 'Biomedical Equipment Technician' (BMET). This study aims to evaluate the effectiveness of deploying a BMET on the functionality of medical equipment in government hospitals of rural Nepal.Methods: We used a mixed-methods approach with a comparative research design. A comprehensive range of 2189 pieces of medical equipment at 22 hospitals with and without BMET were observed to assess their functional status. Medical equipment were stratified into 6 categories based on department and T-tests were conducted. We collected qualitative data from 9 BMETs, 22 medical superintendents, and 22 health staff using semi-structured interviews an...

Community-based participatory research provides communities and researchers with opportunities to develop interventions that are effective as well as acceptable and culturally competent. The present project responds to the voices of the North Carolina American Indian (AI) community and the desire for their youth to recognize tobacco addiction and commercial cigarette smoking as debilitating to their health and future. Seven community-based participatory principles led to the AI adaptation of the Not On Tobacco teen-smoking-cessation program and fostered sound research and meaningful results among an historically exploited population. Success was attributed to values-driven, community-based principles that (a) assured recognition of a community-driven need, (b) built on strengths of the tribes, (c) nurtured partnerships in all project phases, (d) integrated the community's cultural knowledge, (e) produced mutually beneficial tools/products, (f) built capacity through co-learning ...

Significance: The Pacific Center of Excellence in the Elimination of Disparities (Pacific CEED) is governed by the Cancer Council of the Pacific Islands (CCPI), a regional coalition representing health sector leadership from the US Affiliated Pacific Islands (USAPI). CCPI provides regional planning, policy guidance and program coordination for the 10 USAPI Comprehensive Cancer Control Coalitions, the Regional Comprehensive Cancer Control Program (RCCP) and the Pacific Regional Central Cancer Registry (PRCCR). Objective: Pacific CEED is funded by REACH US to support the regional coalition and evaluate cancer prevention and control activities and outcomes in the Pacific region and the USAPI. Methods: The CCPI is conducting a self-assessment to evaluate satisfaction with coalition functioning, perception of sustainability and regional leadership for cancer prevention and control, and the role of regionalism for integrating all chronic disease prevention and control in the Pacific. The ...

Community mobilisation through participatory women's groups might improve birth outcomes in poor rural communities. We therefore assessed this approach in a largely tribal and rural population in three districts in eastern India. From 36 clusters in Jharkhand and Orissa, with an estimated population of 228 186, we assigned 18 clusters to intervention or control using stratified randomisation. Women were eligible to participate if they were aged 15-49 years, residing in the project area, and had given birth during the study. In intervention clusters, a facilitator convened 13 groups every month to support participatory action and learning for women, and facilitated the development and implementation of strategies to address maternal and newborn health problems. The primary outcomes were reductions in neonatal mortality rate (NMR) and maternal depression scores. Analysis was by intention to treat. This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN21817853. After baseline surveillance of 4692 births, we monitored outcomes for 19 030 births during 3 years (2005-08). NMRs per 1000 were 55.6, 37.1, and 36.3 during the first, second, and third years, respectively, in intervention clusters, and 53.4, 59.6, and 64.3, respectively, in control clusters. NMR was 32% lower in intervention clusters adjusted for clustering, stratification, and baseline differences (odds ratio 0.68, 95% CI 0.59-0.78) during the 3 years, and 45% lower in years 2 and 3 (0.55, 0.46-0.66). Although we did not note a significant effect on maternal depression overall, reduction in moderate depression was 57% in year 3 (0.43, 0.23-0.80). This intervention could be used with or as a potential alternative to health-worker-led interventions, and presents new opportunities for policy makers to improve maternal and newborn health outcomes in poor populations. Health Foundation, UK Department for International Development, Wellcome Trust, and the Big Lottery Fund (UK).

