Healthcare Workers In Nepal Research Articles

Psychological Impact of COVID-19 among Health-care Workers in Nepal: An Analytical Cross-sectional Study

Context: Many psychological problems including stress, anxiety, insomnia, depression, frustration, denial, anger, and fear emerged during coronavirus disease 2019 (COVID-19) outbreak. Aims: This study was done to assess the prevalence and associated factors of depression, anxiety, stress, insomnia, and fear experienced by health-care workers (HWs) during COVID-19 in Nepal. Settings and Design: This was web-based analytical cross-sectional study conducted among health-care workers from December 27, 2020, to February 28, 2021, all over Nepal. Subjects and Methods: All the HWs including doctors, nurses, and allied health-care professional from 7 provinces were selected using convenience sampling technique. Data collection was done using the validated questionnaires. Statistical Analysis Used: Univariate and binary logistic regression analyses were performed to find the association between the different variables. Statistical significance was set at P < 0.05. Results: A total of 608 HWs completed the survey with a mean age of 30.82 ± 6.68. About 27% had symptoms of depression, 28% anxiety, 10% stress, 18% insomnia, and 49.8% fear of COVID-19. Resident doctors and health workers who had bachelor level of education and working experience <2 years were significantly associated with higher odds of experiencing depression and anxiety. Health workers working 2–5 years and with more than 5 years' experience had significantly lower odds of experiencing fear. History of tobacco use or medical condition had significantly higher odds of experiencing depression, anxiety, stress, insomnia, and fear. Conclusions: This study concluded that the prevalence of depression, anxiety, insomnia, and fear was found to be high. Resident doctors and health workers with bachelor level of education, working experience <2 years, and history of medical condition were significantly associated with experiencing adverse mental health outcomes.

Novel Approaches to Community-Based Psychoeducation to Improve Mental Health Awareness in Diverse Settings

Background/Objectives: The authors are early career psychiatrists practicing worldwide who aim to increase access to mental health care and reduce associated stigma by utilizing culturally informed psychoeducation-based programs tailored for nontraditional communities. Methods: The authors chose four distinct communities to provide mental health psychoeducation, including churches in Philadelphia, a fandom group in the Philippines, nonpsychiatric healthcare workers in Nepal, and families of patients in Morocco. Results: Dr. Atasha Jordan founded the Christian Mental Health Initiative to improve mental health outcomes of Christians in the US and the Caribbean; in a pilot study (n = 29), the research team used Mental Health First Aid to increase mental health care literacy and mental health care utilization in Black Churches. Dr. Bernadett Carandang co-created Hallyu Wednesdays, an online fandom-based mental health group that meets weekly to explore mental health topics through Korean media and provide online safe spaces for their community. Dr. Kristin Nguyen, as part of the Health, Equity, Action, Leadership (HEAL) global mental health fellowship program, co-created psychoeducational videos on burnout and ways to mitigate it for the staff of a hospital in rural Nepal that can be disseminated to other Nepali healthcare workers. Dr. Wydad Hikmat implemented a family psychoeducation program, Profamille, for caregivers and families of patients with psychosis, leading to improved mood and coping strategies for patients. Conclusions: All four psychoeducational interventions used innovative approaches to addressing mental health challenges and promoting mental wellness among diverse populations worldwide.

Knowledge and Perception of COVID-19 Pandemic during the First Wave: a Cross-Sectional Study among Nepalese Healthcare Workers

Objectives: This study aimed to assess knowledge and perception of COVID 19 among frontline health care workers in Nepal. Methods: A web-based cross-sectional study was conducted among frontline healthcare workers involved in managing and treating COVID-19 in Nepal by adapting the questionnaire from the World Health Organization. Data were analyzed using the Statistical Package for Social Science version 26.0. A chi-square test was used to investigate the association level among variables at 95% level of significance. Results: A total of 285 health professionals participated in this study, among them male (50.5%), and female (49.5%). The mean (± SD) age of participants was 27.21 ± 5.42 years old. Most of the participants got information on COVID-19 from social media (50.5%) and online news/newspapers (40.3%). On the other hand, a significant proportion of Health care workers (HCWs) had poor knowledge about its transmission (n=170, 59.6%) and an incubation period (n=129, 45.3%). Conclusion: There was a significant gap in knowledge and perception, particularly about the transmission and incubation period. A concerned national initiative to respond the pandemic could help better compliance with behavioral guidelines to respond to this public health emergency.

