qualitative research in nepali

• Open access
• Published: 01 November 2022

A qualitative study on gender inequality and gender-based violence in Nepal

• Pranab Dahal 1 ,
• Sunil Kumar Joshi 2 &
• Katarina Swahnberg 1  

BMC Public Health volume  22 , Article number:  2005 ( 2022 ) Cite this article

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Gender inequality and violence are not mutually exclusive phenomena but complex loops affecting each other. Women in Nepal face several inequalities and violence. The causes are diverse, but most of these results are due to socially assigned lower positioning of women. The hierarchies based on power make women face subordination and violence in Nepal. The study aims to explore participants' understanding and experience to identify the status of inequality for women and how violence emerges as one of its consequences. Furthermore, it explores the causes of sex trafficking as an example of an outcome of inequality and violence.

The study formulated separate male and female groups using a purposive sampling method. The study used a multistage focus group discussion, where the same groups met at different intervals. Six focus group discussions, three times each with male and female groups, were conducted in a year. Thirty-six individuals, including sixteen males and twenty females, were involved in the discussions. The study used constructivist grounded theory for the data analysis.

The study participants identify that a power play between men and women reinforce inequality and increases the likelihood of violence for women. The findings suggest that the subjugation of women occurs due to practices based on gender differences, constricted life opportunities, and internalization of constructed differences among women. The study identifies that interpersonal and socio-cultural violence can result due to established differences between men and women. Sex trafficking, as an example of the outcome of inequality and violence, occurs due to the disadvantageous position of women compounded by poverty and illiteracy. The study has developed a concept of power-play which is identified as a cause and consequence of women's subordination and violence. This power play is found operative at various levels with social approval for men to use violence and maintain/produce inequality.

The theoretical concept of power play shows that there are inequitable power relations between men and women. The male-centric socio-cultural norms and practices have endowed men with privilege, power, and an opportunity to exploit women. This lowers the status of women and the power-play help to produce and sustain inequality. The power-play exposes women to violence and manifests itself as one of the worst expressions used by men.

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Violence against women is identified as an attempt by men to maintain power and control over women [ 1 ] and is manifested as a form of structural inequality. This structural inequality is apparent with greater agency among men [ 2 ]. The differences between sexes are exhibited in the attainment of education and professional jobs, ownership of assets, the feminization of poverty, etc., and these differences increase the risk of violence towards women [ 3 ]. The global estimate identifies that thirty percent of women experience physical and/or sexual violence during their lifetime, illustrating the enormity of this problem [ 4 ]. From a feminist perspective, lending ideas of patriarchy [ 5 ] and gender performativity [ 6 ], the understanding of gender roles prescribed by male-dominated social structures and processes helps further explore the violence and abuse faced by women [ 7 ]. According to Heise [ 8 ], men who adhere to traditional, rigid, and misogynistic views on gender norms, attitudes, and behaviors are more likely to use violence towards women. The individual and collective attitudes of men toward different established gender norms, and their reproduction explain men’s use of violence toward women [ 9 ]. It is known that gender norms influence violence, but at the same time violence also directs and dictates gender performance with fear, sanction, and corrective measures for enacting respective prescribed gender functions [ 10 ].

It is difficult for women subjected to violence to enjoy legitimate rights, as most of the infringement of their rights and violence takes place inside a private sphere of the home [ 11 , 12 ]. Violence against women is the major cause of death and disability for women [ 13 ] and globally a major public health concern [ 14 ]. Establishing gender equality is fundamental for fostering justice and attaining sustainable development [ 15 ]; moreover, violence against women has to be acknowledged as a fundamental abuse of human rights [ 16 ]. A report on global violence has identified that violence against women exists at all levels of the family, community, and state. The report recommended the development of frameworks for respecting, protecting, and fulfilling women’s rights [ 17 ]. Fifteen years later, a review of the same identifies that violence continues with impunity, reaffirming violence as a major obstacle to the attainment of justice [ 18 ].

The inclusion of the gender lens to violence against women has provided more contextual evidence to explore these processes of violence. This requires the identification of unequal power relationships and an inquiry into the differences-producing various gender stereotypes [ 19 ]. This analysis of violence requires an understanding of behaviors that promote women’s subordination and factors that favor men to sustain these malpractices [ 8 ]. A closer look at the male-centric structural arrangements embedded in the social, political, and economic organization of life reveals that these structures provide lesser access and lower accountability toward women, promote systemic subordination, and create hierarchies, resulting in the increase of violence against women [ 20 ]. This unequal gender power relationship reinforced and manifested by social approval of men’s authority over women is found operative at multiple levels and helps to produce diversities of inequalities and violence [ 21 , 22 ].

The inequalities faced by women in Nepal majorly stem from socio-cultural, economic, and religious factors and influencers that define traditional roles and responsibilities between men and women [ 23 ]. The inequalities are more evident and pronounced in settings exhibiting prominent patriarchal norms restricting advantages and opportunities for the majority of women [ 24 ]. Women in Nepal are restricted inside their homes, have lesser access to life opportunities, and have limited or no involvement in decision-making on important issues directly affecting their lives [ 25 , 26 ]. Figures indicative of women’s inequalities in Nepal suggest that one-third of women have no education, fifty-two percent of women are involved in non-paid jobs, and women are less likely than men to own a home or land [ 27 ]. The men in Nepalese society are positioned higher and are expected to be the breadwinner and protectors of their families. Most of these men intend to earn respect and obedience from women and are socially expected to discipline women to achieve it [ 28 ]. Many societies across the world including Nepal, recognizes violence as a private affair requiring discussion only within a family. This has led to a serious underreporting of violence committed toward women in Nepal [ 29 ]. The national gender data in Nepal is scarce, the available Nepal Demographic Health Survey 2016 identifies that since the age of fifteen, twenty-two percent of women and seven percent of women experience physical and sexual violence, respectively in the past twelve months [ 27 ].

The contributing factors for violence against women in Nepal include the lower social status of women, illiteracy, economic dependency, patriarchal society, sex trafficking, alcohol-related abuse, dowry-related violence, infidelity, extramarital affairs of husband, unemployment, and denial of sex with husband [ 30 , 31 , 32 ]. Nepalese women have been repressing violence with silence due to the fear of breaking relationships, receiving less love and affection from family, fear of social norms by going against men, lack of faith in the justice system, and the threat of increased violence [ 33 ]. Women and girls in Nepal are sex trafficked to various countries. Sex trafficking in Nepal is prevalent due to persistent gender inequality, violence, stigma, and discriminatory socio-cultural structures; however, the actual extent of sex trafficking is still undetermined [ 17 , 34 , 35 ].

The recent trends in Nepal with the increasing number of out-migration of men for employment have provided women with temporary autonomy, and a shift in the gender roles. Earlier research has identified that migration of male spouses has provided a resistance to the power dynamics for women on the other hand it has limited their mobility, required them to share decision-making with household structures, face continued social vigilance on the money received from remittance, and get central attention with their personal sexual lives [ 36 , 37 ].

Morang district lies in the eastern region of Nepal. A district profile report based on a census survey [ 38 ] identifies that the place is inhabited by a close to a million population, out of which ethnic groups ( close to forty percent) live in the district with a majority (seventy-eight percent) of its population living in the rural areas. Tharu an ethnic group is one of the dominant population in the study area and all study participants for this study were from same Tharu population. A close to thirty-six percent of women in the district are illiterate and the average age of marriage is eighteen years. The report identifies that only twenty-three percent of women engage in economic activities apart from agricultural work and less than fourteen percent of women head the household. Almost eighty percent of the population in the district practice Hinduism.

