Opportunities and Challenges of Implementation Research to Prevent and Control Noncommunicable Disease in LMICs: The Nepal Experience

February 12, 2024

Speaker: Archana Shrestha, PhD

Wednesday, September 15, 2021

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ID: 11302
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00:00<v ->Legislation coordination committee.</v>
00:02She is also the Country Director for Nepal,
00:06for the Northern Pacific Global Health Research Fellows
00:09Training Consortium.
00:11She leads multiple implementation science research projects
00:14to prevent non-communicable diseases,
00:16including cervical cancer, cardiovascular disease
00:20and diabetes.
00:21She and I have been working together for the past six years.
00:25She originally came to work with me when I was at Harvard
00:29as a part of my NIH Director's Pioneer Award,
00:33and we started to develop some of these research projects
00:36that Dr. Shrestha is gonna talk about.
00:38But she's also gone off in her own directions as well.
00:42And we've continued to work together, we're co-PIs,
00:46or I'm site PI of multiple grants
00:49that she has led the submission of and succeeded in winning.
00:53And it's a very productive relationship.
00:56We've had many, many papers published.
00:59She's also an Adjunct Assistant Professor
01:01in our Chronic Disease Epidemiology Department here at Yale.
01:05And she's available for discussions with students
01:10and other researchers here in the Yale community.
01:12She has lots of data that she can collaborate
01:15in the analysis of, and many ideas for other projects
01:19that could be conducted in Nepal.
01:22So, she'll be here until Friday
01:24and she probably still has a few slots available
01:28in her schedule.
01:29And if you would like to meet with her
01:31to discuss any of these things further,
01:33you can also get in touch with William Tootle
01:36who's managing her itinerary.
01:38So, I'd like to turn this over to Dr. Shrestha now
01:42and I'm really looking forward to her talk.
01:44Thanks so much everybody for joining us
01:47and for Dr. Shrestha for traveling all the way over here
01:52in somewhat in the midst of COVID to meet with us
01:56and give this presentation today.
02:00<v ->Thank you, Donna, for such a wonderful introduction.</v>
02:05And thank you everyone for those who are present
02:10in-person in this room and then those who are joining online
02:13and Zoom, thank you so much for your time and interest.
02:17So, today's talk is gonna be a little very informal
02:21kind of discussion on opportunities and challenges
02:24of implementation research to prevent
02:27and control non-communicable diseases in LMIC.
02:30And I'll be sharing a lot of my experience from Nepal.
02:34And I think that a lot of these challenges,
02:37would be also applicable to other parts of the world
02:42where the resources are limited to do these kinds of work.
02:47And my talk would be like more about a general introduction
02:51of what we are doing in Nepal in collaboration with CMIPS
02:57and the second part would be
03:00like what were the major opportunities and challenges
03:02and specific to doing the implementation research
03:05in that context.
03:07So, let me give you like a...
03:09Let me start with a brief introduction of Nepal.
03:14It's a small country in between India and China,
03:18located in Southeast Asia.
03:21And compared to US, it's about 67 times smaller than the US.
03:29There are 11 times fewer people
03:31that live in Nepal compared to US.
03:34The per capita GDP is only 4.3% of the US per capita GDP
03:40and life expectancy is about nine years less
03:44than that of US.
03:48And then Nepal's life expectancy
03:51has been increasing over the past few decades
03:53and then it's expected to keep increasing.
03:57And with this longevity,
03:59a lot of non-communicable diseases
04:01and chronic diseases have crossed our paths.
04:05And if we look at the population pyramid of 2020,
04:11there were lots of bulk of the population
04:17were towards the base of the pyramid,
04:20indicating that lots of young population was in the country.
04:24But the prediction for 2025 shows that we will have
04:29this population pyramid changed by then
04:31and with a lot of middle aged population growing.
04:37<v Donna>Archana, could you go back</v>
04:38to that slide for a second?
04:40It's a little hard to read what the x-axis is and the-
04:43<v ->Oh, sorry.</v> <v ->The chart that-</v>
04:45<v ->So this one?</v>
04:47Yeah, this is year.
04:48<v ->So what's the first year?</v>
04:50<v Archana>1990.</v>
04:51<v ->So that's like a remarkable increase in life expectancy</v>
04:56over a very, very short period of time.
04:59I'm wondering if you could say a little bit
05:01about has that been researched at all?
05:04Is it known or is there good evidence
05:08for why there was this remarkable increase
05:11over such a short period of time where,
05:13what was it? It was like, what was it like in 19?
05:17What did it start at?
05:18Like 55 to 60, so is that what it's hard to read,
05:24but that's the y-axis.
05:25<v ->So in 1990s it was about around around 55 to 60.</v>
05:29And then by 2019 it's a lot about like 72 years.
05:34So a lot of it is contributed
05:37to improvement in maternal child health,
05:40specifically infant mortality rate.
05:42Actually, Nepal was one of the countries that made
05:45that achieved the million development goal
05:48in relation to infant mortality rate.
05:50And the infant mortality rate decreased really rapidly
05:53during that time.
05:54And that is considered one of the major contributors
05:57to what's increasing life expectancy.
06:01<v Donna>And what did Nepal do to break down</v>
06:03that actual mortality?
06:04<v ->A lot of things they were like,</v>
06:08so Nepal's health system was just built
06:14to address maternal child health and infant mortality
06:18and communicable diseases.
06:20So we actually started pretty late
06:23in terms of health system.
06:25We started in 1978 after the Alma-Ata conference
06:28when the primary healthcare was very advocated.
06:33And the Nepal health system was built in '80s,
06:37basically from '84 to '90.
