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Healthcare performance of leprosy management in peripheral health facilities of Dhanusa and Mahottari, Nepal.
(BioMed Central Ltd, 2025-12) Mahato RK; Ghimire U; Bajracharya B; K C B; Bam D; Ghimire D; Pyakurel UR; Hayman DTS; Pandey BD; Das CL; Paudel KP
BACKGROUND: The global elimination of leprosy transmission by 2030 is a World Health Organization (WHO) target. Nepal's leprosy elimination program depends on early case diagnosis and the performance of health workers and facilities. The knowledge and skills of paramedical staff (Leprosy Focal Person, LFP) and case documentation and management by health facilities are therefore key to the performance of health care services. METHODS: The performance of health workers and facilities was evaluated through a combined cross-sectional and retrospective study approach of 31 health facilities and their LFPs in Dhanusa and Mahottari Districts in Madhesh Province, Nepal. An average of 6 patients (paucibacillary, PB, or multibacillary, MB) per health facility registered within the 2018/2019 fiscal year were also enrolled in the study. LFP knowledge (e.g., of the three cardinal signs) and skills (e.g., nerve palpation) and facility processes (e.g., record keeping) were scored (e.g., 0, 1) and then rescaled to a proportion, where 1 is perfect. Internal benchmarking was used to guide performance management. RESULTS: Overall LFP knowledge and skill scores of health workers ranged from 0.16 to 0.63 (median 0.53, 95% confidence interval (CI), 0.46-0.6). Case documentation scores ranged from 0.15 to 0.87 (median 0.37, 95% CI 0.36-0.38), case management scores from 0.38 to 0.79 (median 0.54, 95% CI 0.53-0.55) and overall healthcare scores from 0.36-0.62 (median 0.48, 95% CI 0.47-0.49). Leprosy-related training was significantly related to the knowledge and skills of the health workers. All identified cases (n = 187) adhered to the complete treatment and release after treatment (RFT) scheme, out of which 84.5% were satisfied with the service they were provided. Leprosy disability and ear hand and feet (EHF) scores were not significantly reduced in treated patients during the study period, but counseling by LFPs significantly improved cases' positive beliefs and practices regarding self-care. CONCLUSION: Overall leprosy care median performance was low (53%) and can be improved by evidenced-based training, onsite coaching, monitoring, and supervision to facilitate leprosy transmission elimination. The results highlight many of the challenges facing leprosy elimination programs.
Dietary practices, physical activity and social determinants of non-communicable diseases in Nepal: A systemic analysis.
(PLOS, 2023-02-06) Sharma S; Matheson A; Lambrick D; Faulkner J; Lounsbury DW; Vaidya A; Page R; Kushitor SB
Unhealthy dietary habits and physical inactivity are major risk factors of non-communicable diseases (NCDs) globally. The objective of this paper was to describe the role of dietary practices and physical activity in the interaction of the social determinants of NCDs in Nepal, a developing economy. The study was a qualitative study design involving two districts in Nepal, whereby data was collected via key informant interviews (n = 63) and focus group discussions (n = 12). Thematic analysis of the qualitative data was performed, and a causal loop diagram was built to illustrate the dynamic interactions of the social determinants of NCDs based on the themes. The study also involved sense-making sessions with policy level and local stakeholders. Four key interacting themes emerged from the study describing current dietary and physical activity practices, influence of junk food, role of health system and socio-economic factors as root causes. While the current dietary and physical activity-related practices within communities were unhealthy, the broader determinants such as socio-economic circumstances and gender further fuelled such practices. The health system has potential to play a more effective role in the prevention of the behavioural and social determinants of NCDs.
What Does Social Support Sound Like? Challenges and Opportunities for Using Passive Episodic Audio Collection to Assess the Social Environment.