This study is a part of a large intervention project and it was focused to establish a qualitative baseline of the gender status in the study area. This study aimed to explore participants’ experiences and understanding of gender inequality, violence against women, and information on sex trafficking in the Morang district of eastern Nepal. The selection of sex trafficking topic was motivated to assess the respondents’ general understanding of one of the consequences of inequality and violence faced by women. The study focused to explore factors that help to produce and sustain the practice of gender inequality and violence against women in the local community.

Participants

This study was part of a larger control-comparison project that used Forum Theatre interventions to promote gender equality, reduce violence against women, and increase awareness of sex trafficking [ 39 , 40 ]. The participants for the focus group discussion included the intervention population from one of the randomly sampled intervention sites. A multistage focus group discussion [ 41 ] was used involving the same participants discussing various emerging topics at different periods. The participants were recruited voluntarily during an earlier quantitative data collection for the project. The study used a purposive sampling method for the selection of participants. The local field staff at the study site facilitated the recruitment of the participants. The study formulated separate male and female groups. A total of six focus groups, three each with male and female groups were conducted over twelve months. Two inclusion criteria were set for participation. First, the participants had to be part of the population of the larger study. Secondly, they had to witness and/or participate in the Forum Theatre interventions conducted in between the study. The set inclusion criteria served a dual purpose of understanding the causes of inequality and violence and further helped to develop and determine the efficacy of participatory Forum Theater intervention for awareness-raising among the study intervention groups [ 39 ].

A total of thirty-six participants consisting of sixteen males and twenty females joined the discussions. The first discussion consisted of eight participants each from groups while the second and the third discussion missed two female and four male participants respectively. The majority of the participants were 20–29 years old. Tharu, an ethnic community of Nepal, is a dominant population in the study area, and all the participants belonged to the same Tharu community. Only one female participant was unmarried, and a single married male participated in the discussions. All participants were literate, with four males completing a bachelor's level of education. Seven female participants had education below the high school level. The nuclear family with parents and their children was the major family type identified in both male and female groups. Table 1 provides the detail of the participants.

The focus group discussions were conducted in January 2017, April–May 2017, and January 2018. The discussions were conducted in a place recommended by the participants. An isolated place in an open setting at the premise of a local temple was used for conducting all discussions. The participants were briefed about the objectives of the discussion and written consent was obtained for their participation. Verbal consent was taken for the audio recording of the discussions. Each participant was assigned a unique numerical code before the discussions to ensure anonymity during recording, note-taking, and analysis. The discussions averaged ninety minutes during each session. The discussions were conducted with the same participants and no new participants were added during the follow-ups. A single male and female participant were missing in the second follow up and two male participants missed the final follow-up. The reason for missing participants was due to their unavailability as they were out of the village due to personal reasons.

The discussions were conducted in the Nepali language. The first author moderated all six discussions, a support field staff member took the notes, and the last author observed the discussions. The audio recordings were translated into English, and the transcriptions were checked with the recordings to verify accuracy. The field and the discussion notes were used during various stages of data analysis. The notes provided information on the discussion setting, as well as the verbal and nonverbal expressions of the participants. The notes helped to assess the impressions, emphasis, and feelings of the participants during the discussions.

The discussions used pre-formulated discussion guides with open-ended questions on inequalities, gender practices, violence, and sex trafficking. The guiding questions were based on the theoretical premise of discrimination, patriarchy, oppression, hegemony, and participation of women. Three separate discussion guides were developed for each of discussions. The guides were developed by the first and last authors. Probing was done on several occasions during the discussion to gain more clarity on the issue. Cross-checking among the participants and between the groups was done to triangulate received information. Any topic deemed appropriate for discussions and/or any unclear issues identified during the initial data analysis came up subsequently in the discussion guide during the follow-ups.

Data analysis

This study used the constructivist grounded theory method. This method adheres to a constructivist philosophical approach wherein both researchers and participants mutually co-construct the meaning of a phenomenon [ 42 ]. This interaction is important since it helps to impart the meaning of shared experiences [ 42 ]. The constructivist grounded theory made it possible to (re) discover gender issues, important for both the researcher and the study participants. This method allowed the study to progress with responsiveness to emerging issues with an in-depth exploration of the identified issues. This clarity was achieved through repeated interactive discussions, analysis of explanations, and sharing of emergent findings with the study participants.

The audio recordings were translated and transcribed into English. Six transcripts from discussions were initially analyzed using a line-by-line coding process. The coding process helped with the fragmentation of data through interactive comparisons. Fifty-two initial codes such as gender differences, restricting women, alcohol-related violence, underreporting of sexual violence, coping, etc. were identified. The later stage of focused coding helped to achieve categorized data, providing logical sense to the developed initial codes. Three focused codes, namely, the subjugation of women, violence, and chasing dreams were formulated during the analysis. The abductive reasoning from the codes, memos, and discussion notes helped to develop the theoretical concept. The development of conceptual abstraction involved an iterative comparison of the data, codes, categories, memos, and discussion notes.

The constant communication between the authors during the stages of data analysis such as the formulation of codes, explanations of concepts, and categories helped to refine the analysis. The shared experiences of the participants and the description of the data collection and analysis included substantial details, enabling comparisons for future research and application to other similar contexts. The reliability of the study is warranted by the theoretical saturation [ 42 ] achieved by this study. This is supported by prolonged engagement with the study participants with communication on the emerging findings, and triangulation.

Reflexivity has a greater significance for the constructivist approach. The first and the second author of Nepalese origin were aware of the socio-cultural norms, stereotypes, values, and stigmas associated with gender in the local context. This helped the study to ascertain the depth of inquiry within the acceptable local normative limits. The non-Nepalese author, familiar with the study participants and Nepalese contexts, witnessed the discussions as an observer. The prior knowledge of the authors helped to critically assess different schemas, perspectives, and explanations shared by the participants. The universality of gender inequality and violence against women and its re-examination in the local context helped the authors to build upon existing knowledge by providing contextual explanations. The diversities among the authors and research participants established a basis for co-creating the perceived and observed realities.

The section below describes the participants’ perceptions and understanding of inequality and violence. The section contains subheadings that were derived as themes in the data analysis. The first theme subjugation of women; discusses how norms, beliefs, and practices produce inferior status and positions for women. The second theme domestic and gender violence; provides a narrative of interpersonal and socio-cultural violence present in the study area. The theme of chasing dreams; discusses the process of sex trafficking as an outcome of violence. The theoretically abstracted concept of power-play identifies the cause for the generation of power imbalance producing inequality and the use of violence by men.

Subjugation of women

The subjugation of women reflected practices and beliefs imparting positional differences for women and their social situation compared to men. The participants shared a common understanding that belief systems adhering to male supremacy have positioned women in a lower status. They provided examples of social practices of male supremacy such as males being considered as the carrier of a family name, legacy, and heritage, while women were referred to as someone else’s property. The socialization of the idea that girls will be married off to a husband and relocate themselves to their homes was identified as the major reason for instilling and perpetuating early gender differences. The participants mentioned that discriminatory practices and seclusion have situated women at the bottom rung of the gender hierarchy, establishing them as socially incompetent individuals or groups. Moreover, they inferred that selective preferences provided preparatory grounds for inequalities, and they remain attached to women throughout their lives. The participants provided examples of unequal access to education and life opportunities as a practice of selective preferences occurring in the community. They mentioned that socialization with these discriminatory beliefs and their practice helped to develop specialized gender roles from an early age. The participants provided an example of how gender intersected with mobility and resource generation in the community, it was clear from the discussions that this has restricted women inside homes but provided freedom and opportunities for men. A female participant expressed,

A woman from a poor family is more than willing to work and support her family. But she is not allowed by the men in the family to work outside of the home.