06:40And the government were very progressive towards that
06:45and we built a health system that reached each
06:48and every corner of the country, even the most modest areas.
06:52So all of the villages had at least one
06:55or two health centers
06:56and they had primary healthcare outreach centers.
06:59So from these health centers people,
07:01they were called village health workers were assigned
07:05to run these outreach centers every month they would go
07:09like 5 to 7 times to different parts of the villages
07:12that were not accessible.
07:13And then they distribute family planning,
07:15they did immunization, child growth monitoring
07:19and antenatal care, postnatal care.
07:23So a lot of health system developed during that time.
07:28And it also significantly contributed to maternal
07:32like improvement in maternal child health and reduced,
07:38that's from malaria, tuberculosis.
07:40And Nepal is also has the widest network of dots
07:44and malarias treatment centers,
07:47even in the most remote area,
07:50there is availability of testing for TB
07:53and then there is availability of the dots.
07:55So yeah, I think that was a big leap
07:59for a country like Nepal
08:01and that it is considered one of the successful model.
08:05In fact, the kind of network that it has,
08:08we have like 48,000 volunteers.
08:12In each ward, what is the smallest administrative unit
08:16in Nepal?
08:16In every ward it has one female community health volunteers
08:21who are trained in health.
08:24They get like one month of training
08:26and then are refresher courses every two years.
08:30And these volunteers are connection
08:32between the community and health centers.
08:35And there were the female married,
08:39female of reproductive health who had at least one child
08:42with selected for that volunteer work.
08:46And each woman have, like each volunteer has a network,
08:51a women's group or mother's group in their community.
08:55So whenever someone becomes mother, they join that group
08:58and every month they run health education
09:02or immuno like, and they help with the immunization,
09:07they help with vitamin A distribution in children.
09:10So a lot of community mobilization and social mobilization,
09:14connection of community to the health center.
09:17Each health center has a community-based committee
09:22that has like chairperson of that ward
09:26and then health volunteers like leaders, teachers,
09:29and then they make a joint decisions about the health
09:32of that specific community.
09:33So it's very primary healthcare is very community-based
09:36and it reached to each and every household
09:39and that that is the biggest strength
09:41of the health system in Nepal.
09:43It's quite rare even in the context of low resource setting.
09:49Yeah, and then that has been this network,
09:53also has been now being explored
09:55to deliver the non-communicable diseases.
10:01<v Attendee>Is the 2025 demographic transition,</v>
10:04is that more of like a target or is it more like?
10:08<v ->It's more like forecast?</v>
10:11<v ->I have another question.</v>
10:14It seems like this,
10:15what you've described depends pretty heavily on volunteers,
10:19which from kind of an American point of view,
10:21like it's hard to imagine
10:22that so many people would volunteer and be reliable,
10:26and continue without getting paid.
10:29And is it really true that these volunteers
10:31like are consistently doing this kind of work
10:33and they're not getting paid?
10:35<v ->Yeah, yeah, it's since 1980.</v>
10:37So the first volunteers were recruited in 1984
10:41and since then they have been working
10:43like they are above around 50,000 volunteers
10:45all around Nepal.
10:48And they get paid really, really minimal.
10:50Like the days they work, they get paid about $2.50
10:55for that day.
10:56So let's say if they are,
10:59vitamin A distribution is very successful in Nepal,
11:02like on all on five children get vitamin eight twice a year
11:06and there is a coverage of more than 95%.
11:08And these volunteers do that.
11:11So the day they are distributing vitamin A, they get $2.50.
11:15It's very minimal even in context of them.
11:20And there has been debate whether a government
11:21should pay them or not.
11:23And then with the like expansion of lot
11:26of programs in the health sector
11:27or health sector, like they are considered one
11:30of the biggest liaison between the community
11:34and health center and then
11:37like a role models for awareness raising and all that.
11:40So anyway, so and then this brings to like
11:44how Nepal's health system was like really created
11:48to address maternal child health
11:50and to address the non-communicable diseases.
11:53And then over the last, from 2009 to 2019,
11:58if we look at what has changed, the top 10 cause of death
12:03and disability is still neonatal disorder,
12:05but it has decreased with about 38% in the past decade.
12:12And non-communicable diseases like such as COPD,
12:16ischemic heart disease, stroke, cirrhosis, depression,
12:21low back pain has increased.
12:24So currently, non-communicable diseases
12:28are the number one cause of that in Nepal as well.
12:31And if we look at the risk factors contributing
12:35to these daily, malnutrition is still number one.
12:39But if you look at the change, there is 46% reduction
12:43since 2009 to 2019.
12:47Reduction to air pollution,
12:48but increase in tobacco conjunction, high blood pressure,
12:52the dietary risk.
12:53And if you look at like high body mass index,
12:56like hoping 95% increase from 2009 to 2019.
13:01So these all data indicates towards
13:04like how Nepal is now vulnerable
13:06to the non-communicable disease.
13:08There is existence of dual burden of disease,
13:11like even within a how one household you can find
13:13a malnourished child and overweight mother.
13:18So that's kind of nutrition and epidemiological transition
13:24that our country is facing.
13:28So today, I'm just focusing on three studies
13:32that we are conducting in collaboration
13:35with CMIPS School of Public Health in Nepal.
13:38And these are the three very different kinds of study
13:43all of them like implementation science study
13:47to address non-communicable diseases in some way.
13:52So the first of these studies is the,
13:56we call it Nepal Pioneer Worksite Intervention Study,
13:59that's when we started, it started when I was in Harvard.
14:03Like I remember we, the first conversation was like
14:07as early as in 2015 on November.
14:11I still remember that because I went to Nepal
14:13to explore like what could be done during that time.