Knowledge, attitude and reported practice regarding donning and doffing of personal protective equipment among frontline healthcare workers against COVID-19 in Nepal: A cross-sectional study.

Coronavirus Disease 2019 (COVID-19) is a respiratory infection with a high rate of transmission primarily via airborne route and direct contact. Proper use of personal protective equipment (PPE) is a proven and effective way to prevent COVID-19 spread in healthcare settings. This study was done aiming to assess the knowledge, attitude, and reported practice, and identify the associated factors regarding donning and doffing of PPE among frontline healthcare workers in Nepal. A cross-sectional study was conducted from 25th April to 30th July 2021 among 205 frontline healthcare workers of Nepal selected randomly from among the contacts of the investigators. A structured self-administered questionnaire prepared in google form was used as a study tool and shared via social media to the participants to obtain information on socio-demographic and workplace characteristics along with their knowledge, attitude, and reported practice regarding donning and doffing of PPE. A total of 79.5% of participants had satisfactory knowledge while 75.6% had satisfactory practice scores regarding donning and doffing of PPE. Factors such as the profession of the participants (p-value = 0.048), their workplace (p-value = 0.005), provision of PPE at workplace (p-value = 0 .009), and availability of designated space at workplace for methodical donning and doffing of PPE (p-value = 0.010) were significantly associated with satisfactory knowledge score whereas availability of designated space at workplace for donning and doffing of PPE was significantly associated with good practice score (p-value = 0.009). This study demonstrated an overall good knowledge, attitude, and reported practice regarding donning and doffing of PPE among frontline healthcare workers in Nepal. However, the reported shortcomings like poor knowledge regarding the sequence of donning and doffing and corresponding flawed practice behaviors need to be addressed.

Association of social stigma of COVID-19 with work satisfaction, burnout and fatigue among healthcare workers in Nepal

Background: Stigma towards the patient of coronavirus disease (COVID-19) has been reported in various media reports, including negative behaviour among health care workers (HCWs) towards COVID-19 patients. Moreover, the negative behaviour of HCWs towards COVID-19 patients could affect the professional quality of life of these HCWs.Objective: We aimed to assess stigma related to COVID-19 patients among HCWs and explore its impact on their professional quality of life during COVID-19 pandemic in Nepal.Methods: An online cross-sectional study was carried out among 421 HCWs (health assistants 35.6%, nurses 33%, doctors 23.3% and paramedics 8.1%), 52.7% female, working in health facilities in Nepal. The measures included background characteristics, stigma in terms of - discrimination towards COVID-19 patients, acceptance of COVID-19 patients and fear of COVID-19, and professional quality of life in terms of - work satisfaction, burnout and fatigue. Descriptive and inferential statistics were utilised to analyze the data in SPSSvs20.Results: While around two-third of the study participants showed discriminating attitude towards COVID-19, a half showed negative attitude towards acceptance of COVID-19 patients, and a fifth reported attitude of fear of COVID-19. Multivariable regression analysis indicated that while presence of fear of COVID-19 was associated with low satisfaction, low burnout, and low fatigue; attitude of acceptance of COVID-19 patients was associated with low burnout and low fatigue; and attitude of discrimination towards COVID-19 patients was associated with only low satisfaction.Conclusion: Strategies directed towards - reducing fear and discrimination towards COVID-19 patients, and enhancing positive attitude of acceptance towards COVID-19 patients among HCWs, and thus, creating enabling environment for reducing their burnout and fatigue, and increasing work satisfaction are recommended.

COVID-19 pandemic and its influence on mental health of healthcare professionals in Nepal

Given the unprecedented global public health crisis due to the covid-19 pandemic, it is important to recognize the psychological impact on health care professionals. Previous experiences from the smaller scale epidemiology and new literature on COVID-19 have shown that increased pressure on healthcare professionals is associated with rise in the psychological incidence rates. We have described the psychological burden of the covid-19 pandemic on health care workers in Nepal and reviewed the literature on the impact of previous epidemics on front-line health care workers. In addition, we discussed potential triggers and measures to minimize the front-line psychological pressure to deal with this biological threat.

The wounded healer during COVID-19: unraveling the violence against healthcare workers in Nepal

The wounded healer during COVID-19: unraveling the violence against healthcare workers in Nepal

Prevalence of Anxiety, Depression, and Perceived Stigma in Healthcare Workers in Nepal During Later Phase of First Wave of COVID-19 Pandemic: A Web-Based Cross-Sectional Survey.