The participants informed that differences between the sexes were visible for women from a young age. Sharing practical examples from the community, the participants from both groups stated that girls received education mostly in low-cost government and community schools, while boys were enrolled in expensive private schools. They raised concerns that this selective investment for education, cited as the ‘building block of life’ by the participants, installed lesser capacity, and negotiating abilities in girls. A female participant stated,

There are differences in educational opportunities for boys and girls in our community. Family provides more support for a boy’s education by enrolling him in private schools, while a girl mostly gets her education in a community school together with engagement in household work.

The discussions revealed that women required several male anchors for their survival during their various stages of life. The participants provided examples of the shift of anchors for women which traversed from a father to a husband during marriage and later to the male child during her old age. They believed that this tradition of transferring women’s identity established men as a higher social category and stripped women of their individuality and identity. A male participant added,

Women have to remain dependent on men throughout their lives, first with their fathers and later with their husbands. They remain completely dependent as they are not economically active. This makes men believe that they have higher authority.

The female participants provided an example of marriage to illustrate how someone else’s decision-making had been affecting women’s lives. A participant explained that women were held responsible for household activities after marriage and any support for career progression or education was restricted despite her desire for its continuation. It was inferred that women had to drop their hopes and aspirations as the husband and his family made decisions for them. The female participants agreed that this continuous exposure to the ideas of male supremacy makes them start to believe and internalize the idea that women have lesser cognitive abilities and intelligence compared to men. A female participant stated,

Men and women certainly have different mental abilities. Men think and act differently often in a smart way compared to women.

The participants from both groups expressed that youth in the community were developing flexible attitudes and beliefs towards gender roles and responsibilities. They agreed that both young men and women were observed altering their roles and responsibilities shifting from traditional gender ideologies. The participants expressed that instilling these fluidity and flexible approaches in the older generation was impossible as they strictly followed traditional beliefs and practices. Few of the female participants admitted that at times young women also fail to accommodate the situation and reap benefits from available opportunities. The discussions revealed that a few of the women in the community received opportunities for independence and economic empowerment. These women had received entrepreneurial training and various skill development activities for sustaining livelihoods with practical skill-based training in tailoring, beautician, and doll-making. The female participants expressed that opportunities for independence and growth slipped away from them due to a lack of family support, financial constraints, and self-passivity. They explained that starting a business required approval from a family which was difficult to obtain. Moreover, if women made a self-decision to start up on their own, they lacked the initial capital and had to rely on men for obtaining resources. The participants further explained that the denial of men to support women were majorly due to the fear that norms of staying indoors for women will be breached and economic independence may enable women to have a similar financial footing as men. The participants stated that self-passivity in women emerged due to their engagement in household multiple roles, dependency upon males, and lack of decision-making power and abilities. A female participant summed it up by stating,

Some of us women in the community have received entrepreneurial skills training, but we have not been able to use our skills for our growth and development. Once the training finishes, we get back to our household chores and taking care of the children.

The female participants admitted that acceptance of belief systems requiring women to be docile, unseen, and unheard were the reasons for this self-passivity. The female participants resonated that the external controlling and unfavorable environment influenced by practices of discriminatory norms and beliefs developed self-passivity for women. A female participant expressed the cause and consequence of self-passivity as,

Women have inhibitions to speaking their minds; something stops us from making our position clear, making us lose all the time.

The discussions identified that gender norms were deeply engraved in various social interactions and daily life, and any deviance received strict criticism. The participants shared common examples of sanctions for women based on rigid norms like restrictive movements for women, social gossiping when women communicated with outsider men, prohibition for opinion giving in public, and lesser involvement during key decision-making at home. The participants shared that norms dictating gender roles were in place for both men and women with social sanctions and approval for their performance. A male discussion participant who occasionally got involved with cooking which was a so-called “women’s job” faced outright disapproval from his female relatives and neighbors. The male participant stated,

If I cook or get engaged in any household jobs, it is mostly females from the home and neighborhood who make fun of me and remind me that I am a man and that I should not be doing a woman’s job.

The foreign migration of youth looking for job opportunities has affected the Tharu community. It was known that a large number of men were absent from the community. The participants stated that women in such households with absent men had gained authority and control over resources, moreover, these women have been taking some of the men’s roles. The participants disclosed that these women had greater access and control over resources and were involved in the key decision-making positioning them in a relatively higher position compared to other women. It was known that this higher position for women came with a price, they were under higher social vigilance and at higher risk of abuse and violence due to the absence of ‘protective men’. It was known that women's foreign employment was associated with myths and sexist remarks. The participants shared that women had to face strict social criticisms and that their plans for livelihood and independence were related to an issue of sexual immorality and chastity. The participants from both groups strictly opposed the norms that associated women with sexual immorality but lamented that it continues. A male participant provided an insight into the social remarks received by women if she dares to go for foreign employment,

If a woman wants to go for a foreign job, she is considered to be of loose character. The idea that she is corrupt and will get involved in bad work will be her first impression of anyone.

Although the participant did not explicitly describe what bad work referred to as but it was inferred that he was relating it to sex work.

Domestic and gender violence

The participants identified violence as control, coercion, and use of force against someone will occurring due to unequal status. They primarily identified men as the perpetrators and women as the victims of violence. They explained that two types of violence were observed in the community. The first type occurred in an interpersonal relationship identified as physical, emotional, and sexual violence. The second type, as explained by the participants had its roots in socio-cultural belief systems. They provided examples of dowry exchange and witchcraft accusations for the latter type. The participants identified women as primary victims and listed both men and women as the perpetrators of both types of violence. They reported that physical violence against women by men under the influence of alcohol was the most commonly occurring violence in the community. The participants from both groups confirmed that wife-beating, verbal abuse, and quarrel frequently occurred in the community. It was known from discussions that alcohol consumption among men was widespread, and its cultural acceptance was also increasing episodes of violence. One of the female participants clarified further,

The most common violence occurring in our society is wife-beating by a husband under the influence of alcohol. We see it every day.

The participants reported the occurrence of sexual violence in the community but also pointed out that people refrained from discussing it considering it a taboo and private affair. The participants had hesitation to discuss freely on sexual violence. During the discussions, participants from both groups informed only of rape and attempted rape of women by men as sexual violence present in the community. Despite repeated probing, on several occasions, none of the participants from either group brought up issues and discussions about any other forms of sexual violence. Participants from both groups confirmed that stories about incidents of rape or attempted rape emerged only after cases were registered with the local police. The participants presumed that incidents of rape and attempted rape were not known to the wider community. A female participant stated,

Sexual violence does occur in our community, but people mostly do not report or disclose it, but they tend to keep it amongst themselves and their families.

The participants explained the identity of the rape perpetrator and victim. They identified the perpetrator as a rich, influential, and relatively powerful man from the community. The victim was portrayed as a poor and isolated woman which lesser social ties. It was known from the discussions that most of the rape cases in the community were settled with financial negotiations and monetary compensations for the victim rather than finding legal remedies. It can be inferred that the victimization of women intersects with gender, wealth, social stature, and affluence. The participants feared that this practice of settlement of rape with money could make rape a commodity available for the powerful, rich, and affluent men to exploit and victimize women. A male participant clarifies,

Recently, a man in his sixties raped a young girl near our village. The victim's family was ready to settle with monetary compensation offered by the rapist, but the involvement of the community stopped it and the rapist was handed over to the police.