14:17And then we came up with this idea
14:20that we already have a lot of evidences
14:24to prove to how to modify the lifestyle
14:26and how the lifestyle modification can contribute
14:29to different diseases like diabetes
14:31and other CVD risk factors.
14:34So we designed this study
14:37to prevent the cardio metabolic disorders
14:41in work site setting.
14:43And then I'll get in details of each of the study briefly.
14:46And the second study was,
14:48it is different from the previous study.
14:50The previous study was more about hybrid design.
14:53We were using the evidence-based intervention,
14:55but we spent a lot of time doing formative study,
15:00contextualizing that information into Nepal's context.
15:06And this is one of the, I think,
15:08one of the biggest areas in implementation science research
15:12the context, how do we understand the context
15:15and how we apply existing evidences
15:18that were proved somewhere else like in the US
15:20in Argentina and Thailand.
15:23And then bring that evidences
15:24and implemented in context of Nepal.
15:26So we did a lot of formative study on around
15:28that developed intervention
15:30and then analyzed its effectiveness.
15:33And second study was to evaluate the package
15:36of essential non-communicable diseases in Nepal.
15:38And this is now completely different intervention
15:42was designed by the international agencies, WHO
15:46and then WHO recommended and advocated this intervention,
15:51Nepal government adopted in 2016, piloted in two districts
15:55and then without evaluating it,
15:57it expanded into 32 district.
15:59Now the plan is to expand to all 77 district
16:03and they have also started ruling out the training,
16:07but nobody really knows what is really happening
16:09after that training.
16:10And after the 2016, is it really working, not working?
16:13What's really happening in that specific context?
16:16So we got R21 forward international grant
16:20to study the current implementation outcomes
16:23of the national program in the pilot districts.
16:27And the third is the cervical cancer prevention program
16:31in low resource setting.
16:32It's also a pilot implementation study
16:34and the implementation is a researcher initiated
16:37into implementation.
16:38So this is like a different touch
16:41in the implementation science area.
16:43So we know that HPV screening works
16:48to prevent the cervical cancer,
16:50but it is has not been done in Nepal.
16:53Only 8% of Nepalese women have currently reported
16:57to ever had any cancer screening.
16:59So there is a huge gap
17:01but there has been a lot of,
17:03there is a national protocol as well
17:06which then that advocates for VIA and SPV testing.
17:11But government doesn't really have any specific plan
17:15of action to how to roll this out in the country.
17:18So we are planning to do a small study
17:22among 1500 women and then collect these information
17:25for government to roll it out throughout Nepal
17:28or throughout a certain parts of the country
17:31where it can work.
17:37So the first study was more contextualizing,
17:40second is like evaluating a national program
17:42that has already been implemented in 30 days
17:45like investigator initiated intervention
17:48and collect information for government to scale up it
17:51in further into in like around the country.
17:58So William, I cannot look at the time
18:01so please keep me posted.
18:03<v Donna>It's only 10:25, so you've got plenty of time.</v>
18:05<v ->Okay, thank you.</v>
18:07So the first study is
18:08the Nepal Pioneer Worksite Intervention Study.
18:10This is a picture of one of the interventions that we did.
18:14So employees in the work sites also got instruction
18:22for physical activity
18:24and we used local resources to do that.
18:28Thank you so much.
18:31So this study was started to assess
18:38what would be the effective
18:39of environmental level intervention alone
18:42and individual level intervention in combination
18:44with environmental level intervention on its effect
18:49on the metabolic risks.
18:51So we had three primary outcomes, glycated, hemoglobin,
18:58systolic blood pressure and triglyceride.
19:01And there's a lot of evidences
19:04like a randomized control trial, meta-analysis
19:06that shows that of diet and physical activity
19:09does reduce the risk of cardiovascular diseases.
19:12And there has been developed a lot of models
19:14to deliver that into community
19:16and in like penetrate in the population.
19:18And one of them is diabetes prevention program,
19:20which is pretty popular and it has been contextualized
19:23in many countries.
19:24So we took that as well.
19:27And behavior change intervention
19:30is also more than individual level effort.
19:33So if we ask people to like eat whole grain
19:36and then the whole grain is not available anywhere
19:38in around and nobody can eat here it, right?
19:44So we were very convinced
19:48that until these healthy foods are available,
19:51people will not be able to eat it.
19:53So one of our biggest challenges was
19:57to make these food available.
19:58So that's how we added the environmental intervention
20:01and we were very interested to know
20:03like what would be the effect
20:04of environmental intervention alone.
20:06So we kind of came up with this study design,
20:11let me explain like why we choose the work site
20:13because employees spent a lot of their waking hours at home
20:18before COVID and hopefully, in the coming days.
20:22And there is also natural environment
20:24for social support within our work site.
20:27And we have an access to adult population
20:29who are at risk to do the non-communicable diseases.
20:35We have this population who are in this formal employment
20:38and we can follow them for years to come.
20:41In Nepal, it is very rare for the employee to quit job
20:46and/or to change job if that they are,
20:52most of them are find their job
20:53in their hometown closer to family.
20:55So it's very rare for people to like change
21:00or like move from town to town in Nepal,
21:01so this was a good setting in that context.
21:06And also it has like formal and informal norms
21:10that could facilitate the healthy choices
21:12and we could have like a protected time
21:16for doing some health education programs if we require.
21:19So work site provided a very good platform for us
21:24to deliver this intervention.
21:26And we opted for
21:27the environmental level works site environment
21:30that included healthy foods in the canteen.
21:34Cafeteria is called canteen in that part of the world.
21:37So healthy food in the canteen and health screenings,
21:41and management support for the lifestyle improvements.
21:45And indeed there was individual level components.
