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Background It is unknown whether Female Community Health Volunteers’ (FCHVs) can counsel for hyperlipidemia in rural Nepal. Methods Using the Health Belief Model, we evaluated FCHV’s knowledge, self-efficacy, and barriers to counsel for hyperlipidemia in two phases eleven months apart among 28 FCHVs from rural mid-Western Nepal. In each phase, we conducted four Focused Group Discussions (FGDs), hyperlipidemia-related training and two similar surveys before and after the training. We used inductive and deductive codes for thematic analysis and descriptive statistics for quantitative analysis. We integrated the results for complementarity and convergence using concurrent embedded design (Qual + quan). Results FCHVs’ mean age was 48 years and 21 out of 28 had worked for > 10 years. We found four themes in FGDs. In Phase 1, despite having interest, FCHVs had limited knowledge and confidence in counseling for hyperlipidemia. However, with sufficient training, they believed they could counsel. In Phase 2, FCHVs conveyed improved knowledge and self-efficacy. They expressed community might be concerned about their expertise, which improved in Phase 2. Quantitatively, FCHVs’ knowledge improved immediately after the initial training, which was stable in Phase 2. Inadequate training was identified less as a barrier in Phase 2, but inadequate time and incentive were identified more often, and community’s perception of FCHVs’ skills remained unchanged. Conclusion FCHVs want to provide hyperlipidemia counseling. Despite our trainings and FCHV’s perceived self-efficacy, knowledge gap persisted. FCHVs’ workload, inadequate incentives and knowledge were important barriers. Balanced workload, regular trainings and adequate incentives are important to engage FCHVs in hyperlipidemia management.

Introduction Healthcare provider burnout is highly prevalent and has negative consequences. However, many healthcare workers in LMICs, including Nepal, rarely recognize or ameliorate it. This problem is worse in rural settings. Competency-focused interventions that are developed using theoretical frameworks can address this gap. Methods We used Kern’s framework of curriculum development to create, refine, and assess a theory-driven intervention tailored to the needs and constraints of rural healthcare workers in Nepal. During the first phase, we conducted a targeted needs assessment using an online survey among nine rural primary care physicians working in Charikot Hospital. We then developed learning objectives for knowledge, attitude, and skills domains based on the World Health Organization (WHO) definition of burnout. Then, we created animated educational videos designed to meet the learning objectives. We then implemented the educational intervention with rural physicians and assessed their knowledge, attitudes, and feedback. During the second phase, we further developed the intervention based on findings from the first phase and assessed acceptability, feasibility, and preliminary impact using pre- and post-intervention questionnaires and key informant interviews. Results In the first phase, nine physicians participated in the targeted needs assessment, and eight responded to the post-intervention assessment. In the second phase, 18 attendees completed the pre-intervention burnout assessment, and 16 completed both the pre-test and post-test questionnaires. On the pre-test, correct answers across questions ranged from 31–88%, while on the post-test, participants responded correctly 88–100% of the time. Related-samples Wilcoxon signed-rank test showed a statistically significant difference ( P  = 0.007) in the post-test scores on the knowledge domain. Qualitative results showed burnout as an unrecognized and unreported issue, and its drivers included stigma and feelings of helplessness. Participants praised the interventions and reported that they translated learned skills into practice. Conclusion In this proof-of-concept study, we found that educational interventions developed using a theory-driven framework to meet the unique needs of rural healthcare workers are acceptable and feasible. Future studies can test the intervention impact in well-powered trials to support scale-up efforts to identify and address burnout.

The increase in the chemsex phenomenon among gay, bisexual, and other men who have sex with men (GBMSM) is alarming, as it is associated with risky sexual behaviors, including condomless sex and multiple sex partners. Despite increasing concerns, there is nonexistent research on chemsex among GBMSM in Nepal. Therefore, our study aimed to identify the prevalence and factors associated with engagement in chemsex among GBMSM in Nepal. A cross-sectional online survey of 842 Nepali GBMSM was conducted between March and May 2024. Multivariable logistic regression was used to identify factors associated with chemsex engagement within the past 12 months. Among 842 participants (mean age 27.6 ± 7.1 years), 24.7% reported ever engaging in chemsex, and 19.1% did so in the past 12 months. GBMSM who had completed high school were less likely to have engaged in chemsex in the past 12 months (aOR: 0.5; 95% CI: 0.3–0.8). However, GBMSM who reported having multiple sex partners (aOR: 9.6; 95% CI: 1.3–71.4), being involved in party/group sex in the past 12 months (aOR: 2.5; 95% CI: 1.5–3.9), and with depressive symptoms (aOR: 2.0; 95% CI: 1.3–3.0) were more likely to have engaged in chemsex in the past 12 months. An integrated approach is urgently needed, encompassing awareness raising, safe drug use support, sexual health services, and mental health care.

