BACKGROUND:The Aotearoa New Zealand COVID-19 pandemic response has been hailed as a success story, however, there are concerns about how equitable it has been. This study explored the experience of a collective of Māori health and social service providers in the greater Wellington region of Aotearoa New Zeland delivering COVID-19 responses.METHODS:The study was a collaboration between a large urban Māori health and social service provider, Tākiri Mai Te Ata whānau ora collective, and public health researchers in Aotearoa New Zealand. Two online workshops were held with staff of the Māori service provider, collectively developing a qualitative causal loop diagram and generating systemic insights. The causal loop diagram showed interactions of various factors affecting COVID-19 response for supporting whānau (Māori family/households) at a community level. The iceberg model of systems thinking offered insights for action in understanding causal loop diagrams, emphasizing impactful changes at less visible levels.RESULTS:Six interacting subsystems were identified within the causal loop diagram that highlighted the systemic barriers and opportunities for effective COVID-19 response to Māori whānau. The medical model of health service produces difficulties for delivering kaupapa Māori services. Along with pre-existing vulnerability and health system gaps, these difficulties increased the risk of negative impacts on Māori whānau as COVID-19 cases increased. The study highlighted a critical need to create equal power in health perspectives, reducing dominance of the individual-focused medical model for better support of whānau during future pandemics.CONCLUSIONS:The study provided insights on systemic traps, their interactions and delays contributing to a relatively less effective COVID-19 response for Māori whānau and offered insights for improvement. In the light of recent changes in the Aotearoa New Zealand health system, the findings emphasize the urgent need for structural reform to address power imbalances and establish kaupapa Māori approach and equity as a norm in service planning and delivery.

Many of society’s most pressing problems, such as climate change, poverty, and waste, are categorized as “wicked” problems because they are seemingly resistant to change. Interventions designed to address these problems can produce unintended consequences, which then perpetuate the problem. Evaluating the effectiveness of such interventions is challenging and requires understanding of the social systems in which the problems are embedded. Multimethodology approaches can support such holistic understanding by combining different methodologies which complement and overlap with each other. This article reports on a study that combined two different methodologies—realist review and qualitative system dynamics. The result was a program theory for waste minimization interventions in Aotearoa New Zealand and a causal loop diagram, which allowed us to identify potential leverage points for change. The two methodologies highlighted different aspects of the problem in complementary ways. For example, the first program theory proposition emphasized the important role of people who were critically conscious of the need for sustainability, while the causal loop diagram showed that there needed to be enough critically conscious people for change to be embedded in the system. The program theory’s third and fourth propositions noted the important role of leadership and resource allocation in shifting interventions away from waste management initiatives, such as recycling plastic bags, towards waste minimization initiatives, such as banning single-use plastic bags. The causal loop diagram demonstrated why resource allocation to waste management initiatives, such as recycling, are not effective in addressing the overall problem of waste by showing the feedback loops that operate in the system. Such insights show that realist reviews and qualitative system dynamics can usefully complement each other for greater understanding of wicked problems.

Public health problems are often complex and 'wicked' in nature. Wicked problems have multi-factorial causation, are dynamic and often understood and acted upon differently by different actors. Multi-sectoral collaboration is increasingly emphasized for tackling wicked problems through developing a strategic multi-sectoral plan and then taking collective action. Critical systems thinking can support the development of a shared perspective of the problem, strengthen participation in collective action and foster reflective practices to continuously improve both problem understanding and action. In this paper, we present a critical collaboration model, drawing together two complementary theoretical frameworks, as well as insights from three case studies from New Zealand, to offer a systematic approach to adopting a critical systems perspective in public health collaboration. The model provides six questions to make explicit individuals' understandings or assumptions about how others perceive an issue, problem or evidence, and the process of identifying answers strengthens the dialogical and reflective aspects of the collaboration. We indicate some potential areas for the application of the model to integrate critical systems thinking in collaborative practices.