(Frontiers Media S.A., 2021-03-29) Poudyal A; van Heerden A; Hagaman A; Islam C; Thapa A; Maharjan SM; Byanjankar P; Kohrt BA; Kyriakopoulos M
Background: The social environment, comprised of social support, social burden, and quality of interactions, influences a range of health outcomes, including mental health. Passive audio data collection on mobile phones (e.g., episodic recording of the auditory environment without requiring any active input from the phone user) enables new opportunities to understand the social environment. We evaluated the use of passive audio collection on mobile phones as a window into the social environment while conducting a study of mental health among adolescent and young mothers in Nepal. Methods: We enrolled 23 adolescent and young mothers who first participated in qualitative interviews to describe their social support and identify sounds potentially associated with that support. Then, episodic recordings were collected for 2 weeks from the mothers using an app to record 30 s of audio every 15 min from 4 A.M. to 9 P.M. Audio data were processed and classified using a pretrained model. Each classification category was accompanied by an estimated accuracy score. Manual validation of the machine-predicted speech and non-speech categories was done for accuracy. Results: In qualitative interviews, mothers described a range of positive and negative social interactions and the sounds that accompanied these. Potential positive sounds included adult speech and laughter, infant babbling and laughter, and sounds from baby toys. Sounds characterizing negative stimuli included yelling, crying, screaming by adults and crying by infants. Sounds associated with social isolation included silence and TV or radio noises. Speech comprised 43% of all passively recorded audio clips (n = 7,725). Manual validation showed a 23% false positive rate and 62% false-negative rate for speech, demonstrating potential underestimation of speech exposure. Other common sounds were music and vehicular noises. Conclusions: Passively capturing audio has the potential to improve understanding of the social environment. However, a pre-trained model had the limited accuracy for identifying speech and lacked categories allowing distinction between positive and negative social interactions. To improve the contribution of passive audio collection to understanding the social environment, future work should improve the accuracy of audio categorization, code for constellations of sounds, and combine audio with other smartphone data collection such as location and activity.
Evaluating active leprosy case identification methods in six districts of Nepal.
(BioMed Central Ltd., 2023-12-06) Mahato RK; Ghimire U; Lamsal M; Bajracharya B; Poudel M; Napit P; Lama K; Dahal G; Hayman DTS; Karna AK; Pandey BD; Das CL; Paudel KP
BACKGROUND: Nepal has achieved and sustained the elimination of leprosy as a public health problem since 2009, but 17 districts and 3 provinces with 41% (10,907,128) of Nepal's population have yet to eliminate the disease. Pediatric cases and grade-2 disabilities (G2D) indicate recent transmission and late diagnosis, respectively, which necessitate active and early case detection. This operational research was performed to identify approaches best suited for early case detection, determine community-based leprosy epidemiology, and identify hidden leprosy cases early and respond with prompt treatment. METHODS: Active case detection was undertaken in two Nepali provinces with the greatest burden of leprosy, Madhesh Province (40% national cases) and Lumbini Province (18%) and at-risk prison populations in Madhesh, Lumbini and Bagmati provinces. Case detection was performed by (1) house-to-house visits among vulnerable populations (n = 26,469); (2) contact examination and tracing (n = 7608); in Madhesh and Lumbini Provinces and, (3) screening prison populations (n = 4428) in Madhesh, Lumbini and Bagmati Provinces of Nepal. Per case direct medical and non-medical costs for each approach were calculated. RESULTS: New case detection rates were highest for contact tracing (250), followed by house-to-house visits (102) and prison screening (45) per 100,000 population screened. However, the cost per case identified was cheapest for house-to-house visits [Nepalese rupee (NPR) 76,500/case], followed by contact tracing (NPR 90,286/case) and prison screening (NPR 298,300/case). House-to-house and contact tracing case paucibacillary/multibacillary (PB:MB) ratios were 59:41 and 68:32; female/male ratios 63:37 and 57:43; pediatric cases 11% in both approaches; and grade-2 disabilities (G2D) 11% and 5%, respectively. Developing leprosy was not significantly different among household and neighbor contacts [odds ratios (OR) = 1.4, 95% confidence interval (CI): 0.24-5.85] and for contacts of MB versus PB cases (OR = 0.7, 95% CI 0.26-2.0). Attack rates were not significantly different among household contacts of MB cases (0.32%, 95% CI 0.07-0.94%) and PB cases (0.13%, 95% CI 0.03-0.73) (χ2 = 0.07, df = 1, P = 0.9) and neighbor contacts of MB cases (0.23%, 0.1-0.46) and PB cases (0.48%, 0.19-0.98) (χ2 = 0.8, df = 1, P = 0.7). BCG vaccination with scar presence had a significant protective effect against leprosy (OR = 0.42, 0.22-0.81). CONCLUSIONS: The most effective case identification approach here is contact tracing, followed by house-to-house visits in vulnerable populations and screening in prisons, although house-to-house visits are cheaper. The findings suggest that hidden cases, recent transmission, and late diagnosis in the community exist and highlight the importance of early case detection.