IntroductionThe COVID-19 pandemic has caused discrimination and social stigma among healthcare workers (HCW) causing psychological problems due to prolonged work shifts, uncertain pay, lack of personal protective equipment (PPE), added fear of infection to self or family, and so on. This online survey is directed towards the determination of anxiety, depression, and stigma among healthcare providers in Nepal during the later phase of the first wave of the COVID-19 pandemic.Materials and methodsAnxiety and depression were assessed using standard Generalized Anxiety Disorder-7 (GAD-7), and Patient Health Questionnaire-9 (PHQ-9), respectively. Data for the survey were collected from January 10, 2021, to February 6, 2021, and analyzed using Stata 15 (College Station, TX: StataCorp LLC).ResultsA total of 213 participants were enrolled in the study from different parts of Nepal and their mean age was 29.90±6.43 years. The prevalence of anxiety and depression among healthcare workers was 46.95% and 41.31%, respectively. A bidirectional relationship was present between GAD-7 and PHQ-9 score interpretation. About 57% of HCW experienced some form of perceived stigmatization due to COVID-19. Frontline HCW were six times more likely to be stigmatized compared to non-front line HCWs and diagnosis of COVID-19 was associated with three times higher odds of facing perceived stigmatization.ConclusionA significant number of HCW experienced symptoms of anxiety and depression during the later phase of the COVID-19 pandemic. Frontline HCW who were infected experienced a higher level of stigma.

Health System Preparedness for COVID-19 and Its Impacts on Frontline Health-Care Workers in Nepal: A Qualitative Study Among Frontline Health-Care Workers and Policy-Makers.

Rapidly growing coronavirus disease 2019 (COVID-19) pandemic has brought unprecedented challenges to the health system in Nepal. The main objective of this study was to explore the health system preparedness for COVID-19 and its impacts on frontline health-care workers in Nepal. Semi-structured interviews were conducted among 32 health-care workers who were involved in clinical care of COVID-19 patients and four policy-makers who were responsible for COVID-19 control and management at central and provincial level. Interviews were conducted through telephone or Internet-based tools such as Zoom and Skype. All interviews were audio-recorded, transcribed into English, and coded using inductive and deductive approaches. Both health-care workers and policy-makers reported failure to initiate pre-emptive control measures at the early stages of the outbreak as the pivot in pandemic control. Although several measures were rolled out when cases started to appear, the overall health system preparedness was low. The poor governance, and coordination between three tiers of government was compounded by the inadequate personal protective equipment for health-care workers, insufficient isolation beds for patients, and poor engagement of the private sector. Frontline health-care workers experienced various degrees of stigma because of their profession and yet were able to maintain their motivation to continue serving patients. Preparedness for COVID-19 was affected by the poor coordination between three tiers of governance. Specifically, the lack of human resources, inadequate logistic chain management and laboratory facilities for testing COVID-19 appeared to have jeopardized the health system preparedness and escalated the pandemic in Nepal. Despite the poor preparedness, and health and safety concerns, health-care workers maintained their motivation. There is an urgent need for an effective coordination mechanism between various tiers of health structure (including private sector) in addition to incentivizing the health-care workers for the current and future pandemics.

Occupational health and safety of the frontline healthcare workers in Nepal in COVID-19 pandemic

Occupational health and safety (OHS) is essential for every professional especially healthcare workers who work day and night serving patients. According to the WHO, health workers should not face any kind of workplace violence during their professional activities. Attention should also be paid to the mental and psychological health of healthcare workers and their protection should be of paramount importance. OHS related policies, rules and regulations have been formulated in Nepal. According to the law, the responsibility of the OHS of the employees has to be taken by the concerned organization.
 In Nepal, during the COVID-19 pandemic, health workers have to take the risk of infecting themselves while providing care for the patients. This has led to the infection of thousands of health workers and we have also lost quite a few healthcare workers in the line of duty in Nepal. On one hand, there is a psychological fear of acquiring COVID-19 infection in healthcare workers despite adopting health and safety measures, while on the other hand, in case of infection they will have to pay for the treatment from their own pockets. Sometimes ICU and ventilator services are not available not only in their working hospital but also in government referral health institutions which have given rise to incidences that healthcare workers themselves have to be admitted to other hospitals for the treatment. In such a situation, not just mental but also a financial burden has been added to the healthcare workers.

Psychological distress among health service providers during COVID-19 pandemic in Nepal.