The participants shared available coping mechanisms against violence practiced in the community by women. It was learned that the victim of household violence mostly used community consultation and police reporting to evade further violence. They divulged that community consultation and police reporting resulted in decisions in favor of victim women, directing abusive husbands to show decency and stop committing violence. The fear of legal repercussions such as spending time in police custody and getting charged under domestic violence cases was understood as the reasons for husbands to stop abuse and violence. The discussions revealed that women who file a formal complaint about their husband’s violent behavior could face an increased risk of violence. The participants disclosed that sharing such incidents publicly brought shame to some of the men and increased their anger, and often backlashed with increased violence. The participants in both groups stated that not all women in the community reported violence. They identified that women tend to be quiet despite facing continuous violence due to the fear of encountering more violence and to keeping their families together. A female participant clarifies,

Lodging public complaints against the abusive husband can sometimes escalate the violence. The husband’s anger for being humiliated in public must be faced by the woman inside the closed doors of the house with more violence and the men’s threat of abandoning the relationship.

The participants stated that socio-cultural violence against women in dowry-related cases was widespread and increasing. The dowry exchange was explained as a traditional practice with the family of the bride paying cash and kind to the groom's family. The participants clarified that the practice of dowry in the earlier days must have been an emergency fund for the newly wedded bride in a newer setting. According to the participants, the system of dowry has now developed and evolved as a practice of forced involuntary transfer of goods and cash demanded by the groom’s family. The discussions disclosed that the demands for dowry were increasing with time and failing to provide as promised immediately resulted in violence for the newly wedded bride. The participants described that dowry-related violence starts with taunts and progresses to withholding of food, verbal abuse, and finally, physical violence. They added that perpetrators of such violence were both men and women from the groom’s family. They stated that due to poverty not all bride families in the community were able to supply all demanded dowry which has exposed a large number of women to face dowry-related abuse and violence. The discussions also informed of a newer trend among girls by demanding goods during their wedding. It was shared that this new emerging trend had increased a two-fold financial burden on the bride’s family with heavy marriage debts. The male participants when questioned about the dowry demands cunningly shifted the responsibilities towards family and stated that it was not the groom but their families who were making such dowry demands. The discussions verified that dowry practice was so engraved in the community that it was impossible to even imagine a marriage without any dowry. A male participant reflected,

If I marry without any dowry, my family, neighbors, and all whom I know would consider that I am insane.

The participants also discussed and identified harmful traditional practices present in the community. The participants informed a common practice of accusing women of as witches existed in the community. It was mentioned that women faced witchcraft allegations in different situations. They provided examples of witchcraft allegations in common situations such as when someone’s cow stops producing milk when a child has a sore eye, when someone is bedridden due to sickness for days, or when a woman undergoes a miscarriage, etc. The participants stated that women accused of witch were always elderly/single women living in seclusion, poverty, and with fewer social ties. They also shared that the witch doctors, who ascertain whether a woman is a witch or not, were surprisingly mostly always men and hold higher status, respect, and social recognition. The consequences of being labeled as a witch, as explained by the participants, haunted victim women with torture, name-calling, social boycott, and extremes of physical violence. The participants informed that inhumane practices such as forceful feeding of human excreta prevailed during the witch cleansing sessions. A female participant explaining the witchcraft situation stated,

Witchcraft accusation is very real in our community; I know someone who has tortured his mother, citing reasons for his wife being childless. The old woman was called names, beaten, and later thrown out of the home.

The participants felt that men’s use of violence and its legitimization primarily existed due to gender hierarchy and internalization of the belief that violence was the best method to resolve any conflict. They inferred that men’s use of violence was further reinforced by women's acceptance and belief that violence had occurred due to their faults and carelessness. The female participants shared examples of common household situations that could result in an episode of violence such as women cooking distasteful food, failing to provide timely care to children and the elderly due to workload, and forgetting to clean rooms. These incidents make women believe that violence majorly occurred due to their mistakes. Furthermore, the participants believed that this self-blaming of the victim resulted due to constant exposure to violence and a non-negotiable social positioning of women for raising questions. The participants stated that beliefs instilled by religion increased the likelihood of victimization for women. They explained that religious practices and ideologies required women to refer to their husbands as godly figures, and a religious belief that anything said or done against husbands was a disgrace bringing sin upon her and family positioned women in an inferior position. A male participant added,

We belong to a culture where females worship their husbands as a god, and this might be an important reason for men to feel powerful as a god to exploit and abuse women.

The discussions put forward the idea that the existence of discriminatory beliefs, reinforcement of such beliefs, and a blind following of such practices produced differences and violence. The male participants acknowledged that the idea of male supremacy not only produced violence but also established a belief system that considered violence as an indispensable way to treat deviated women. One male participant stated this idea of male supremacy and privilege as,

The language of the feet is essential when words fail.

The participants also discussed violence committed toward men by women. The male participants burst into laughter when they stated that some men were beaten by their wives when they were drunk. The male participants admitted that intoxication reduced their strength and they got beaten. The female participants, on the other hand, assumed that women hit intoxicated men due to frustration and helplessness. They further clarified that the act of husband beating was a situational reaction towards men who had spent all of their daily earnings on alcohol. They stated that women with the responsibility to cook and feed family find themselves in an utterly helpless situation by the irresponsible drinking behavior of men. The male participants shared incidences of violence against men due to foreign migration. It was revealed in the discussions that some of the migrating men’s wives had run away with remitted money, abandoning marriage, and breaking up the family. The male participants identified this as a form of victimization of men, furthermore, the spreading of rumors and gossip caused emotional instability in those men. The female participants confirmed that some returning men failed to find their homes, property, money, and/or their wives. The discussion participants in both groups identified that this practice was on the rise in the community. It became apparent from the discussions that this increasing trend of women running away with the money and breaking away from family was a personal issue requiring social remedies.

Chasing dreams

The participants referred to sex trafficking as the exploitation of women, arising from poverty, illiteracy, and deceit. Explaining the causes of trafficking, the participants stated that women living in poverty, having dreams of prosperity and abundance were tricked by the traffickers making them victims of sex trafficking. The participants mentioned that women who had dreams larger than life and yearned for a comfortable and luxurious life in a short time were at a greater risk for sex trafficking. The participants from both groups resonated that the traffickers had been manipulating the dreams of poor women and deceiving them into trafficking. A female participant elaborated,

Women in poverty can be fooled easily with dreams. She can be tricked by a trafficker by saying I will find you employment with good pay abroad, and she gets into the trap easily.

A male participant further clarified,

Women readily fall into fraud and trickery shown by the traffickers who assure of luxurious life with foreign employment and this bait often leads to sex trafficking.

They identified that false hopes for foreign jobs were primarily used as an entry point by the traffickers to trap potential victims. Besides, they stated that some traffickers tricked women with false romantic relationships and marriages to win over their trust enabling traffickers to maneuver women as they wished.

It was identified that traffickers were not always strangers but known and familiar faces from the community, allowing the traffickers to gain the victim’s trust. The discussions divulged that traffickers strategically chose women who were less educated and poor. The participants explained that sex trafficking mostly occurred among women from a lower caste (the caste system is hierarchy-based in Hindu society which is determined by birth and unchangeable). They further explained that if one of these lower caste women went missing, it seldom raised any serious concerns in society, making these women easy targets for the traffickers. The discussions revealed that life for the survivors of sex trafficking was difficult. They identified that the survivor had to face strong stigmas and stereotypes which further increased their risk for re-victimization. The participants explained that the social acceptance of the trafficking survivors was minimal and finding a job for survival was very difficult. It was reported that social beliefs, norms, and practices were rigid for sex trafficking survivors and provided lesser opportunities for complete social integration. A female participant stated,

The story of a sex-trafficked woman does not end after her rescue. It is difficult for her to live in society, and this increases her chances of being a further victim.