21:47It was based on the diabetes prevention program.
21:50It has like peer lead lifestyle education,
21:52weight-loss and physical activity goals
21:54and 16 core courses, classes,
21:57each class was one hour long.
22:00First 20 minutes was about lecture.
22:04Second 20 minutes was more discussion
22:07about how this lifetime modification is going on
22:11in their life and then experience sharing.
22:14And the third, last minute was physical activity.
22:16They would like come to a place, there was a specific site
22:22that was dedicated for the physical activity
22:24and a physiotherapist would go
22:26and then they do the exercise together for 20 minutes.
22:31And then we conducted the studies in three steps.
22:34The first was formative study
22:36and then designed the intervention based
22:39on the formative study.
22:40Like I would more say like adopt the intervention
22:44and then test its effectiveness.
22:47So we did a lot of things for formative study.
22:49We were concerned about the quality of oil,
22:51so we brought the oil samples from,
22:54there were four canteens in this hospital
22:56where we were doing this study
22:59and we got oil samples from all four canteens,
23:03both used oils as well as unused oil.
23:06And there is this practice of reusing the oil.
23:10So we were concerned
23:11if the reheating or reusing the oil,
23:14it might have an impact on the nutrients, oil nutrients.
23:18So, but then we found that there was not much difference
23:21between the used and unused oil
23:23and they were all using, basically using soya bean oil,
23:27vegetable oil or sunflower oil.
23:31So we decide that we will not do any intervention
23:36for the oil part.
23:37And then the second part was,
23:39which was a big challenge was,
23:42we did a small study among 40 participants
23:45and did brown and white rice tasting.
23:49So we blinded the people, everybody would get white rice
23:52or brown rice in different combination, five combinations.
23:56So, and then that were randomly assigned for each day.
23:59So 25% white rice, 50%, 75%, 100% white rice
24:05or 0% white rice.
24:06And then they would rate after they eat their lunch,
24:10they would rate it in terms of
24:11how do they like overall, appearance,
24:14taste, aroma and texture.
24:16So 100% brown rice was not that much liked,
24:20and then these people are eating brown rice
24:22for the first time, even Nepal has been like,
24:24its stapled food is rice.
24:27Everybody eats rice two times a day and a huge hip of rice.
24:33And then so we took upon the taste and aroma
24:38that were rated for 50% brown and 50% white rice
24:41and 100% white rice were rated similarly.
24:43And then texture was even it's 50/50 was better,
24:49rated better than 100% brown rice.
24:50So we started to introduce the brown rice
24:54by mixing 50% brown rice, 50% white rice in the cafeteria.
24:58And we also conducted the focus group discussions
25:02with the cafeteria clients.
25:04And this paper has been published
25:07and then one of the big major facilitators
25:10was the availability of healthy foods in the cafeteria.
25:13And major barrier was human resources
25:16and lack of knowledge in the canteen,
25:19chef and a person working in the cafeteria,
25:23and then difficulty in changing the food habits.
25:26Like it's food is culture, it's not just a thing
25:29that you eat, it's like it's more into your social structure
25:33and culture so those were identified
25:37and from the canteen operator's point of view,
25:41we found that making profit was not a priority
25:45in that context.
25:46So that was a good facilitator for us.
25:49And they also had a physical facility and commitment,
25:54and the barrier was again the lack of human resources
25:56in the canteen, they were not aware about healthy food
26:01and how to like modify their existing recipe
26:04to convert the food into like healthy options.
26:06And then lastly, we also analyzed the seals
26:09of the cafeteria in the past year.
26:11And then we wanted to focus on those foods
26:14that were being sold in maximum volume.
26:18So we selected like...
26:22We categorized foods into different categories
26:27based on how much were they sold.
26:29And then we focused on those that were sold
26:31like more than 10,000 items in that year.
26:37And based on these information,
26:38we had actually four stakeholders meetings
26:43with the cafeteria manager,
26:45like the administrative director of the hospital.
26:50And then we formed our canteen improvement team
26:57in the hospital and that has like people from finance
27:00because one of the things that we identified
27:04in our formative study was
27:06the people who are making the decision about menu
27:08were the people from finance department
27:11because that had the direct implication on the cost.
27:14And then NCD department, there was a nutritionist involved
27:19and then our study research staff
27:22and consumers were involved and we had, first,
27:24we trained this, we made this kind of team
27:27and then we trained them on what
27:29to make a common understanding of healthy diet,
27:32what are we talking about when we are saying healthy diet?
27:35So there was a lot of differences
27:38in that perception as well.
27:39So we had to get a common understanding on that.
27:42And then we made implementation
27:44and monitoring plan in collaboration with this team.
27:49And then we did three rounds of training
27:53with the cafeteria staffs, specifically shifts.
27:57And then this training would be more interactive,
28:01like interactive conversations
28:04between our research staff and the canteen staff.
28:08And then we focused on healthy eating plate
28:11and then healthy cooking.
28:16And so adding vegetables and fruits wherever possible,
28:19just add fruits and vegetables.
28:20So fruits was not at all available in the canteen
28:23when we started this intervention.
28:25And whole grain was not at all available,
28:27not a single option of whole grains,
28:30and/or using oil, oil was used very evidently,
28:33so we focused on these three things.
28:36And then we did our workshops to determine like what we add
28:43and what we remove from the existing cafeteria.
28:45So we decided to add like fruits, banana
28:50and apple was chosen
28:51because there was no system for refrigeration.
28:54And then these two are like banana would be consumed
28:56on the same day, apple could be stored for a long time.
28:59And then we added whole grains like oats, buckwheat,
29:01whole wheat, roti and then drinks,
29:03water was made available free and whole and vegetables.