Assessing the welfare of pasture-based dairy cows of New Zealand and transhumance chauris of Nepal : a thesis presented in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Veterinary Science at Massey University, Runenga Porehuroa, University of New Zealand, School of Veterinary Science, Manawatu
(Massey University, 2024-06-14) Sapkota, Sujan
There is no industry-recognized welfare assessment protocol for pasture-based dairy cows of New Zealand. Also, the welfare assessment in yak/chauri raised under the transhumance system is at the preliminary stage. So, there is a strong necessity of a pastured-based welfare assessment protocol for pasture-based dairy cows in New Zealand and transhumance yak/chauri in Nepal. The aim of the research studies presented in this thesis were to develop a practical and time-limited welfare assessment protocol suitable to pasture-based dairy farms, and transhumance yak chauri focused on a single visit around milking. During the process, 84 different welfare measures were collected from six protocols and 4 welfare studies which were screened and trialed in two pasture-based farms to finalise 32 welfare measures including 5 additional measures specific to New Zealand. These measures were tested on 23 different dairy farms from the Waikato and Manawatu. All the measures were feasible except for the measure related to water availability and behavior. Testing of the repeatability and reliability should be performed for all the selected measures on more number of farms before taking this protocol for commercial use. Also, we further did subsampling-based locomotion scoring on five different pasture-based dairy farms to know if they could predict herd level prevalence. The findings were that there was a significant association between the order in which cows were milked and their susceptibility to lameness. However, the percentage of lame cows within the sub-sampled group was not uniform and was significantly influenced by the farm and the timing of the visit. For our yak/chauri protocol, 31 potential welfare measures were submitted to 120 Nepalese experts for evaluation identifying 13 measures, plus a new one (hematology) was deemed useful. The resulting protocol was tested in five chauri herds in northern Nepal, encompassing animal-based evaluations, mastitis and parasite sampling, and hematology. The protocol was found to be feasible and offers a valuable starting point for yak/chauri welfare assessment.
Characterization and management of human-wildlife conflicts in mid-hills outside protected areas of Gandaki province, Nepal
(PLOS, 2021-11-19) Baral K; Sharma HP; Rimal B; Thapa-Magar K; Bhattarai R; Kunwar RM; Aryal A; Ji W; Sharma LK
With the intent to better management human wildlife conflict (HWC) and wildlife conservation in mid-hills outside protected areas of Gandaki province, Nepal, we analyzed the patterns and drivers of HWC. Using data collected from literature, government records and questionnaire survey, we investigated temporal, seasonal and spatial distribution of human casualties caused by wildlife attacks. We also appraised the perception of local people towards wildlife conservation. We have recorded 77 cases (69 human injuries and 8 mortalities) during the period of nine year between 2011 and 2019. The number of wildlife attacks increased over this period. Wildlife attacks were more frequent in winter with 50% (42) of attacks occurred between September and December. Common leopard (Panthera pardus) and Himalayan black bear (Ursus thibetanus laniger) were the major species involved in these conflicts. Common leopard was the most feared species that causes highest number of human mortalities (87%, n = 67); the most severe type of HWC outcome. Forty-eight percent (n = 37) attacks were reported at human settlement areas followed by 27% attacks in agriculture land (n = 21) and 24% (n = 19) in forest. Generalized linear model analysis on spatial variables showed that the probability of human attacks increases with decreasing elevation (β = -0.0021, Z = -1.762, p = 0.078) and distance from the forest (β = -0.608, Z = -0.789, p = 0.429). We recommend to decrease habitat degradation / fragmentation, carry out habitat management program within forest to increase prey availability to decrease the wildlife invasion into human settlement area, and decrease dependency of people on forest resources by providing alternative livelihood opportunities. Simplified relief fund distribution mechanism at local level also helps alleviate the impact of HWC. The knowledge obtained by this study and management measures are important for better human-wildlife co-existence.