The discussions in both groups highlighted that education and awareness were important for reducing sex trafficking. The participants felt that securing a livelihood for women was essential, but they identified it as a major challenge. The female participants recommended the use of education and awareness for reducing sex trafficking. They demanded effective legal actions and stringent enforcement of the law with maximum punishment for offending sex traffickers. They mentioned that the fear of law with maximum punishment for culprits could help decrease cases of trafficking.

The theoretical concept of power play

The discussions identified that gender inequality and violence against women occurred as men possessed and exercised greater authority. The participants explained that the authority emerging from male-centric beliefs was reinforced through established socio-cultural institutions. It was known that oppressive practices toward women in both public and private life have led to the domination and devaluation of women. The differences between men and women were known to be instilled by evoking discriminatory beliefs and due to internalization of them as fundamental truths by women which further helps to sustain these created differences.

The concept of power-play developed from the study has its roots in the belief systems and was found constantly used by men to maintain created differences. The power-play rise due to patriarchy, guiding discriminatory norms and unequal gender practices. These norms and practices in the canopy of patriarchy positions women inferior to men and impose control and restrictions. The power play possessed multi-dimensional effects on women such as creating further barriers, restricted life opportunities, the need for men-centered anchoring systems, and exclusion from the public arena. The power play gains its strength from the strict enforcement of stereotypical practices and committed adherence to gender performances. This leads to internalization of subordination as a natural occurrence by women. These further isolate women putting them into several non-negotiating positions. The power play at an individual level provides restrictive movement for women, barring them from quality education and other life opportunities, and is exhibited in alcohol-related assault and sexual violence. At the structural level, this power play limits women from economic opportunities, access to resources, and decision-making, and induces socio-cultural inequality exhibited in dowry and cases of witchcraft. The socio-cultural acceptance of power-play allows men to use violence as a misuse of power and use it as an effort to maintain authority. The use of power-play for committing violence was identified as the worst display of exercised power play.

Figure  1 describes the concept of power-play developed from the study. The power-play model is based on discussions and inferences made from data analysis. The model provides a description and explanation of how women are subjected to inequality and face violence. The concept of power play derives its strength from the subjugated status of women which are based on selective treatment, self-embodiment of inferiority, imposed restrictions and due to lesser life opportunities. The power play gain legitimacy through social approval of the status differences between men and women and through social systems and institutions majorly developed and favoring men. The status difference between men and women and its approval by developed social institutions and processes give rise to the concept of powerplay. It identifies that status differences allow men to gain and (mis)use power play not only to maintain differences but also enable men to use violence. The use of power-play exists at both interpersonal and cultural levels. Further, the model elaborates on influencers causing subjugation of women, display of power-play, and violence. The model identified that lodging public complaints and seeking legal remedies are the influencers that suppress violence against women. The influence of Forum Theater was perceived to have greater influence for victim, perpetrator, and bystanders. The influencers that aggravate violence are fear of further violence, the nature of the interpersonal relationship, alcohol-related abuse, and remaining silent especially on sexual violence. The cultural violence mentioned in the model refers to dowry and witchcraft-related violence and stands as systemic subordination. In the model, sex trafficking is depicted as one of the outcomes of inequality and violence faced by women majorly occurring due to deceit and fraud.

The theoretical concept of power-play developed in this study identifies that inequality produces violence and violence further reinforces inequality, creating a vicious circle. The power play situates hierarchy based on gender as the primary cause and identifies violence as an outcome of this power asymmetry. The authority to use power by men is received by social approval from embedded structures and institutions. The functioning of associated structures and norms is designed and run by men helping to perpetuate the dominance and subjugation of women. The study identifies that both interpersonal and socio-cultural violence emerges due to the positional differences and use of power. The study found that an element of control exists in interpersonal violence. The findings show that few victim women in the community took advantage of consultations and rely on the law to evade and /or cope during the occurrence of interpersonal violence. A large number of victims women however suffer silently as they are unable and unwilling to take a stand on violence due to their perceived positional differences and strict norms following. The study finds that violence originating from socio-cultural systems is widely accepted and no established means of control exists. The practice of heinous acts against a fellow human during witchcraft allegations and dowry exchanges is prohibited by the law of Nepal but is widespread. This situates that practices which are based on belief systems are more effective than prevailing national laws which try to stop them. Sex trafficking as a form of sexual violence use deceit and fraud against women. Poverty and illiteracy compel women to search for alternatives, and they become easy victims of sex trafficking when their dreams of a better life are manipulated by the traffickers. The false promise of a better life and highly paid job put women in a non-negotiating position with traffickers. The cherished dream of escaping the prevailing status-quo of oppression, subordination, violence, and poverty mesmerizes women to take risky decisions, falling into the risk and trap of sex trafficking.

The socio-cultural norms are the unwritten script of social operatives and functioning. These social norms function as codes of operation and are a major determinant for behavior and interactions between people [ 43 ]. The study has found that these norms were skewed, and most favored men, giving rise to status differences and producing inequalities for women. This is observed with lesser life opportunities, lower participation in decision-making, and a constant need to anchor women. This further helps men to maintain their hierarchical positional status and use violence. The subjugation of women does not occur in a linear process, it is influenced by the internalization of discrimination resulting in lower self-esteem, suppression, and domination of women based on norms and unequal practices. Earlier research has identified that norms and beliefs encourage men to control women, and direct them to use force to discipline women which increases the risk of violence occurrence [ 44 , 45 ]. An earlier study shows that traits of masculinity require men to become controlling, aggressive, and dominant over women to maintain status differences [ 46 ]. The study confirms that men upon receiving both normative and social approval for using violence against women can do so without hesitation.

Violence against women in Nepal mostly occurs inside the home and is only reported when it reaches higher levels of severity. The acceptance of violence as a private affair has restricted women from seeking support and discourages them from communicating their problems with outsiders [ 47 ] this increases more likelihood for men to use violence. The study finds issues related to sex and sexual violence is a taboo and are seldom reported. The study could only identify cases of sexual assault registered with the police and other cases known to the wider community as sexual violence. A community with known incidents of rape may have other cases of abuse, harassment, incest, forceful sexual contact, etc. Failure to report incidents of sexual violence infer that a large number of women could be suffering in silence. Earlier research identifies that increased stigmatization associated with sexual violence, and fear of seclusion cause reluctance in victims to report or seek support [ 48 ]. This silencing of victims provides men with greater sexual control over women [ 49 ] increasing more likelihood of use of violence. Gender-based inequality and violence intersect structures, institutions, and socio-cultural processes, making inequality and violence visible at all levels. The dowry-related violence and witchcraft allegation intersect interpersonal and structural violence. This cultural violence forces women to be a victim of lifelong abuse and trauma. The intersecting relationship between gender norms, social structures, and individual is so closely knitted that it produces varieties of inequality and violence at all levels [ 50 ]. Emotional violence in this study only emerged as a type of violence, during discussions in both groups. It did not emerge as a major concern for the participants except for dowry-related violence and violence against men. The intertwined nature of emotional violence and its occurrence with each abusive, exploitative, and violent situation may have influenced the participants understand it as a result, rather than as a specific type of violence.