29:08So we added salad like cucumber and radish
29:11are very considered, so Nepal salad means cucumber
29:16and radish, it's not like greens like here.
29:20So every meal they would offer either cucumber
29:24or radish on site.
29:26And we introduced popcorn and then for the snack,
29:32we introduced fruits and again water.
29:37And we removed all white bread, puff,
29:42puff is like a croissant and donut,
29:45and then biscuits, cake.
29:48And then we also altered rice.
29:52So we mixed white rice with brown rice
29:54and then we completely got rid of white bread
29:57and then all the sugar-sweetened beverages
30:00were completely off.
30:01So they were not available even if on demands.
30:12And then we did a kickoff event where,
30:14so we made a big fuss of it, we had a kiosk desk
30:18and then we were talking like all the research staff
30:22were talking to the consumers who were dropping
30:24in the canteen, discussing about these changes
30:26like how they felt, like why we are doing the changes.
30:29We made like big posters in the cafeteria
30:32and then why should we,
30:35just basically justifying these interventions.
30:38And then we did a weekly observation checklist
30:42and monthly CIT meetings.
30:43So we would, one of the research staff
30:46and one of the CIT team members would go visit
30:49all of this cafeteria every week
30:51and then see whether it was sustained or not.
30:57And these are some pictures that were some modifications.
31:02So this is like we added oats for breakfast
31:05and then we added this fresh water.
31:09We wanted to make it look beautiful
31:11because we were getting rid
31:13of all of the sugar-sweetened beverages.
31:15And then because there was a lot of pushback
31:18for two things, specifically two things.
31:20One was the sugar-sweetened beverages.
31:22And the second was white rice,
31:25mixing white rice and brown rice.
31:26So a lot of people who are angry for,
31:29because they are so used to eating 100% white rice,
31:32so then we had to add 100% white rice,
31:35but it was not available on the counter,
31:40it was available like behind the scene.
31:42It was not visible.
31:43So only those who really, really wanted would
31:45like ask for the brown rice
31:46and would get like 100% white rice and would get it.
31:51And then the individual level intervention
31:53had 16 core courses like goal setting, stress management,
31:57healthy eating and mostly they had four themes.
32:02So one was healthy eating, promoting healthy eating,
32:04physical activity and demoting alcohol, tobacco and stress.
32:12And so this is the current status of the data.
32:23This is the current status.
32:25Actually we have completed
32:26the behavior intervention as well.
32:28Behavior intervention was randomized,
32:31so everybody received cafeteria intervention.
32:33So all four cafeteria received intervention
32:36and then we measured the outcomes before
32:40and after the cafeteria intervention.
32:42And we also wanted to do,
32:44to compare it with control-timing.
32:47So we did a six month gap.
32:49So we measured the outcomes and then we measured it
32:54after six months without any intervention.
32:56And then six months after the cafeteria intervention.
33:06So this is the baseline characteristics of the participants.
33:10Most of like mean age was 32 years,
33:14most of them were like our ethnic groups.
33:17So that whole town is more predominantly this ethnic group.
33:20I'm also from this ethnic group
33:23and most of them were married, 69%,
33:28like 89% were Hindu religion,
33:31they identified themself as Hindus.
33:35And they had like high school
33:38or more education, more than 76%
33:43because this is the hospital setting,
33:45a lot of them are nurses and doctors, and paramedics.
33:53So after the cafeteria intervention,
33:55this is what we found for the health outcomes.
34:02So systolic blood pressure decreased by 5mm,
34:07just after only screening without even cafeteria
34:11and more after the cafeteria intervention.
34:15So it was at statistically significant.
34:17We saw a statistical significant difference
34:20in systolic blood pressure, diastolic blood pressure
34:23and fasting blood sugar.
34:27So the fasting blood sugar is little bit weird
34:30because in the cafeteria intervention
34:32we saw a little bit increase in fasting blood sugar
34:36and then there was a decrease in low density lipoprotein
34:41and others there was not a significant difference
34:44in other outcomes.
34:48So this is interesting.
34:49So when we look at the whole grains at baseline,
34:52they were only eating like 0.87 servings per week.
34:56At six months, it changed to 0.51 servings per weeks.
35:00And then after the cafeteria intervention
35:02it was 4.22 servings per week.
35:05So it has a, considering that they eat only one meal
35:08in the cafeteria, one or two.
35:12And the decrease in refined grains
35:14are like amazing like about 20, there is 22.8 servings.
35:18Like we eat a lot of refined grains, 22.8 servings
35:22of refined grains per week
35:26and then it decreased to 21.2 servings
35:29of refined grains per week.
35:31There was increase in consumption of fruits and nuts.
35:38And then there was a decrease,
35:40a little bit of decrease in consumption
35:42of sugar-sweetened beverages,
35:43but it was not that statistically significant.
35:45So people were still drinking it outside of the hospital.
35:52So this is like basically our experience
35:55in like how we develop, contextualized this intervention
36:01and what had its effect on change in diet.
36:04Like it definitely had significant contribution
36:07in change in quality of diet
36:09and then few of the health outcomes as well.
36:15<v Donna>I just have a quick,</v>
36:16did you collect data on how much of it was all outside
36:20of the hospital setting
36:21and outside of their work setting?
36:22<v ->Yeah, we do have that.</v> <v ->Whereas, changes made</v>
36:24in the home like shipped in the kind of rice that they had
36:27and other kinds of- <v ->So the total sales</v>
36:29in the cafeteria had not changed.
36:31So there was not a very significant drop.
36:34And that we also asked individually if they had,
36:38how many times did they eat in the cafeteria?
36:41But unfortunately, we didn't ask that in the baseline.