There is a strong association between alcohol use disorder (AUD) and intimate partner violence (IPV), both widely prevalent global health issues. However, few interventions target both IPV and AUD, include both partners in the intervention, and are delivered by non-specialist providers in low- and middle-income country (LMIC) settings with scarce mental health resources. This paper describes the protocol for a randomized controlled trial of a combined motivational interviewing (MI) and behavioral couples therapy (BCT) intervention delivered in urban primary care settings in India by nurses with no behavioral health training prior to joining the study. A total of 400 couples will be enrolled and randomized to one of two arms: an intervention arm comprised of 10, hour-long sessions of the MI + BCT intervention, and a control arm receiving enhanced usual care and medical-legal referrals. Data collection will take place at five timepoints: baseline (pre-intervention), three-, six-, nine-, and 12-month follow-ups. Primary quantitative outcomes include the frequency of intimate partner violence over the last 6 months and self-reported quantity and frequency of alcohol use, drinking behaviors, and alcohol-related problems as assessed on the Alcohol Use Disorders Identification Test (AUDIT). Secondary outcomes include number of days with a negative breathalyzer test over a one-week period, communication patterns, and the quality of marital relationship. Qualitative interviews with a sub-sample (n = 40 couples) from the intervention arm will take place immediately post-intervention and at 12 months to explore underlying mechanisms of change. If successful, study results can inform future efforts to develop scalable interventions for IPV and AUD that can be sustained in the Indian public health system through existing PHC staff and infrastructure and be adapted to similar sociocultural settings.

Eating last is a gendered cultural norm in which the youngest daughters‐in‐law are expected to eat last after serving others in the household, including men and in‐laws. Using women's eating last as an indicator of women's status, we studied the association between eating last and women's mental health. Using four rounds of prospective cohort data of 18–25‐year‐old newly married women (n = 200) cohabiting with mothers‐in‐law between 2018 and 2020 in the Nawalparasi district of Nepal, we examined the association between women eating last and depressive symptom severity (measured using 15‐item Hopkins Symptom Checklist for Depression; HSCL‐D). Twenty‐five percent of women reported eating last always. The prevalence of probable depression using the established cutoff was 5.5%, consistent with the prevalence of depression in the general population. Using a hierarchical mixed‐effects linear regression model, we found that women who always ate last had an expected depressive symptom severity (0–3 on HSCL‐D) 0.24 points (95% confidence interval [CI]: 0.13–0.36) greater compared to women who did not eat last when adjusted for demographic variables, household food insecurity, and secular trends. Sensitivity analysis using logistic regression also suggested that women who eat last have greater odds of having probable depression (adjusted odds ratio [AOR] = 4.05; 95% CI: 1.32–12.44). We explored if the association between eating last and depressive symptom severity was moderated by household food insecurity and did not observe evidence of moderation, underscoring the significance of eating last as a woman's status indicator. Our study findings highlight that newly young married women in Nepal are a vulnerable group. Key points/highlights Newly married women in rural Nepal face harmful gender norms, such as eating last in the family, which does not improve over the first 2 years of marriage. In patrilocal societies like Nepal, newly married women often occupy the lowest status in the household, and eating last is a reflection of their low status. Women who eat last in the household experience greater depressive symptoms, irrespective of their household food insecurity status. The low status of women and harmful gender norms place them in situations that are detrimental to their mental health and well‐being.

Abstract Toxicological emergencies pose a significant health burden in Nepal, particularly in rural agricultural regions. Intentional pesticide self-poisoning, especially with organophosphates, contribute heavily to this burden. This narrative review synthesizes the current state of toxicological care in Nepal, highlighting epidemiological data, educational programs, policy developments, and resource availability up to 2024. Despite hospital-based studies, aggregate data on toxicology care is lacking. Major barriers include insufficient trained human resources and limited access to antidotes and antivenoms. The review emphasizes the urgent need for formal clinical toxicology training, improved toxicological emergency management, and policy implementation to reduce the burden of poisoning in Nepal.