The power play between sexes was found in synchronicity with the established norms and prevailing stereotypes, helping to perpetuate gender power imbalance. The gender system is influenced and governed by norms and the social arena becomes the site of its reproduction through the interaction and engagement of people. This interaction provides approval to the institutions and processes that are based on constructed differences between men and women [ 51 ]. The power, as identified by Fricker [ 52 ], controls a social group and operates and operates through the agent or established social structures. A man can actively use the vested power to either patronize and/or abuse women while passively women’s internalization of social settings and embedded norms can put them docile. The social controls as reported by Foucault [ 53 ] work with the embedded systems of internalization, discipline, and social monitoring and uses coercion rather than inflicting pain. The internalization of status differences among women as indicated by the study confirms this schema of social control. The dominance of men over women with patriarchal beliefs establishes the significance of male-centered kinship. This requires women to constantly anchor with men providing grounds for inequalities to perpetuate further. This idealizes men and reinforces the belief that women are non-existent without their presence. The requirement for male anchorage has an attachment to prevailing structural inequality. The family property and resources are mostly controlled by men and it usually transfers from father to son limiting inheritance to women [ 51 ]. These glorified idealizations of men's competence as described by Ridgeway [ 54 ] idealize men as individuals with abilities, status, power, and influences. The need for women to rely on men as anchors, fear of going against the norms and social sanctions explains the positional difference and show that men possess greater competencies. The internalization of men-centric superior beliefs by women occurs due to self-passivity and devalues women creating false impressions of their abilities. The gender roles and responsibilities were strict for both sexes but provided greater flexibility, privilege, and opportunity for men. Earlier studies in congruence with this study find that socio-cultural expectations limit women from deviation, and strictly adhere to their prescribed role and expectations [ 55 , 56 ] providing an upper hand to the men. The unequal social positioning of women, as defined by a few of the participants, can help define men's use of violence. As inferred by Kaufman [ 57 ], the disadvantageous position of women and support from the established structures enable men to use aggression and violence with considerable ease. The concept of power-play derived from this study also reflects that inequalities not only create hierarchies, putting women into a subordinating position but also legitimize norms of harmful masculinity and violence [ 57 , 58 , 59 , 60 ] creating a vicious cycle of inequality and violence. The concept of power-play developed by this study requires further exploration of gender relations, injustice, and patriarchy to identify multiple operatives of power with an outcome of inequality and violence.

Strengths and limitations of the study

The study followed the same participants over a period, which helped the study to achieve clarity on the topics through constant engagement. The data collection and the initial data analysis of the study were conducted by the same person, which reduced the risk of misrepresented findings. The study used follow-up discussions, which provided an opportunity to meet the participants again to resolve any ambiguities. The constant engagement with the participants helped to develop rapport and trust, which is essential to enable meaningful discussions. The study gathered rich data for developing the theory of power play in the Nepalese context. The study has attempted to explain the interplay of men’s use of power play, gender inequality, and violence against women, which, in itself, is a complex, but important issue. The study helped to develop a platform by identifying a level of awareness and needs for a Forum Theatre intervention study, a first of its kind in Nepal.

The major limitation of the study is that it was conducted with only one of the ethnic populations of Nepal; thus, the findings from this study cannot be generalized to a completely different setting. However, the transferability of the study is possible in a similar setting. The incidences of inequality and violence shared by the participants were self-reported, and no other means of verification were available to crosscheck those claims. The differences among the participants both in and between groups based on education and marital status might have influenced the study participants to understand, observe, and experience the phenomenon. The possibility of social desirability bias remains with the study, as a constant engagement with the study participants might have influenced them to answer differently. Furthermore, the discussions were conducted in groups, and participants might have had hesitation to bring up any opposing views. The study relied on collecting information on social norms and individual experiences and the perceptions of the study participants. It cannot be claimed that the study is devoid of any data rigidity as participants were free to choose what they wanted to share and express.

Study implications

The study explains gender practices, norms, violence against women, and sex trafficking in Nepal. The study helps to increase the understanding of how gender systems are operative in the daily lives of the Tharu community in the Morang district of Nepal. Future studies can explore the established linkages of interpersonal and socio-cultural violence. Like the complex link existing between gender inequality and violence against women, interpersonal violence and socio-cultural violence cannot be studied in isolation. The study provides an opportunity for future research on exploring how changing norms have been altering the position and victimization of women. The study finds that changing gender norms and responsibilities have, on the one hand, provided agency and empowerment for women, but on the other hand, they have also increased their risk of being a victim, an area that requires further exploration. The study has identified that constant engagement with the study participants through follow-up studies ensures the richness of data, which can be useful information for a future research study design. The study can be helpful for policy development, social activists, leaders, and researchers as it discusses prevalent gender oppressions and victimization, which need to be addressed. The findings from the study can be helpful for dialogue imitation and for designing intervention projects aimed at providing justice and equality to women.

The study identifies the presence of gender inequalities and violence against women in the study area. The positional differences based on norms, institutions, and practices have assigned greater privileges to men. The concept of power-play devised by the study ascertains the maintenance of gender hierarchy to produce inequality further and victimization of women. The subjugation of women based on the social-cultural process, embedded belief systems, and norms prevent women from life opportunities and dignified life. It situates men at the highest rung of the gender and social ladder providing a comparative advantage for men to use power. Violence emerges as men’s use of power play and as a strategy for the continued subjugation of women. Sex trafficking as a consequence of inequality and violence has its origins in illiteracy and poverty with women falling prey to the deceit of traffickers. It is important that dreams for progression provide motivation for women to develop further but at the same time, dreams should not be exchanged with trickery and fraud offered by the traffickers. Awareness and attitudinal changes are imperative to challenge unequal norms, and practices, and reduce the risks of sex trafficking. This can help to develop negotiations for power-sharing which helps to reduce inequality, violence, and preparedness in chasing dreams. Changes at both individual and societal levels are necessary to develop a collective action for establishing belief systems and practices providing women with an equal position and reducing the risk of violence.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available due to privacy but are available from the corresponding author upon reasonable request.

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Acknowledgements

The authors are grateful to all the focus group discussion participants. The authors are indebted to Bhojraj Sharma, Deekshya Chaudhary, Subham Chaudhary, and Dev Kala Dhungana for their coordination and facilitation in reaching the discussion participants.

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PD, SKJ, and KS were involved in the study design. PD and KS developed the discussion guides. PD was responsible for the data collection and the data analysis. All authors read and approved the final manuscript.

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Dahal, P., Joshi, S.K. & Swahnberg, K. A qualitative study on gender inequality and gender-based violence in Nepal. BMC Public Health 22 , 2005 (2022). https://doi.org/10.1186/s12889-022-14389-x

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Qualitative research and its place in health research in Nepal

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• PMID: 22710544
• DOI: 10.3126/kumj.v9i4.6350

There has been a steady growth in recent decades in Nepal in health and health services research, much of it based on quantitative research methods. Over the same period international medical journals such as The Lancet, the British Medical Journal (BMJ), The Journal of the American Medical Association (JAMA) and the Journal of Family Planning and Reproductive Health Care and many more have published methods papers outlining and promoting qualitative methods. This paper argues in favour of more high-quality qualitative research in Nepal, either on its own or as part of a mixed-methods approach, to help strengthen the country's research capacity. After outlining the reasons for using qualitative methods, we discuss the strengths and weaknesses of the three main approaches: (a) observation; (b) in-depth interviews; and (c) focus groups. We also discuss issues around sampling, analysis, presentation of findings, reflexivity of the qualitative researcher and theory building, and highlight some misconceptions about qualitative research and mistakes commonly made.