36:45But then the overall
36:46like the food sales when we analyzed the food sales
36:50had not changed in the cafeteria.
36:52So there was no not much drop.
36:56<v ->Well, I think Mayer was asking,</v>
36:58did they change their eating patterns
37:00at home? <v ->Home, oh we didn't...</v>
37:01Oh, sorry, we didn't ask that.
37:03We didn't ask that.
37:05That's a very interesting, though.
37:08So now we have extended this program to schools.
37:11We have enrolled 22 schools
37:13that I have not included in this presentation
37:15and then conducted a randomized control trial among
37:18with this behavior intervention.
37:21We couldn't do the cafeteria intervention,
37:23although it was on the plan because all schools were closed
37:26for the past like one and a half years.
37:29It's still closed in Nepal,
37:31but as soon as it opens we will go
37:34for the cafeteria intervention in this school as well.
37:37So next is to evaluate the package
37:41of essential non-communicable.
37:42I will go a little bit quickly-
37:44<v Donna>(faintly speaking) we have about 15 minutes.</v>
37:49<v ->Yeah, so I'll just give up-</v>
37:52<v Donna>Not that we want you to rush.</v>
37:53<v ->Yeah, we don't have that, so it's just a status.</v>
37:59So as I explained before the WHO proposed
38:02this cost-effective program,
38:04it's called package efficiency of non-communicable diseases.
38:06A lot of LMIC adopted it,
38:08it got very famous in Bhutan as well.
38:12And then Nepal also adopted this and this intervention,
38:16it aims for early detection and modification of risk factors
38:19and avoidable medications for prevention
38:22and treatment of four major NCD, CVD cancer
38:26in Nepal we focus on two cancers, breast cancer
38:28and cervical cancer,
38:30chronic respiratory diseases and diabetes.
38:32And PEN also aims to reinforce health system
38:35and integrated NCD care into the primary healthcare.
38:38Right now, what's happening is NCD care
38:41is very more delivered by the private sector.
38:44It's not integrated into the public sector
38:46and not much was available in primary healthcare
38:50before this program.
38:51And the government endorsed it in the 16
38:55out of 77 districts in 2016
38:57and expanded to 33 district in 2019,
39:01and the program is still in expansion.
39:04So different versions of PEN is available,
39:07so this is for Nepal.
39:10Prevention of heart attacks, stroke and kidney diseases
39:13and focusing on heart attack, stroke,
39:14rheumatic heart disease, diabetes
39:17and chronic respiratory diseases,
39:20management of asthma and chronic respiratory diseases,
39:23and assessment and early diagnosis of cancer.
39:28And it only focuses on breast cancer
39:30and cervical cancer in Nepal.
39:34And then our goal was to measure
39:37these implementation outcomes.
39:38So we were measuring acceptability, adoption,
39:41appropriateness, cost, feasibility, fidelity
39:43and penetration, and sustainability.
39:47And so these, I just wanted to give this example
39:52of how we are measuring it and then we compare it
39:55with the other project that we are doing.
39:57So for the PEN we are mostly doing at the provider level
40:00and health facility level.
40:01For the other study,
40:02we're doing at the individual client level as well.
40:05So like satisfaction of the program itself
40:08and what percent of the health workers
40:11actually completed the training
40:13and what percent of health volunteers
40:15were completed the orientation
40:17and what percent of the PEN,
40:20the clinic did set up the program.
40:26And for the feasibility we were seeing
40:28what percent of the eligible clients were screened
40:31and what percent of the eligible clients were treated
40:34and what percent of the eligible clients were referred.
40:37And for the feasibility, we observed health workers,
40:41whether or not they were following the protocol
40:46on the prevention of heart attack, stroke and kidney disease
40:49and health education and management
40:51of chronic obstructive diseases and assessment of cancer.
40:56And then for the penetration,
40:58we are estimating the percent
41:00of active pain clinics in the past a year.
41:04And for the implementation cost,
41:06we are estimating the capital cost
41:08and then as well as indeed cost from the perspective
41:11of health facility and for the sustainability also,
41:14we will be estimating the annual facility level cost
41:20and reporting system.
41:23And the project right now, we had a target
41:27to do the quantitative assessment of facilities, 106
41:32and then we have achieved that.
41:33We're doing the qualitative interviews
41:35and data analysis is in process.
41:38This is one of the typical health center in western Nepal.
41:42So just to give you like a glimpse
41:44of what we are actually talking about.
41:47And this is like inside the health centers
41:49where we are doing the facility.
41:51So it's nothing close to any smallest clinic
41:55that you would go to in the US,
41:58but it's a very typical in context of Nepal and other NMIC.
42:03So the third is cervical cancer.
42:05Again it was investigator initiated intervention
42:09and then we wanted to collect data
42:12for government to scale it up.
42:14So more in like international guidelines are advocating
42:18for HPV testing, which is considered highly sensitive
42:22and accurate and women also prefer
42:24the self-sample collection,
42:26avoiding the speculum examination in Nepal.
42:29So there has been already conducted a study in Nepal
42:31that women prefer self-sample collection
42:34and that also did in better screening
42:37and covers in context of Nepal.
42:39So again, we are estimating the same implementation metrics,
42:44but in context to the previous study,
42:46we are doing it at in client level and provider's level.
42:50For at the client level, we will measure satisfaction
42:53and partner support.
42:54At the provider's level, we will measure the adoption,
42:58we measure the feasibility at the provider's level
43:00where in the previous study we were doing it
43:02at the health facility level
43:04and then we are measuring the fidelity
43:06at the client's level, whether or not they are following
43:08the protocol for self-sample collection
43:11and home care adherence for post-treatment
43:15and cost for health facility level,
43:17if we are replicating this program,
43:19what would be the cost that or health facility
43:22I will have to incur and sustainability
43:24like what would be the annual cost to sustain this program
43:28and what can be the reporting system
43:32within the government health system?