Background As the field of global mental health grows, many psychotherapy trainees will work across cultures in low-resource settings in high-income countries or in low- and middle-income countries. Mentors and supervisors, including faculty members, may face several challenges in providing supervision for psychologists in low-resource settings. As such, there is a need to develop best practices for psychotherapy supervision in global mental health. We describe the common challenges and potential strategies in psychotherapy supervision based on our research, clinical, and academic partnerships between academic institutions, a nonprofit organization, and the Nepali government. The strategies and considerations we have found helpful include focusing on therapies with strong behavioral and interpersonal (rather than emotional or cognitive) components and using locally validated therapies or standard manuals that have been endorsed by the WHO for low-resource settings. Other strategies include providing psychotherapy training for local psychiatrists who may be in supervisory roles using the train-the trainer models to help them gain competence in navigating different expectations of social structures and family dynamics. Supervisors face many challenges while supporting trainees and early psychologists in global mental health settings. While ensuring local adaptation, key considerations can be developed into best practices to support supervisors, particularly psychiatrists and other faculty members based in high-income settings, and trainees based in low- and middle-income countries.

IntroductionDespite 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.MethodsWe conducted a 2-year mixed-methods study to assess the implementation and clinical impact of CoCM using the WHO Mental Health Gap Action Programme protocols in a primary care clinic in rural Nepal. We used the Capability Opportunity Motivation-Behaviour (COM-B) implementation research framework to adapt and study the intervention. To assess implementation factors, we qualitatively studied the impact on providers’ behaviour to screen, diagnose and treat mental illness. To assess clinical impact, we followed a cohort of 201 patients with moderate to severe depression and determined the proportion of patients who had a substantial clinical response (defined as ≥50% decrease from baseline scores of Patient Health Questionnaire (PHQ) to measure depression) by the end of the study period.ResultsProviders experienced improved capability (enhanced self-efficacy and knowledge), greater opportunity (via access to counsellors, psychiatrist, medications and diagnostic tests) and increased motivation (developing positive attitudes towards people with mental illness and seeing patients improve) to provide mental healthcare. We observed substantial clinical response in 99 (49%; 95% CI: 42% to 56%) of the 201 cohort patients, with a median seven point (Q1:−9, Q3:−2) decrease in PHQ-9 scores (p<0.0001).ConclusionUsing 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.

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. Methods A chart review was conducted for all patients whose cases were reviewed by the treatment team from January to June 2017, after CoCM had been operational for 6 months. Free text of the recommendations were extracted and two coders analyzed the data using an inductive approach to group and categorize recommendations until the coders achieved consensus. Cumulative frequency of the recommendations are tabulated and discussed in the context of an adapted CoCM in rural Nepal. Results The clinical team discussed 1174 patient encounters (1162 unique patients) during panel reviews throughout the study period. The consultant psychiatrist made 214 recommendations for 192 (16%) patients. The most common recommendations were to revisit the primary mental health diagnosis (16%, n  = 34), add or increase focus on counselling and psychosocial support (9%, n  = 20), increase the antidepressant dose (9%, n = 20), and discontinue inappropriate medications (6%, n  = 12). 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

Men who have sex with men (MSM) are disproportionately burdened by poor mental health. Despite the increasing burden, evidence-based interventions for MSM are largely nonexistent in Nepal. This study explored mental health concerns, contributing factors, barriers to mental health care and support, and preferred interventions to improve access to and use of mental health support services among MSM in Nepal. We conducted focus groups with MSM in Kathmandu, Nepal, in January 2023. In total, 28 participants took part in 5 focus group sessions. Participants discussed several topics related to the mental health issues they experienced, factors contributing to these issues, and their suggestions for potential interventions to address existing barriers. The discussions were recorded, transcribed, and analyzed using Dedoose (version 9.0.54; SocioCultural Research Consultants, LLC) software for thematic analysis. Participants reported substantial mental health problems, including anxiety, depression, suicidal ideation, and behaviors. Contributing factors included family rejection, isolation, bullying, stigma, discrimination, and fear of HIV and other sexually transmitted infections. Barriers to accessing services included cost, lack of lesbian, gay, bisexual, transgender, intersex, queer, and asexual (LGBTIQA+)-friendly providers, and the stigma associated with mental health and sexuality. Participants suggested a smartphone app with features such as a mental health screening tool, digital consultation, helpline number, directory of LGBTIQA+-friendly providers, mental health resources, and a discussion forum for peer support as potential solutions. Participants emphasized the importance of privacy and confidentiality to ensure mobile apps are safe and accessible. The findings of this study have potential transferability to other low-resource settings facing similar challenges. Intervention developers can use these findings to design tailored mobile apps to facilitate mental health care delivery and support for MSM and other marginalized groups.