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• Health Services Research / methods*
• Interviews as Topic
• Qualitative Research*
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A qualitative study to understand drivers of psychoactive substance use among Nepalese youth

Roles Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Validation, Writing – review & editing

Affiliation Department of Public Health, School of Health and Allied Sciences, Pokhara University, Pokhara, Nepal

Contributed equally to this work with: Bhushan Khatiwada, Bibika Rajbhandari

Roles Data curation, Formal analysis, Methodology, Software, Writing – original draft, Writing – review & editing

Affiliations Torrens University, Pyrmont Campus, Sydney, Australia, Centre for Research Policy and Implementation, Biratnagar, Nepal

Roles Formal analysis, Methodology, Supervision, Writing – review & editing

Affiliation The George Institute for Global Health, University of New South Wales, Sydney, Australia

Roles Formal analysis, Methodology, Validation, Visualization, Writing – review & editing

Affiliation Centre for Primary Health Care and Equity, University of New South Wales, Sydney, Australia

Roles Formal analysis, Methodology, Validation, Visualization, Writing – original draft, Writing – review & editing

Affiliations School of Optometry and Vision Science, Faculty of Medicine and Health, UNSW, Sydney, Australia, Department of Infection and Immunology, Kathmandu Research Institute for Biological Sciences, Lalitpur, Nepal

Roles Investigation, Methodology, Supervision, Visualization, Writing – review & editing

Affiliation School of Health Medical and Applied Sciences, Central Queensland University, Sydney, Australia

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected] , [email protected]

Affiliations Torrens University, Pyrmont Campus, Sydney, Australia, Centre for Research Policy and Implementation, Biratnagar, Nepal, Centre for Primary Health Care and Equity, University of New South Wales, Sydney, Australia, National Centre for Epidemiology and Population Health, The Australian National University, Canberra, Australia

• Tulsi Ram Bhandari, 
• Bhushan Khatiwada, 
• Bibika Rajbhandari, 
• Amy Bestman, 
• Sabuj Kanti Mistry, 
• Binod Rayamajhee, 
• Lal B. Rawal, 
• Uday Narayan Yadav

• Published: November 5, 2021
• https://doi.org/10.1371/journal.pone.0259021
• Reader Comments

Psychoactive substance use among youth is an emerging public health issue in Nepal. This exploratory study aimed to better understand the drivers of psychoactive substance use among Nepalese youth in Rupandehi district of Nepal.

Materials and methods

This study used a qualitative approach for data collection. Both in-depth interviews (IDI, seven participants) and focus group discussions (FGD, 13 participants) were conducted among study participants who self-reported as psychoactive substance users or had history of psychoactive substance use. Participants for IDI were aged between 11 and 24 years and between 18 and 35 years old for FGDs. Semi-structured interview guides were prepared separately for IDIs and FDGs. Interviews were conducted in Nepali language and were audio recorded, which were there transcribed and translated into English for coding and analyses. In addition, interviews notes were taken by two research assistants. An inductive thematic analysis was used to analyze the data.

This study identified a range of drivers of psychoactive substances use among Nepalese youths. Themes included (i) socio-cultural factors, (ii) individual factors, (iii) academic environment, (iv) physical environment and the (v) influence of media. The socio-cultural factors were categorized into sub-themes of family relationships, ethnic identity and psychoactive substance use and lack of social acceptance. Individual factors included peer pressure, stress relief and coping with financial challenges. Accessibility and availability of psychoactive substances in the surrounding environment and lack of monitoring and reinforcement of rules/ law and regulations were other drivers to psychoactive substance use among this Nepalese youth cohort.

Our study identified several important drivers of psychoactive substance use among youth in the Rupandehi district of Nepal. Future works are anticipated to further explore youth initiation and use of psychoactive substances and support the design of interventions that address these risk factors to reduce and prevent subsequent harms.

Citation: Bhandari TR, Khatiwada B, Rajbhandari B, Bestman A, Mistry SK, Rayamajhee B, et al. (2021) A qualitative study to understand drivers of psychoactive substance use among Nepalese youth. PLoS ONE 16(11): e0259021. https://doi.org/10.1371/journal.pone.0259021

Editor: Chhabi Lal Ranabhat, Global Center for Research and Development (GCRD), UNITED STATES

Received: December 23, 2020; Accepted: October 11, 2021; Published: November 5, 2021

Copyright: © 2021 Bhandari et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All datasets generated and analyzed are not publicly available but are available from Centre for Research, Policy and Implementation, Nepal ( [email protected] ) upon reasonable request. The interview and focus group records are identifiable which cannot be shared because of legal and ethical boundaries.

Funding: The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Psychoactive substances include alcohol, tobacco, licit and illicit drugs, that when consumed, can harm the mental wellbeing of an individual [ 1 ]. In 2017, the United Nations Office on Drugs and Crime (UNODC) estimated 271 million people of age group 15–64 years used any form of drugs and 35 million people suffered from disorders associated with psychoactive substance use [ 2 ]. By the end of 2017, 11.8 million deaths were recorded globally due to direct and indirect use of psychoactive substances (predominantly tobacco, alcohol and drugs), out of which 11.4 million were premature deaths [ 3 ]. According to the World Health Organization (WHO) Global Health Estimates, in 2019 the proportion of Disability Adjusted Life Years (DALYs) due to alcohol use disorders globally was 0.76% and 0.78% due to drug use disorders [ 4 ] whereas, in Nepal, DALYs were 0.5% and 0.29% due to alcohol and drug use disorders, respectively [ 5 , 6 ].

In Nepal, sale of tobacco and alcohol products by non-licensed vendors have been restricted by law [ 7 , 8 ]. For example, it is illegal to sell tobacco products to individuals younger than 18 years [ 7 ] or alcohol to individual under 21 years [ 8 ]. However, despite these laws, it has been estimated that over 21,000 children between 10–14 years consume tobacco each year in Nepal [ 9 ]. Additionally, the narcotics control act of Nepal does not allow any person to consume cannabis/marijuana, with penalties such as one month behind the bars or a fine of NRs. 2000 (17 USD) for possession, however these vary on the amount of cannabis/marijuana possessed by an individual [ 10 ]. The most prevalent psychoactive substances used in Nepal are cannabis, tranquilizers, and opiates and the highest number of users has been reported from Bagmati Province, capital city of the country [ 11 ]. The influence of psychoactive substance misuse during early adolescence has been linked to entertainment, relaxation, curiosity, peer, and media influence [ 12 ].

The Government of Nepal survey conducted in 2019, found 130,424 people were using drugs in Nepal with 5.06% average annual growth from 2013 to 2019. Males accounted 93.3% of drug users (females account 6.7% of users) and 76.2% were below of age group 30 years [ 11 ]. According to another study conducted in Nepal in 2018 with 387 psychoactive substance users, 10.8% of psychoactive substance users began at 13–15 years and 44.4% started using psychoactive substances between 16 and 20 years [ 13 ]. Psychoactive substance use among youths is an important issue that effects both physical and mental health outcomes of youths [ 14 ]. Early-onset use of psychoactive substances has been linked to a range of health and social issues including poor physical and mental health, inadequate school performance, unemployment, substance use disorder, and seclusion, a strained relationship with family [ 15 ]. Previous research has also identified that the initiation of psychoactive substance use from early adolescence, can lead to cumulative public health challenges [ 16 ]. Evidence suggests that the high prevalence of adolescents using psychoactive substances in Nepal is significantly associated with parental use and cultural acceptance of psychoactive substances [ 17 , 18 ]. However, to date, there is scarce qualitative research that enables deeper understanding of experiences, phenomena and context of psychoactive substances use in Nepal, especially among youths. Thus, the current study was conducted to understand drivers of psychoactive substance use among Nepalese youth in Rupendehi district of Nepal.