Human wildlife conflict and impacts on livelihood: A study in community forestry system in mid-hills of Nepal
(MDPI (Basel, Switzerland), 2021-12-01) Baral K; Sharma HP; Kunwar R; Morley C; Aryal A; Rimal B; Ji W; Yosef R
Human wildlife conflict (HWC) impacts the livelihood of many rural communities world-wide. This study investigated the impact of HWC on people living near community forests (CF) in Nepal. Using databases provided by the Division of Forest Offices and data obtained from surveys between October 2019–March 2020, we quantified the financial loss of HWC to the local people. Between 2015 and 2019, 3315, or 27%, of the livestock owned by the survey respondents were killed by wild predators in the Kaski and Tanahun Districts. Chicken (Gallus spp.) was the most common prey taken (80%), followed by sheep (Ovis spp.) and goats (Capra spp.) (15%), cows (Bos spp.) (2%), pigs (Sus spp.) (2%), and buffalo (Bubalus spp.) (1%). Leopards (Panthera pardus) were the primary predators, followed by golden jackals (Canis aureus), jungle cats (Felis chaus), yellow-throated mar-tens (Martes flavigula), and Himalayan black bears (Ursus thibetanus). The financial loss of livestock during this period was USD $115,656.00, equivalent to USD $142.61 per household. Crops were also damaged and eaten by wildlife, and 2165 crop-raiding events were recorded between 2015 and 2019. Rice (Oryza sativa), followed by maize (Zea mays), millet (Panicum miliaceum), and potatoes (Solanum tuberosum) were the main crops lost. Rhesus monkeys (Macaca mulatta) were the most common crop raiders, causing 74% of the damage, followed by Indian field mice (Mus booduga) (12%). From 2015 to 2019, crop losses equated to USD $83,424.00. Forest regeneration on abandoned agricultural land expanded wildlife habitats, enabling wild animals to come within reach of human settlements, which increased the likelihood of HWC events. Although the success of the community forest res-toration program resulted in increased forest-cover, marginally increasing biodiversity, the reduced distance between human settlements and wildlife habitat, compounded by a lack of natural prey, may have unwittingly exacerbated HWC in this region. We recommend surveying predator and prey populations in the forest habitat, and implementing a habitat management program to improve prey populations within the community forests. Meantime, we propose establishing a financial relief and insurance program for crop and livestock losses at the local community level to alle-viate any financial difficulties to the local communities caused by HWC.
Predator-prey interactions in subtropical forest and ecology and conservation of swamp deer or barasingha (Rucervus duvaucelii duvaucelii) : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Conservation Biology at Massey University, Auckland, New Zealand
(Massey University, 2021) Yadav, Hemanta Kumar
The tiger, an apex predator, is an indicator of a healthy ecosystem. Therefore, the conservation of this immensely important umbrella species necessitates ecological knowledge on its interaction with co-predators and status of significant prey species sharing the habitat. Royal Bengal tiger (Panthera tigris tigris) and common leopard (Panthera pardus fusca) are two sympatric carnivores in suitable habitats of the Indian subcontinent where sympatric ungulates cervids are prevailing as major prey species. This thesis investigated the diet overlap of these sympatric apex predators and the population status of prey species in the subtropical lowland landscape popularly known as Terai Arc Landscape (TAL), Nepal. This thesis further explored ranging behaviour, habitat preference, movements, conservation genetics and food habits of the swamp deer or barasingha (Rucervus duvaucelii duvaucelii), the largest cervid prey species of tiger in the western portion of TAL, Nepal. The line transect survey revealed high density and biomass of major cervid prey species compared to other tiger bearing protected areas, with large-sized swamp deer, medium-sized spotted deer (Axis axis) and hog deer (Axis porcinus) being main prey species. Scat analysis revealed