43:36So we have target to enroll 1500
43:40and then we have completed enrolling 926
43:43self-sample collection has done for 226 women
43:47and we are starting HPV testing this week.
43:50So we really, really excited, we had a meeting this morning
43:53about it and then we will conduct
43:55a follow up survey as well.
43:58And this is the setting that that's,
44:01this is a like, just to give a glimpse of the setting
44:04where we are working.
44:05So these are the women in this municipality
44:10and our health staff visit them and they give them
44:14like instruction, they're reading the instruction
44:16how to collect the self-samples.
44:18So the volunteers, we have network of like 34 volunteers
44:23in that municipality as well.
44:24So we ask them, they facilitate to bring women
44:27in one courtyard we're doing in the open spaces
44:31and then they get the sample collection kit
44:34and then they collect the sample
44:36and give back to our research staff.
44:39And then our research staff is like answering
44:41if they have any questions
44:42and then showing this little pamphlet
44:45about the self-sample collection.
44:50So quickly, I'm not taking much time now.
44:54And then we do have a lot of challenges
44:56to particularly in research,
45:01but I'm not getting into that
45:02like we have limited resources.
45:04We have like geographical challenges,
45:05Nepal's mountainous country, like lack of human resources,
45:08everything, all of that is there.
45:10But today, really wanna focus on
45:11like implementation research challenges.
45:14So first is stakeholder-related
45:17and it's of utmost importance
45:19to engage stakeholders in every process.
45:23And it's like a lot of time that we really need
45:27as an implementation science researchers,
45:29we really need to allocate that time
45:33to engage with stakeholders
45:34and we have to do it in multiple setting.
45:36It's not like one meeting
45:37and then you give information, you collect feedback.
45:42It doesn't work in case of implementation science research,
45:46for example, we spent whole one year
45:49just doing formative study to develop that intervention
45:52and even for the PEN study, we had to collaborate
45:57with the Ministry of Health,
45:59Epidemiologic Disease Control Division
46:01and there was a lot of discussion ongoing.
46:03We made a lot of changes in the design
46:08and we initially planned to do it only 16 districts,
46:12but then because because of their demand,
46:13we added that we did it in all seven provinces
46:18and 32 districts.
46:19So there was a lot of changes in design,
46:21in positive way and it took a lot of time
46:24and it was a little bit complex
46:25because everybody comes with their own agenda
46:27and then call to like to really,
46:30get the buy-in of all of these people from different setting
46:35and bring them into one focus,
46:38into one objective has been a challenging,
46:41but a very good lesson for me overall.
46:45And research has been viewed as like a short-term project,
46:49within implementers as well as the evaluators.
46:51So when we approach any stakeholders, like they were saying,
46:55okay, you collect data for three months
46:56and then you go, so nobody is thinking about
46:59like long-term engagement, long-term partnerships.
47:02And it took some time to like really make them understand
47:06and convince that this is not a one-time event
47:09or even like few times event.
47:12And there has been challenging in health system,
47:16for example, there has been external factors
47:18and then we had to keep changing the study designs.
47:20It's not like a randomized control trial protocol.
47:22You just come with a protocol and do it,
47:26though, it didn't work like that.
47:28So for example, when we were doing the PEN survey,
47:33suddenly the COVID hit us
47:34and then we had to change the strategy
47:36and then there was this big flooding,
47:38and then we had to change the health facilities,
47:42the selected group that we selected randomly,
47:45but we had to exchange it to different
47:47because roads were all blocked.
47:49And then there was this government,
47:54they really after they knew that we are doing this study,
47:56they chipped in, they also added some funding.
48:00Nepal health research council got into
48:03as an official partner of this study
48:05and they wanted to do it faster.
48:07So we had to really like add on like human resource
48:13that they paid for.
48:14So we had like eight resource assistants that were hired.
48:17And what they really wanted to,
48:19because they want to enroll it fast in the country,
48:21they wanted the resource faster.
48:23So they actually paid for eight more resource assistance
48:26and then we had to like change
48:27the whole field plan and everything.
48:29So that's very expected.
48:31And there is a strong bureaucracy in the health system
48:34and that also caused some misunderstandings,
48:38and some delays or there are a lot of transfers happening.
48:41So we engaged with one stakeholder
48:43and that person get transferred or something else,
48:45a new person come in, so it introduces some delays.
48:49And then there is a lack of evaluation plan
48:52within the health program.
48:53So for example, the PEN or HPV screening
48:56within the government sector, they had this program,
48:58but they did have any evaluation plans.
49:01So we had to come, build completely new after the program
49:06has been evaluated, has been like implemented.
49:09So it has some limitations in terms of what kind of the data
49:12that we need and what kind of data
49:13that we collect at that point.
49:17And then the routine healthcare data did not,
49:19was very incomplete and then more often,
49:22it may also be inaccurate.
49:24So for even for the PEN, we wanted to see
49:27what percent of the clients had been screened,
49:29but there was no data available to do that.
49:33And there was some issues with IRB.
49:36IRB was, we had a really long discussions with IRB
49:40because they didn't understand
49:41implementation science research.
49:43In Nepal it's very, very common for IRB
49:47to also give scientific feedback.
49:49So they would say why this many women
49:51that you are recruiting, like why this many things,
49:53why is not there is a control group for the HPV care.
49:56And then we have to do a lot of back and forth
50:00with the IRB and it took quite some time.