Background: The effects of waste on the environment and human health continue to increase despite behavioral, technological and policy actions for the management and minimization of waste. We plan to undertake a realist review of waste management and minimization interventions within New Zealand to inform effective approaches to waste minimization and management interventions. This protocol paper describes the steps of the realist review, including the objectives, theoretical frameworks and steps used. Methods: Realist review is a theory guided approach that seeks to understand the context-mechanism-outcome configuration of an intervention and generate insights on what works for whom, under what conditions and how. The protocol presents an integrated working theoretical framework comprising of three social theories (Social Learning Theory, Collective Action Theory and Social Practice theory), set within an indigenous Māori implementation framework, He Pikinga Waiora. The initial program theory generated from a first stage rapid review is presented. This initial program theory will be tested through a full literature review and analysis, as well as participatory sense making workshops with key stakeholders. Discussion: The review will help to generate insights on the generative causal mechanisms of waste minimization interventions in the context of New Zealand. This protocol emphasizes the initial program theory of change as a starting point for further review and design of improved interventions for waste minimization. Through identifying and testing the program theory, with insights from both indigenous and social practice theories, the proposed review will support the design of policies, programs and activities required to achieve the desired outcome of waste minimization in the context of New Zealand.

Introduction: Non-communicable diseases (NCDs) are a rapidly emerging global health challenge with multi-level determinants popularly known as social determinants. The objective of this paper is to describe the individual and community experiences of NCDs in the two case districts of Nepal from a social determinants of health perspective. Method: This study adopted qualitative study design to identify the experiences of NCDs. Sixty-three interviews were conducted with key informants from different sectors pertinent to NCD prevention at two case districts and at the policy level in Nepal. Twelve focus group discussions were conducted in the selected communities within those case districts. Data collection and analysis were informed by the adapted Social Determinants of Health Framework. The research team utilised the framework approach to carry out the thematic analysis. The study also involved three sense-making workshops with policy level and local stakeholders. Results: Three key themes emerged during the analysis. The first theme highlighted that individuals and communities were experiencing the rising burden of NCDs and metabolic risks in both urban and rural areas. The other two themes elaborated on the participant's experiences based on their socio-economic background and gender. Disadvantaged populations were more vulnerable to the risk of NCDs. Further, being female put one into an even more disadvantaged position in experiencing NCD risks and accessing health services. Conclusion: The findings indicated that key social determinants such as age, geographical location, socio-economic status and gender were driving the NCD epidemic. There is an urgent need to take action on social determinants of health through multi-sectoral action, thus also translating the spirit of the recommendations made a decade ago by the Commission on Social Determinants of Health in addressing a complex challenge like NCDs in Nepal.

The Coronavirus pandemic of 2019–20 (COVID-19) affected multiple social determinants of health (SDH) across the globe, including in New Zealand, exacerbating health inequities. Understanding these system dynamics can support decision making for the pandemic response and recovery measures. This study combined a scoping review with a causal loop diagram to further understanding of the connections between SDH, pandemic measures, and both short- and long-term outcomes in New Zealand. The causal loop diagram showed the reinforcing nature of structural SDH, such as colonization and socio-economic influences, on health inequities. While balancing actions taken by government eliminated COVID-19, the diagram showed that existing structural SDH inequities could increase health inequities in the longer term, unless the opportunity is taken for socio-economic policies to be reset. Such policy resets would be difficult to implement, as they are at odds with the current socio-economic system. The causal loop diagram highlighted that SDH significantly influenced the dynamics of the COVID-19 impact and response, pointing to a need for purposeful systemic action to disrupt the reinforcing loops which increase health inequities over time. This will require strong systems leadership, and coordination between policy makers and implementation at local level.