that wild ungulates were the main food of both predators. Large-sized wild preys (mainly swamp deer) were found more frequently in tiger scats, and domestic cattle were found more frequently in leopard scats. Both predators consumed the medium-sized spotted deer in high proportions resulting in a high diet overlap. Swamp deer played a critical role in diet partition between the two cats. Dominant tigers displaced leopards to the degraded fringe habitat where the latter subsisted on the domestic livestock, a major cause of human-wildlife conflict. The monitoring of nine radio-collared swamp deer showed a high 95% Minimum Convex Polygon (MCP) and 95% Fixed Kernel (FK) home ranges compared to other sympatric ungulates such as spotted deer, hog deer, and barking deer (Muntiacus muntjac). There was no significant variation in 95% FK annual home ranges between sexes and across three seasons. Overall, the grassland was the most preferred habitat of swamp deer in all the seasons, and the dense Sal (Shorea robusta) forest was the least preferred. In the monsoon season, the moderately dense Sal forest followed the grassland. Within grassland, swamp deer preferred Imperata cylindrica assemblage followed by Imperata cylindrica – Narenga porphyrocoma and Narenga porphyrocoma assemblage. A range shift from the grassland to the Sal (Shorea robusta) forest, only during the monsoon season, indicated that the grassland had reached the carrying capacity during this season. The radio-collared swamp deer crossed the international border. During the rutting season, they consistently used contiguous habitat patches of Lagga-Bagga area of Pilibhit Tiger Reserve, India, thus emphasising the need for transboundary cooperation to conserve this species. The genetic variability, population structure and effective population size of Shuklaphanta National Park (SNP) and Bardia National Park (BNP) populations of swamp deer were examined using the mitochondrial (mt) DNA and microsatellite markers. The analysis revealed moderate to high genetic diversity compared to other swamp deer populations in India. Neutrality tests, which are used to evaluate demographic effects, did not support population expansion. The multimodal pattern of mismatch distribution indicated that both swamp deer populations are under demographic equilibrium. Furthermore, population bottleneck analysis indicated no signature of a bottleneck for both populations. Bayesian cluster analysis and population differentiation test revealed two population clusters with low population differentiation. The effective population size in BNP was below 50, which is often regarded as a threshold below which inbreeding depression is likely to occur. It is recommended to design and implement an effective conservation strategy to enhance the genetic diversity and increase the population size of swamp deer in BNP through an in-situ conservation program and translocation of some breeding individuals from SNP to BNP. Faecal microhistological analysis of swamp deer, sympatric hog deer, and spotted deer from both grassland and the Sal forest habitats revealed that graminoids constituted the majority of the diet of these species in both habitats. However, the proportion of woody plants in diets of spotted deer was significantly higher than the other two. Apart from the graminoids, woody plant Shorea robusta and herb Phoenix humilis were major plant species consumed in the Sal forest. Among graminoid species, early successional tall grasses, especially Saccharum spontaneum, were the dominant food of all three deer species in both habitats. The importance of early successional tall grasses in their diet emphasised the key role of the threatened alluvial floodplains in conserving threatened mammal species in South Asia. Swamp deer foraged more in late succession tall grasses (Saccharum narenga and Themeda spp.) and short grasses (Imperata cylindrica, Cyperus spp., Chrysopogon zizanioides, Cymbopogon spp.) than hog deer and spotted deer. Despite the similarity of their diet, the three ungulates coexisted through differential consumption of plants species and seasonal habitat partitioning.
