Lessons from the 2015 earthquake(s) in Nepal: implication for rehabilitation.

PURPOSE: There has been an increase in the number of natural disasters in recent history, and the rate of disability is increasing among survivors. The most recent major natural disaster was the earthquake(s) that occurred in Nepal on 25 April 2015 and 12 May 2015. In total, more than 8500 people were killed and over 18,500 people were left injured. This article aims to demonstrate the role of rehabilitation professionals in post-disaster relief and beyond in Nepal. METHOD: This is an experiential account of physiotherapists present during the earthquake and participating in the post-disaster relief. RESULTS: Rehabilitation professionals played an important role in the acute phase post-disaster by providing essential services and equipment. However, discharge planning emerged as an important role for rehabilitation providers in the early days of post-disaster and signaled a relatively new and innovative function that facilitated the heavy imbalance between little supply and tremendous demand for care. In the coming years, rehabilitation will need to support local initiatives that focus on minimizing the long-term effects among people with a newly acquired disability. CONCLUSIONS: Rehabilitation serves an important role across the continuum in post-disaster relief from the initial stages to the months and years following an event. IMPLICATIONS FOR REHABILITATION: Driven by medical advances in acute field medicine, the relative proportion of casualties following natural disasters is decreasing, while relative rates of disability are rising among survivors. In post-disaster settings, the growing number of people with newly acquired disabilities will be added to the existing proportion of the population who lived with disabilities, creating a significant growth in the total number of people with disabilities (PWDs) in communities that are often ill prepared to provide necessary services. Rehabilitation interventions in the initial stages of emergency humanitarian response can minimize the long-term effects among people with newly acquired disabilities through early activation and prevention of secondary effects. Rehabilitation providers thus appear to have an important mediating effect on outcomes of disabilities in the early stages, but must also be strong partners with PWDs to advocate for social and political change in the long term.

The ecocultural context and child behavior problems: A qualitative analysis in rural Nepal.

Commonly used paradigms for studying child psychopathology emphasize individual-level factors and often neglect the role of context in shaping risk and protective factors among children, families, and communities. To address this gap, we evaluated influences of ecocultural contextual factors on definitions, development of, and responses to child behavior problems and examined how contextual knowledge can inform culturally responsive interventions. We drew on Super and Harkness' "developmental niche" framework to evaluate the influences of physical and social settings, childcare customs and practices, and parental ethnotheories on the definitions, development of, and responses to child behavior problems in a community in rural Nepal. Data were collected between February and October 2014 through in-depth interviews with a purposive sampling strategy targeting parents (N = 10), teachers (N = 6), and community leaders (N = 8) familiar with child-rearing. Results were supplemented by focus group discussions with children (N = 9) and teachers (N = 8), pile-sort interviews with mothers (N = 8) of school-aged children, and direct observations in homes, schools, and community spaces. Behavior problems were largely defined in light of parents' socialization goals and role expectations for children. Certain physical settings and times were seen to carry greater risk for problematic behavior when children were unsupervised. Parents and other adults attempted to mitigate behavior problems by supervising them and their social interactions, providing for their physical needs, educating them, and through a shared verbal reminding strategy (samjhaune). The findings of our study illustrate the transactional nature of behavior problem development that involves context-specific goals, roles, and concerns that are likely to affect adults' interpretations and responses to children's behavior. Ultimately, employing a developmental niche framework will elucidate setting-specific risk and protective factors for culturally compelling intervention strategies.

Documenting the Contextualization and Implementation of mhGAP-HIG in Post-earthquake Nepal

Background: The burden of mental health is increased in humanitarian settings, and needs to be addressed in emergency situations. The World Health Organization has recently released the mental health Global Action Programme Humanitarian Intervention Guide (mhGAP-HIG) in order to scale up mental health service delivery in humanitarian settings through task-shifting. This study aims to evaluate, contextualize and identify possible barriers and challenges to mhGAP-HIG manual content, training and implementation in post-earthquake Nepal.

Methods: This qualitative study was conducted in Kathmandu, Nepal. Key informant interviews were conducted with fourteen psychiatrists involved in a mhGAP-HIG Training of Trainers and Supervisors (ToTS) in order to assess the mhGAP-HIG, ToTS training, and the potential challenges and barriers to mhGAP-HIG implementation. Themes identified by informants were supplemented by process notes taken by the researcher during observed training sessions and meetings.

Results: Key themes emerging from key informant interviews include the need to take three factors into account in manual contextualization: culture, health systems and the humanitarian setting. This includes translation of the manual into the local language, adding or expanding upon conditions prevalent in Nepal, and more consideration to improving feasibility of manual use by non-specialists.

Conclusion: The mhGAP-HIG must be tailored to specific humanitarian settings for effective implementation. This study shows the importance of conducting a manual contextualization workshop prior to training in order to maximize the feasibility and success in training health care workers in mhGAP.

Participatory Methods for Climate Change and Mental Health Research: Photovoice in Nepal

Background: The relationship between mental health and climate change are poorly understood. Participatory methods represent ethical, feasible, and culturally-appropriate approaches to engage community members for mental health promotion in the context of climate change. Aim: Photovoice, a community-based participatory research methodology uses images as a tool to deconstruct problems by posing meaningful questions in a community to find actionable solutions. This community-enhancing technique was used to elicit experiences of climate change among women in rural Nepal and the association of climate change with mental health. Subjects and methods: Mixed-methods, including in-depth interviews and self-report questionnaires, were used to evaluate the experience of 10 women participating in photovoice. Quantitative tools included Nepali versions of Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI) and a resilience scale. Results: In qualitative interviews after photovoice, women reported climate change adaptation and behavior change strategies including environmental knowledge-sharing, group mobilization, and increased hygiene practices. Women also reported beneficial effects for mental health. The mean BDI score prior to photovoice was 23.20 (SD=9.00) and two weeks after completion of photovoice, the mean BDI score was 7.40 (SD=7.93), paired t-test = 8.02, p<.001, n=10. Conclusion: Photovoice, as a participatory method, has potential to inform resources, adaptive strategies and potential interventions to for climate change and mental health.

Periodic Breathing and Behavioral Awakenings at High Altitude.

Objectives. To study the relationship between nocturnal periodic breathing episodes and behavioral awakenings at high altitude. Methods. Observational study. It is 6-day ascent of 4 healthy subjects from Besisahar (760 meters) to Manang (3540 meters) in Nepal in March 2012. A recording pulse oximeter was worn by each subject to measure their oxygen saturation and the presence of periodic breathing continuously through the night. An actigraph was simultaneously worn in order to determine nocturnal behavioral awakenings. There were no interventions. Results. 187-hour sleep at high altitude was analyzed, and of this, 145 hours (78%) had at least one PB event. At high altitude, 10.5% (95% CI 6.5-14.6%) of total sleep time was spent in PB while 15 out of 50 awakenings (30%, 95% CI: 18-45%) occurring at high altitudes were associated with PB (P < 0.001). Conclusions. Our data reveals a higher than expected number of behavioral awakenings associated with PB compared to what would be expected by chance. This suggests that PB likely plays a role in behavioral awakenings at high altitude.