50:07And then there was researcher-related,
50:09the people we were hiring in the Nepal
50:12didn't have any background
50:13on implementation science research.
50:15And then we had to like first train them,
50:17they didn't have any experiences.
50:19There was complete disconnect
50:20between the implementing like government agencies
50:22that were implementing the program
50:24and the evaluating bodies that was university-wide
50:27to create these new linkages before we initiate the program.
50:32And then there was this very weird challenge
50:36that we did not have same understanding
50:40of implementation science research
50:42even among the implementation researchers.
50:44So like there was like big pushback
50:46to use any kind of framework, which is we,
50:49as an academician find very rare
50:52because we think that, okay, implementation science
50:55here is a framework
50:57and we give so much emphasis to the framework.
50:59And then there was this group of people
51:00who were implementation scientists
51:04and then they were saying frameworks
51:05are just for academic exercise, we don't use framework.
51:09Like, and then we had to like had two hours conversation
51:12like why we wanna use framework
51:14and like they were debating why
51:16we don't want to use frameworks.
51:17So anyway, so those were I think, were explored on the way.
51:24So there were some opportunities as well.
51:26I think, for me, number one reason
51:29for pursuing the implementation science is
51:31it has a potential to make a huge impact on public health.
51:34There are lots of promising research areas.
51:37Nothing is really happening in the context
51:39of implementation science research, so we can do a lot.
51:43And there is a like real need
51:45to embed this implementation science within healthcare
51:47because healthcare program are running on their own.
51:50They are never evaluated.
51:51Like nobody really knows what's really going on
51:55because there is no activate proper data system
51:58or analyze mechanism, or feedback system.
52:01So I see them as this is a limitation
52:07to do the study right now,
52:08but I see them as a big opportunity for us.
52:11And then we can have a really, really big leap
52:13in this context of LMIC.
52:18And so compared to 10 years ago,
52:22even like when we were starting Donna in 2015,
52:24there was not that much of resources on IS
52:27and now we have all of these worldwide IS networkings
52:31within the LMIC, I'm part of two of such networks
52:35and there is a growing interest from funding agency,
52:38NIH like National Cancer Institute
52:40has this big interest in implementation science.
52:44NHLBI is taking a lot of interest.
52:46There is interest from Gates Foundation,
52:48we got a smaller grant from Resolve to Care,
52:50another organization and there is also a lot
52:52of interest at the local level from WHO.
52:55WHO also chipped in
52:58in our PEN implementation evaluating program.
53:03And there is also a big opportunity
53:06in the program evaluation funding
53:07from non-government organization if we want to explore that.
53:12And there are also training opportunities available.
53:15A lot of available,
53:16a lot of free resources is available online.
53:18And then in our master of science in public health course
53:21we also offer two credit course on implementation science
53:25that our student can take and other researchers
53:28all over Nepal can also take that course.
53:31So with that, I would really like to thank you all
53:34for your time and really nice to be here.
53:38This is one of the typical mountain village in Nepal.
53:43<v Donna>Thanks so much.</v>
53:48So I think Luke Davis has a question.
53:51We don't really have a lot of time just one-
53:53(speaker faintly speaking)
53:56<v ->Okay, well, why don't we let Luke ask his question</v>
53:58if Luke, if you're still...
54:01Luke, if you're still here,
54:02we'd love to have you ask your question
54:05and then I think we probably have to wrap up.
54:08<v ->Great, it's kind of a big question so-</v>
54:11<v ->We can't hear you, oh there you go.</v>
54:13<v ->I'll just share it and perhaps we'll have a chance</v>
54:15to talk more when we meet on Friday
54:17or when we meet in person Archana.
54:19But I think the general question is
54:21how do you collect implementation measures such as fidelity
54:25in a real world setting without interrupting that setting?
54:28I think that's the big question you gave,
54:29I think some examples of the challenges,
54:31but it'd be really fun to hear,
54:33you know, if you just have one brief example
54:35or how you've been able to do it
54:37'cause you've obviously figured out how to do it
54:40for lots of different conditions.
54:41So thanks so much for the talk.
54:43<v ->Yeah, thank you.</v>
54:44Thank you Luke, really nice question.
54:47We struggled a lot to do, to collect the fidelity
54:50of our PEN protocol implementation.
54:52And then we discussed a lot among ourselves
54:56and with staff how we can do it.
54:58So one of the things that we decided
55:00before we get in the field, we decided that
55:03we will just let the health workers know
55:06that we are observing them and then assessing the fidelity,
55:10but would not tell like which exact patient
55:13and we will like observe them from a distance
55:16and we would obviously get their consent.
55:20So, and then we did that approach
55:23and then when the feedback from the field work came up,
55:27it was like in Nepal, they were so busy.
55:31Like they didn't care about altering,
55:34that was the general impression.
55:36They were so busy, like they didn't care
55:39about our assessment at all. (chuckles)
55:41So it was good for us,
55:45but it is good for the health system.
55:49So one of the things that we did,
55:51but yeah, of course, I think even after that
55:56it would be a difficult, it's pretty challenging to do that.
56:04<v ->Great, thanks.</v>
56:06(Donna faintly speaking)
56:09<v ->I think we probably need to conclude given the time,</v>
56:13but I can see on the chat that many people are Archana
56:16are writing to thank you for the talk
56:18and note how, what an insightful
56:21and excellent presentation it was.
56:24And I know you'll be meeting with many of us
56:26and you've met with many of us before
56:28and as I mentioned, there's still opportunities
56:31for people who have things they'd like to discuss
56:34with Archana to connect with William and try to find a time.
56:38So thank you all and have a good rest of your day.
56:41<v ->Thank you.</v> <v ->Bye.</v>