COVID-19 pandemic has provoked a wide variety of psychological problems such as anxiety, depression, and panic disorders, especially among health service providers. Due to a greater risk of exposure to the virus, increased working hours, and fear of infecting their families, health service providers are more vulnerable to emotional distress than the general population during this pandemic. This online survey attempts to assess the psychological impact of COVID-19 and its associated variables among healthcare workers in Nepal. For data collection purposes, Covid-19 Peritraumatic Distress Index (CPDI) Questionnaire, was used whose content validity was verified by Shanghai mental health center. Data for the survey were collected from 11 to 24 October 2020 which was extracted to Microsoft Excel-13 and analyzed. A total of 254 health care workers from different provinces of the country participated in this study with a mean age of 26.01(± 4.46) years. A majority 46.9% (n = 119) of the participants were not distressed (score ≤28) while 46.5% (n = 118) were mild to moderately distressed (score >28 to ≤51) and 6.7% (n = 17) were severely distressed (score ≥52) due to the current COVID-19 pandemic. Female participants (p = 0.004) and participants who were doctors by profession (p = 0.001) experienced significantly more distress. COVID-19 pandemic has heightened the psychological distress amongst health care service providers. The findings from the present study may highlight the need for constructing and implementing appropriate plans and policies by relevant stakeholders that will help to mitigate the distress among health service providers in the current pandemic so that we can have an efficient frontline health workforce to tackle this worse situation.

Prevalence of Extended Spectrum Beta Lactamase Producing and Carbapenems Resistance Isolates from Hands of Health Care Workers in a Health Care Setting of Nepal

Background: Hands of healthcare workers (HCWs) could be colonized by potential drug resistant bacteria like Extended Spectrum Beta Lactamase producers (ESBLs) and Carbapenems-resistant (CR) isolates and could become vectors of nosocomial pathogens in healthcare facilities that are associated with an increase of morbidity, mortality and healthcare costs. This study aimed to investigate the prevalence of ESBLs and CR isolates from hands of HCWs with their antibiotic susceptibility pattern.
 Materials and methods: This was a cross-sectional study that included a total of 150 hand swabs collected from March, 2018 to September, 2018 in Gandaki Medical College and Teaching Hospital. Isolation, identification and antimicrobial susceptibility tests were done using standard microbiological procedures.
 Results: Among the total isolates of 219 obtained from growth positive samples 92/219(42.01%) were Gram negative bacteria (GNB) and the most common were Klebsiella spp 32(34.78%) followed by Escherichia coli 17(18.48%), Pseudomonas aeruginosa12 (13.04%), Acenetobacter spp 11(11.96%), Proteus spp 9(9.78%), Citrobacter spp 7(7.61%) and Enterobacter spp 4(4.35%). The prevalence of ESBLs, CR and ESBLs with Co-resistant to Carbapenems were 19.56%,14.13% and 9.78%, respectively. The most effective drugs for isolates were Nitrofurantoin followed by Amikacin, Tetracycline and Gentamycin. Distribution pattern of the ESBLs and CR isolates among doctors, nurses, laboratory technicians, helpers and basic science faculties were not significant (p>0.05).
 Conclusions: This report revealed the emerging and moderately high prevalence of ESBLs, CR and ESBLs with Co-resistant to Carbapenems GNB with their antibiotic susceptibility patterns found on hands of HCWs in Nepal. Thus, this study could be helpful in developing proper guidelines on hand hygiene and implementation of infection control measures including contact precautions against the spread of infections by such pathogens in healthcare settings.

1361. Knowledge, Attitude, and Practices on Drug-Resistant Tuberculosis Infection Control Among Healthcare Workers in Nepal: A Cross-Sectional Study