This paper aims to explore the burgeoning burden of cardiovascular and metabolic disease (CMD) risk factors among South Asian labor migrants to the Middle East. We conducted a qualitative synthesis of literature using PubMed/Medline and grey literature searches, supplemented by a policy review of policies from the South Asian countries. We found a high burden of cardio-metabolic risk factors among the migrants as well as among the populations in the home and the host countries. For example, two studies reported the prevalence of diabetes mellitus (DM) ranging between 9 and 17% among South Asian migrants. Overweight and obesity were highly prevalent amongst South Asian male migrants; prevalence ranged from 30 to 66% (overweight) and 17-80% (obesity) respectively. The home country population had a significant CMD risk factor burden. Nearly 14 to 40% have three or more risk factors: such as hypertension (17 to 37%), diabetes (3 to 7%), overweight (18 to 41%), and obesity (2 to 15%). The host country also exhibited similar burden of risk factors: hypertension (13 to 38%), diabetes (8 to 17%), overweight (33 to 77%) and obesity (35 to 41%). Only Nepal, Bangladesh and Sri Lanka have some provisions related to screening of CMDs before labor migration. Further, analysis of policy papers showed that none of the reviewed documents had requirements for screening of any specific CMDs, but chronic diseases were used generically, failing to specify specific screening target. Given the high burden of risk factors, migrants' health should become an urgent priority. The lack of specific focus on screening during different stages of labor migration should receive attention. The International Labour Organization and the International Office for Migration, through their country coordination teams should engage local stakeholders to create policies and plans to address this concern. Similarly, there is a need for the host country to become an equal partner in these efforts, as migrant's better cardiometabolic health is in the benefit of both host and home countries.

Developing countries such as Nepal are experiencing a double burden of communicable and non-communicable diseases (NCDs) resulting in social and economic losses. In Nepal, more than half of the disease burden is due to NCDs. The major NCDs in Nepal are cardiovascular diseases, cancers, chronic respiratory diseases and diabetes. Behavioural factors such as tobacco use, alcohol consumption, physical inactivity and unhealthy diet are driving the epidemic of NCDs, which are further influenced by social, economic and environmental determinants. The health system of Nepal has not been able to address the ever-increasing burden of NCDs. With the formulation of the Multisectoral Action Plan for Prevention and Control of NCDs 2014–2020, there has been some hope for tackling the NCDs and their social determinants in Nepal through a primary prevention approach. This paper discusses the systemic challenges and recommends two key actions for the prevention and control of NCDs in Nepal.

Background: Prevalence of non-communicable diseases has been increasing at a greater pace in developing countries and, in particular, the South Asia region. Various behavioral, social and environmental factors present in this region perpetuate common metabolic risk factors of non-communicable diseases. This study will identify social determinants of common metabolic risk factors of major non-communicable diseases in the context of the South Asian region and map their causal pathway.Methods: A systematic review of selected articles will be carried out following Cochrane guidelines. Review will be guided by Social Determinants of Health Framework developed by the World Health Organization to extract social determinants of metabolic risk factors of non-communicable diseases from studies. A distinct search strategy will be applied using key words to screen relevant studies from online databases. Primary and grey literature published from the year 2000 to 2016 and studies with discussion on proximal and distal determinants of non-communicable risk factors among adults of the South Asia region will be selected. They will be further checked for quality, and a matrix illustrating contents of selected articles will be developed. Thematic content analysis will be done to trace social determinants and their interaction with metabolic risk factors. Findings will be illustrated in causal loop diagrams with social determinants of risk factors along with their interaction (feedback mechanism).Discussion: The review will describe the interplay of social determinants of common NCD metabolic risk factors in the form of causal loop diagram. Findings will be structured in two parts: the first part will explain the linkage between proximal determinants with the metabolic risk factors and the second part will describe the linkage among the risk factors, proximal determinants and distal determinants. Evidences across different regions will be discussed to compare and validate and/or contrast the findings. Possible bias and limitations of this study will also be discussed.Systematic review registration: PROSPERO CRD42017067212