Inability to reduce neonatal and maternal mortality in poor countries is sometimes blamed on a lack of contextual knowledge about care practices and care-seeking behavior. There is a lack of knowledge about how to translate formative research into effective interventions to improve maternal and newborn health. We describe the findings of formative research and how they were used to inform the development of such an intervention in rural Nepal. Formative research was carried out in four parts. Part 1 involved familiarization with the study area and literature review, and parts 2, 3 and 4 involved community mapping, audit of health services, and qualitative and quantitative studies of perinatal care behaviors. Participatory approaches have been successful at reducing neonatal mortality and may be suitable in our context. Community mapping and profiling helped to describe the community context, and we found that community-based organizations often sought to involve the Female Community Health Volunteer in community mobilization. She was not routinely conducting monthly meetings and found them difficult to sustain without support and supervision. In health facilities, most primary care staff were in post, but doctors and staff nurses were absent from referral centers. Mortality estimates reflected under-reporting of deaths and hygiene and infection control strategies had low coverage. The majority of women give birth at home with their mother-in-law, friends and neighbors. Care during perinatal illness was usually sought from traditional healers. Cultural issues of shyness, fear and normalcy restricted women's behavior during pregnancy, birth and the postpartum period, and decisions about her health were usually made after communications with the family and community. The formative research indicated the type of intervention that could be successful. It should be community-based and should not be exclusively for pregnant women. It should address negotiations within families, and should tailor information to the needs of local groups and particular stakeholders such as mothers-in-law and traditional healers. The intervention should not only accept cultural constructs but also be a forum in which to discuss ideas of pollution, shame and seclusion. We used these guidelines to develop a participatory, community-based women's group intervention, facilitated through a community action cycle. The success of our intervention may be because of its acceptability at the community level and its sensitivity to the needs and beliefs of families and communities.

Objective:
This study was aimed at exploring the cultural safety from the perspective of Native Hawaiians and describes its relevance in the context of research participation. Three community co-facilitators were recruited and trained in research ethics and qualitative methodology. Focus group and interview guides were used to ensure consistency. Qualitative data were collected from adult residents of purposefully selected three Hawaiian Homesteads.

Methods:
A total of 27 participants were recruited from communities- Wai‘anae, Papakolea, and Waimanalo on the island of O‘ahu. Five focus groups patterned on the local tradition of ‘talking story’; and subsequently, five semi-structured in-depth interviews with key informants were conducted. All participants completed a social-demographic survey. A content analysis using a priori coding was performed. Data were audio-recorded and transcribed. Following preparatory transcript review, the investigator developed the codebook and code the data. Codes and coded output were compared to identify primary themes and notable agreement or contrasts. Data were also feedback to community co-facilitators to increase validity.

Results:
The result explored the perception of cultural safety and Hawaiian values that promote their participation in research. Detailed findings were derived from 67 preliminary codes to 6 major themes and 28 sub-themes. Major themes included -upstream factors influence perceptions of cultural safety, attention to ethical values of Hawaiian culture and homestead community promotes cultural safety; culturally safe research reflects “culture” as multi-dimensional; community empowerment intricately linked to cultural safety, cultural safety is relationally-based; and safety is holistic with systemic and community factors influencing personal perceptions.

Conclusion:
Results pointed that Hawaiian homestead residents are skeptical about traditional research and distrusted outside researchers. Cultural safety is a relevant framework for promoting active engagement in research that honors the culture and helps Hawaiian people achieve health equity. In the lived experience of Hawaiian Homestead residents on O‘ahu, cultural safety in community-based health research refers to attitudes and behaviors that demonstrate an honoring of traditional Native Hawaiian values and ways of relating, as well as an acknowledging the contemporary concerns of those living in Hawaiian homestead communities. Health researchers practicing cultural safety demonstrate respect for diverse ways of knowing and being, are inclusive of all people, and understand that health may be viewed as holistic, with attention to environmental, physical, relational, and spiritual wellness. To promote cultural safety in homestead communities, non-native, non-resident researchers need to monitor their actions such that power and decision-making are equitably shared. When defined in this way, cultural safety promotes learning mutuality and open communication.

Application:
Such studies promoting health, culture and civic engagement are critical. Results can inform health policy makers and researchers how to design and implement culturally safe research among Native people. Major implications to pacific health equity include culturally relevant policy, program, research and practices, cultural safety training that can be useful for building capacity of the health professionals, culturally safe organizational and program development.