BackgroundHealthcare centers are important sites for tuberculosis transmission, particularly in low-income settings where the burden of tuberculosis is high and infection control practices are often inadequate. This study aims to assess the knowledge, attitude, and practices of drug-resistant tuberculosis infection control among the healthcare workers under the National Tuberculosis Control Program in Nepal.MethodsIn this descriptive cross-sectional survey, we studied the healthcare workers from all the functioning drug-resistant tuberculosis treatment centers across Nepal between March 1, 2018 and March 15, 2018. Nepal Health Research Council provided ethical clearance. Trained enumerators obtained informed consent and conducted face-to-face interviews with a pretested questionnaire to collect data on the basic characteristics of healthcare workers, their self-reported knowledge, attitude, and practice on tuberculosis infection control. We assigned a score of one to the correct response and zero to the incorrect or no response and calculated a composite score in each of the knowledge, attitude, and practice domains. We ascertained the healthcare workers as having good knowledge, appropriate attitude, and optimal practices when the composite score was at least 50%. We summarized the numerical variables with median and interquartile range (IQR) and the categorical variables with proportions.ResultsA total of 95 out of 102 healthcare workers from 11 drug-resistant tuberculosis treatment centers participated in the study. There were 46 male and 49 female respondents. The median age was 33 years (IQR 26–42). The majority of them (53, 56%) were mid-level paramedics. The median work experience in drug-resistant tuberculosis was 2 years (IQR 1–5). We found 91 (96%) respondents had a good knowledge of tuberculosis infection control with the median knowledge score of 14 (IQR 12–14), 49 (52%) respondents had an appropriate attitude with the median attitude score of 5 (IQR 4–6) and 35 (37%) respondents had optimal practices with the median practice score of 5 (IQR 4–7).ConclusionHealthcare workers at the drug-resistant tuberculosis treatment centers in Nepal had good knowledge of tuberculosis infection control but it did not translate into an appropriate attitude or optimal practices. Disclosures All authors: No reported disclosures.

The development and effect of the education program on hand hygiene and use of personal protective equipment: A randomized controlled study

This study aimed to evaluate the effect of an education program on the accuracy of performance of hand hygiene (HH) and the use of personal protective equipment (PPE) over time. This randomized controlled pretest–posttest study was performed with 34 experimental and 34 control group participants in the Western Development Region of Nepal. The intervention was a three hours education program on how to perform HH and use PPE, using multifaceted methods such as watching a movie, demonstration, practice, and peer feedback. The accuracy of HH and PPE use was measured three times with an observation checklist and was analyzed with a repeated measures ANOVA. The experimental group showed higher increase in accuracy of HH (F = 40.78, p < 0.001), putting on PPE (F = 112.75, p < 0.001), and taking off PPE (F = 34.72, p < 0.001) than the control group. As the education program had positive effects on the accuracy of HH and PPE use among nurses in Nepal, we suggest that the program be widely applied to healthcare workers in Nepal. Considering the decrease in the effect of the program on proper HH and PPE over time, it is recommended to provide re-education on HH and PPE at least three months and one month later, respectively.

Reducing stigma among healthcare providers to improve mental health services (RESHAPE): protocol for a pilot cluster randomized controlled trial of a stigma reduction intervention for training primary healthcare workers in Nepal

BackgroundNon-specialist healthcare providers, including primary and community healthcare workers, in low- and middle-income countries can effectively treat mental illness. However, scaling-up mental health services within existing health systems has been limited by barriers such as stigma against people with mental illness. Therefore, interventions are needed to address attitudes and behaviors among non-specialists. Aimed at addressing this gap, REducing Stigma among HealthcAre Providers to ImprovE mental health services (RESHAPE) is an intervention in which social contact with mental health service users is added to training for non-specialist healthcare workers integrating mental health services into primary healthcare.MethodsThis protocol describes a mixed methods pilot and feasibility study in primary care centers in Chitwan, Nepal. The qualitative component will include key informant interviews and focus group discussions. The quantitative component consists of a pilot cluster randomized controlled trial (c-RCT), which will establish parameters for a future effectiveness study of RESHAPE compared to training as usual (TAU). Primary healthcare facilities (the cluster unit, k = 34) will be randomized to TAU or RESHAPE. The direct beneficiaries of the intervention are the primary healthcare workers in the facilities (n = 150); indirect beneficiaries are their patients (n = 100). The TAU condition is existing mental health training and supervision for primary healthcare workers delivered through the Programme for Improving Mental healthcarE (PRIME) implementing the mental health Gap Action Programme (mhGAP). The primary objective is to evaluate acceptability and feasibility through qualitative interviews with primary healthcare workers, trainers, and mental health service users. The secondary objective is to collect quantitative information on health worker outcomes including mental health stigma (Social Distance Scale), clinical knowledge (mhGAP), clinical competency (ENhancing Assessment of Common Therapeutic factors, ENACT), and implicit attitudes (Implicit Association Test, IAT), and patient outcomes including stigma-related barriers to care, daily functioning, and symptoms.DiscussionThe pilot and feasibility study will contribute to refining recommendations for implementation of mhGAP and other mental health services in primary healthcare settings in low-resource health systems. The pilot c-RCT findings will inform an effectiveness trial of RESHAPE to advance the evidence-base for optimal approaches to training and supervision for non-specialist providers.Trial registrationClinicalTrials.gov identifier, NCT02793271

A phenomenological study of student nurses volunteering in Nepal: Have their experiences altered their understanding of nursing?