Understanding the social determinants of non-communicable diseases in Nepal : a systems perspective : a thesis presented in the partial fulfilment of the requirements for the degree of Doctor of Philosophy (PhD) in Health Sciences at Massey University, Wellington Campus, New Zealand
(Massey University, 2020) Sharma, Sudesh Raj
Non-communicable diseases (NCDs) constitute more than half of the total disease burden in Nepal. Global evidence indicates the problem of NCDs is influenced by the complex interaction of social determinants including behavioural, socio-economic and environmental. These determinants are the focus of global prevention strategies for tackling NCDs. The health system of Nepal, however, is yet to adopt this comprehensive prevention strategies. The main objective of this research was to understand the social determinants of NCDs in Nepal and identify leverage points for systemic actions in Nepal. The study utilized a systems thinking methodology which enabled a creative combination of case study methods and qualitative causal loop diagramming. In each of the two selected case districts (Bhaktapur and Morang), semi-structured interviews (n=39) and focus group discussions (n=12) were conducted with key stakeholders and community members. These case studies were informed by policy level interviews (n=24). Thematic analysis, guided by the adapted social determinants of health framework, helped to identify key themes and develop causal loop diagrams (CLDs). The findings of the thematic analysis, and CLDs, were then validated through local and policy sense-making workshops. The analysis showed four key interlinked thematic areas, each of which is being published as separate papers. The first paper describes the community and stakeholders’ perception and experience of the rising burden of NCDs. The social experience of NCDs metabolic risks such as hypertension and diabetes were shown to be normalised. Moreover, differences in social experience were observed based on gender and socio-economic circumstances. The second paper described the critical role played by tobacco and alcohol in the interaction of social determinants of NCDs. The analysis indicates that socio-economic circumstances was root cause of changing, and damaging alcohol and tobacco practices, and increased the vulnerability to exploitation by industries. The third paper revealed that poor dietary practices and physical inactivity were resulting due to changes in social practices shaped by worsening dietary and physical environment. Socio-economic circumstances, urbanisation and migration all contributed to the population being exposed to an obesogenic environment. While all three papers discussed specific health system challenges, the fourth paper elaborated on health sector challenges, including the curative focus and limited capacity of the health system both at district and policy or national level to prevent NCDs in Nepal. Three key leverage points for health system action on the social determinant of NCDs were identified by viewing the final CLD through the lens of Donella Meadows’ framework for identifying key health system action on the social determinants of health. These leverage points indicated that the health sector should focus on the development of a robust prevention system for effective NCDs action. Overall, the study highlighted the interactions of socio-economic, gender, commercial and health system determinants driving the NCDs problem in Nepal. The leverage analysis indicated that the health sector should focus on the development of a robust prevention system for effective action on complex problem like NCDs. The Ministry of Health could play a proactive role in creating the prevention system that could effectively guide all sectors towards collective action to impacting social and commercial determinants of health.
Some diagnostic techniques for small area estimation : with applications to poverty mapping : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Statistics at Massey University, Palmerston North, New Zealand
(Massey University, 2019) Livingston, Alison
Small area estimation (SAE) techniques borrow strength via auxiliary variables to provide reliable estimates at ﬁner geographical levels. An important application is poverty mapping, whereby aid organisations distribute millions of dollars every year based on small area estimates of poverty measures. Therefore diagnostics become an important tool to ensure estimates are reliable and funding is distributed to the most impoverished communities. Small area models can be large and complex, however even the most complex models can be of little use if they do not have predictive power at the small area level. This motivated a variable importance measure for SAE that considers each auxiliary variable’s ability to explain the variation in the dependent variable, as well as its ability to distinguish between the relative levels in the small areas. A core question addressed is how candidate survey-based models might be simpliﬁed without losing accuracy or introducing bias in the small area estimates. When a small area estimate appears to be biased or unusual, it is important to investigate and if necessary remedy the situation. A diagnostic is proposed that quantiﬁes the relative effect of each variable, allowing identiﬁcation of any variables within an area that have a larger than expected inﬂuence on the small area estimate for that area. This highlights possible errors which need to be checked and if necessary corrected. Additionally in SAE, it is essential that the estimates are at an acceptable level of precision in order to be useful. A measure is proposed that takes the ratio of the variability in the small areas to the uncertainty of the small area estimates. This measure is then used to assist in determining the minimum level of precision needed in order to maintain meaningful estimates. The diagnostics developed cover a wide range of small area estimation methods, consisting of those based on survey data only and those which combine survey and census data. By way of illustration, the proposed methods are applied to SAE for poverty measures in Cambodia and Nepal.

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