Birth weight of a child is an important indicator of its vulnerability for childhood illness and chances of survival. A large number of infant deaths can be averted by appropriate management of low birth weight babies and prevention of factors associated with low birth weight. The prevalence of low birth weight babies in Nepal is estimated to be about 12-32%.Our study aimed at identifying major determinants of low birth weight among term babies in Nepal. A hospital-based retrospective case control study was conducted in maternity ward of Tribhuvan University Teaching Hospital from February to July 2011. A total of 155 LBW babies and 310 controls were included in the study. Mothers admitted to maternity ward during the study period were interviewed, medical records were assessed and anthropometric measurements were done. Risk factors, broadly classified into proximal and distal factors, were assessed for any association with birth of low-birth weight babies. Regression analysis revealed that a history of premature delivery (adjusted odds ratio; aOR5.24, CI 1.05-26.28), hard physical work during pregnancy (aOR1.48, CI 0.97-2.26), younger age of mother (aOR1.98, CI 1.15-3.41), mothers with haemoglobin level less than 11gm/dl (aOR0.51, CI0.24-1.07) and lack of consumption of nutritious food during pregnancy (aOR1.99, CI 1.28-3.10) were significantly associated with the birth of LBW babies. These factors should be addressed with appropriate measures so as to decrease the prevalence of low birth weight among term babies in Nepal.

Background: In Nepal, about 75% people rely on wood and other biomass fuels for cooking. The majority of Nepali families cook on a traditional stove, an open fire in the kitchen resulting in indoor air pollution, one of the key risk factors for Acute Lower Respiratory Infection (ALRI) among under-five children.The study aimed at exploring the association of indoor air pollution due to use of traditional cooking stoves with ALRI among under-five children in Rasuwa, a Himalayan district of Nepal.Methods: A cross-sectional survey was conducted in Rasuwa district from October to November 2011. The mothers with under-five children who lived in household using biomass fuels were interviewed. The total sample size of 210, calculated on the basis of Proportion to Population Size, was selected by using cluster sampling method. Children who suffered from common cold and fast breathing/higher respiratory rate were defined as having ALRI. Logistic regression was used to find out association of types of cooking stove and other factors with ALRI among the children.Results: Only about 30% of the households used improved stoves for cooking. Nearly one-third (31.4%) of the children under five years of age who lived in household using biomass fuels suffered from ALRI. After adjusting for the factors like mother’s group status, ethnic group, age of children, mother’s group membership status and father’s occupation, use of traditional/open type of cooking stove was found to be highly associated with ALRI [aOR:2.30; 95%CI (1.03-5.10)] among children.Conclusion: Exposure to smoke from a traditional stove is one of the factors leading to ALRI among children. The ALRI could be substantially reduced if these stoves be replaced by improved ones in rural areas of Nepal.

Culture plays a key role in influencing health related behaviours. However, cultural issues are often neglected in public health interventions. The viewpoint attempts to highlight key prerequisites for developing culturally sensitive public health interventions in the context of Nepal. Qualitative research should be promoted to understand the critical link of cultural issues with health problems and tailor interventions accordingly. Making key elements of Behaviour Change Communication (source, message, and channel) process culturally appropriate can render positive effects for health interventions. On an operational level, involving an anthropologist can act as a bridge between community and health workers throughout the implementation process; community organization and empowerment strategies within interventions have proven to be beneficial and sustainable in terms of health promotion and disease prevention. Focusing on developing culturally competent health workforce can produce a synergistic effect in health promotion efforts. To conclude, culturally sensitive interventions should not only be evidence based but empowering and engaging community.DOI: http://dx.doi.org/10.3126/hprospect.v13i1.11104 Health Prospect Vol.13(1) 2014: 1-3

BACKGROUND:Promotion of institutional delivery is a key intervention in reducing maternal mortality and improving maternal and neonatal health. This study explored factors associated with institutional delivery in rural Nepal.METHOD:A household survey was conducted in three rural Village Development Committees of Kavrepalanchowk district to identify the individual, household and health service factors associated with the institutional delivery. All 240 eligible mothers from the study area were interviewed during the study period. Multiple logistic regression analysis was applied to establish the factor associated with the institutional delivery, the outcome variable.RESULTS:Antenatal care practice, adverse pregnancy outcome, ethnicity and time taken to reach the health institution were significantly associated with the institutional delivery. Utilization of an antenatal care service had the greatest effect on institutional delivery.CONCLUSION:Universal antenatal care service utilization may be a critical intervention for increasing institutional delivery. There is a need to raise awareness in hard-to-reach areas where adverse pregnancy outcomes is not considered a serious event.