BackgroundNepal is a small country in the central Himalayas, with approximately 26.5 million inhabitants. Student Volunteer Placements International (SVPI) organise volunteer experiences with the Children’s Welfare Organisation in Nepal (CWON) in the Chitwan region of Nepal. These programs focus on the health of communities of this region. This research was undertaken to uncover the experiences of student nurses (participants) who volunteered as health care workers in Nepal. More specifically, the research explores the effect that the experience of delivering health care within the context of a low socio-economic setting had on the participant’s perceptions of nursing. ObjectivesTo gain an insight into how (if at all) the professional identity of student nurses had been impacted through volunteering as health care workers in Nepal. MethodThe research used the phenomenological paradigm. Five student nurses, who had volunteered in Nepal as healthcare workers and participated in the CWON/SVPI program for three week intervals, were interviewed. These semi-structured one on one interviews were recorded, the audio was transcribed and analysed using thematic analysis. ResultsFrom the research five emergent themes were derived from the participant’s experiences. Participants reported that the experience of delivering healthcare in the context of a developing country forced them to get creative and ‘think outside the box’. ConclusionEngaging in overseas volunteering assisted student nurses to reconnect with their empathy and compassion, and explore the humanistic and interpersonal nature of nursing rather than the technical skill based components of nursing identity. Additionally, the participants were forced to enact their nursing skills to the very boundaries of their capabilities and to be more innovative.

NSI: A major occupational hazards among the health care workers in Nepal

A percutaneous piercing wound as in needle stick injury is a typically set by a needle point, but possibly also by other sharp instruments or objects. These events are of concern because of the risk to transmit blood-borne diseases through the passage of the hepatitis B virus (HBV), the hepatitis C virus (HCV), and the Human Immunodeficiency Virus (HIV), the virus which causes AIDS. The present study was done to determine the risk status regarding NSI among health care workers of Private Hospitals, Pokhara, Nepal. Samples were selected through purposive sampling. Self administered questionnaire & risk assessment tool were used to collect data. Study revealed that majority of health care workers were females (93%) with mean age of 22.66 years (±3.1). Sixty eight percent had got NSI, among them 41% had NSI more than 2times in life. Maximum NSI cases happened either by recapping of the needle (18%) or during disposal of sharps (16%) or while transferring a body fluid (blood) to a specimen bottle (15%). The study concludes that majority of health workers had NSI more than two times which denotes NSI is a major occupational hazard. Cases happened either by recapping of the needle or during disposal of sharps or while transferring a body fluid to a specimen bottle. DOI: http://dx.doi.org/10.3126/ijosh.v3i1.9098 International Journal of Occupational Safety and Health, Vol 3 No 1 (2013) 22-25

Measuring the Quality of Rural-Based, Government Health Care Workers in Nepal

A representative, cross-sectional clinical skills assessment of 163 mid-level, rural-based, government health care workers was conducted in four districts of Nepal in June 2007. All Health Assistants and Auxiliary Healthcare Workers within the target districts were scored using checklists of standardized key skills in clinical encounters with model patients or clinical models. Participant scores were reported as a mean percentage in adult medicine 28(%), pediatric medicine 56(%), maternity medicine 35(%), orthopedic medicine 45(%), clinical procedures 59(%), and management 46(%). This was measured against the government’s 60(%) standard on clinical skills. There was little significant difference between categories of health workers by district of posting or years of experience. There was a minor difference in skills by level of facility - workers in higher level facilities scored better across the domains. Reasons for poor performance in clinical skills were attributed to a lack of clinical in-service training programs, training only focusing on prevention and public health, and poor on-sight supervision. Poor pre-service schooling factors included heavy theory concentration in pathophysiology and inadequate clinical exposure opportunities. Recommendations for the improvement of clinical skills and decision-making include the institution of in-service competency-based training with a high emphasis on real patient exposure. Pre-service recommendations include implementation of a national certification program and an expansion of the current government clinical training sites and clinical teacher development programs.

Midlevel Primary Health Care Workers in Nepal

"Midlevel Primary Health Care Workers in Nepal." South African Family Practice, 46(2), pp. 32–33