Research design

This qualitative study used an interpretivist epistemological view to understand the drivers of psychoactive substance use among Nepalese youth in the Rupandehi district of Nepal [ 19 ]. This study used both in-depth interviews (IDI) and focus group discussions (FGD) in order to capture holistic description of the phenomenon. IDIs were selected to allow participants to share experiences openly in a safe environment without hesitation and allows researchers to pursue new themes that emerge during the interview. FDGs were chosen to explore diverse views on a particular phenomenon through group discussion and interaction of prominent issues [ 20 ].

Participant’s recruitment and sampling

Participants for this study were recruited from rehabilitation and treatment centers of Rupandehi district. Purposive sampling was used to recruit participants to ensure sampling variation across age, ethnicity, education status, occupation and economic status of the adolescents. Participants representing various ethnic groups were included; upper caste (Brahmin and Chhetri), indigenous groups (Newar, Tamang) and marginalized communities (Dalit). We only included participants who had reported previous use of psychoactive substances and excluded individuals diagnosed with severe psychiatric disorders, intent to harm self and others, or failed to produce assent consent.

Data collection

Data were collected from August 2017 to April 2018. This study recruited seven participants for face-to-face IDIs aged between 11 and 24 years. Each IDI lasted 18–25 minutes. Thirteen participants of aged 18–35 years were recruited for FGDs. Two FGDs were conducted at two different settings (one with a group of six participants and another with seven). Duration of FGDs were 40–45 minutes. All FGDs and IDIs were conducted in Nepali language by one of the investigators where notes were taken by two research assistants and were audio-recorded. Interviews were conducted in a comfortable environment to ensure open discussion and encourage all participants to describe their experiences. Questions and sub-questions invited open-responses and related to attitudes and perceptions of adolescents and reasons behind the early initiation of psychoactive substances. The scripts of data were read, re-read and discussed between two investigators to decide the point of saturation. After reaching saturation point, data collection process was topped.

Trustworthiness of the study

Validity and reliability of the findings were measured in terms of trustworthiness which comprises credibility, transferability, dependability and conformability of the study participants [ 21 ]. The investigator who conducted the IDIs and FGDs had a public health background and shared the same language and culture with majority of the study participants. This supported investigators to build rapport and ask appropriate follow up questions. Participants were genuinely willing to take part in the study and provided relevant information freely. The collected data were transcribed, translated, coded and analyzed by four authors and were checked by two lead authors (TB and UNY) for accuracy and consistency of the translations. Analyzed results were also checked by lead authors to examine any discrepancies and data obtained through both FGDs and IDIs were triangulated for similarities and variation [ 22 ].

Ethics approval

This study protocol was reviewed and approved by the Nepal Health Research Council Ethics committee, and approval from the District Education Office, Rupandehi, was also obtained prior to commencing field data collection. Written assent consents were obtained from parents of participants who were below 18 years old. Written informed consents were obtained from the rehabilitation centers and study participants. The confidentiality of all the participants and information obtained was maintained.

Data analysis

Data were analyzed using an inductive thematic approach, as suggested by Braun and Clarke [ 23 ]. Initial codes were developed, and researchers met to discuss the validity of codes in a broader context. The investigators reviewed the transcripts verbatim then developed codes and higher order themes until consensus was reached. The codes were critically analyzed to develop sub-themes and themes. Given that qualitative data was translated into English, some quotes have been edited to increase clarity for readers. Where quotes have been changed, these have included minor edits to language, however the meaning of quotes has remained same.

Out of 20 participants, 18 were male and two were female and half (n = 10) of participants did not reveal their ethnic identity. Among ten participants who provided information on ethnic identity, five were from indigenous groups, 2 from Dalit (so called low caste/ untouchable caste according to traditional Hindu caste system) and two from so called higher caste (one from Chhetri and another from Brahmin). There were total of 4 participants who were below 18 years old.

Five broad themes socio-cultural factors, individual factors, physical environment, academic environment and influence of media emerged from the data analysis of both FGD and IDI. These have been presented in Table 1 and have been explained below.

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https://doi.org/10.1371/journal.pone.0259021.t001

A. Socio-cultural factors

Socio-cultural factors included active engagement of people and, the cultural practices and influence of people, which impacted psychoactive substance use. This included environments created by families, cultural identity, cultural differences, attitudes and behaviors of people, parenting practices, ethnic identity and societal discrimination. Based on the information provided by participants, we identified the following sub-themes, youth and family relationships, role of peers, ethnicity and social acceptance.

i) Family relationships.

Participants described lack of supervision such as poor parental care, less support and minimal attention to youth as reasons for initiation and engagement in psychoactive substance use. Some participants referred to the impact of parental separation on their mental health and the role of psychoactive substance use in coping with resulting increased mental stress. For example, one participant from the Dalit community said:

“I got involved [with psychoactive substances] when I was seven years old while studying in a government school . My dad divorced my mum . You can imagine how much stress I had , and I could not bear that stress . To cope with that , I started using psychoactive substances” [Male participant, 12 years, Dalit community, IDI]

Some participants described that detachment from family members or the absence of family members to guide during adolescence period forced them to engage in psychoactive substance use. These participants mentioned that they used psychoactive substances as stressor and loneliness solace. One participant from the FGD explained after his parents separated, his mother went overseas to earn money. While he was without his mother, his elder brothers from the community who were involved in psychoactive substance encouraged him to initiate psychoactive substance use:

“After my mother left when I was eight years old there was no one to spend time with me at home . So , I started spending time outside and my cousins involved me in using psychoactive substance (drugs like Brown sugar . ” [Male Participant, 14 years, FGD].

Lack of attention from parents was also identified as a factor that influenced youth psychoactive substance use. Participants noted family members poor knowledge of youth activities, lack of parental affection, and lack of involvement of parents in their adolescent daily life. Some of the participants from the FGDs expressed parental inability to understand how the complexity of youth problems (for example, low grades in school, financial problems, stigma based on caste or ethnicity) led youths to escape through psychoactive substance use. One participant of FGDs told investigators that his parents adopted very cruel strategies in response to their psychoactive substance use.

“My family failed to understand me when I involved into drugs; they gave me different tortures in a sick mood (electric shock , canning , restricted me to go out , etc . ) . This forced me to engage more deeply into drugs use . ” [Male Participant, 19 years, Indigenous, FGD].

Some of the participants in IDI mentioned that poor parental monitoring and limited concern around adolescents’ activities prompted adolescents to become involved in psychoactive substance use, such as smoking cigarette and progression into the use of ‘hard’ psychoactive substances (drugs, nitrogen tablets, injection). One participant said,

“I think family members were responsible as well because they never asked for reasons behind asking the money to me . They (parents) usually provided me large sums of money , which is the main reason for getting indulged in these behaviors (using drugs) . ” [Male Participant, 24 years, FGD] “Family and friends are responsible for an equal amount . Nowadays , family members are more focused on earning money and in a way , they don’t care about adolescents . This leads to the development of the circle (people using psychoactive substance ) . ” [Male participant, 23 years, Chhetri, FGD].

ii) Ethnic identity and psychoactive substance use.

In Nepal, some ethnic groups such as Dalits, Indigenous groups like Rai , Magar , Newar , Sherpa and Limbu have a traditional value where they make alcohol in their own home to offer God and drink alcohol in festivals like Dashain or any family occasions like marriage or death ceremonies. Participants from indigenous groups identified that psychoactive substance use, mainly alcohol and tobacco use, as normal behavior. Nearly half of participants (n = 8) explained these cultural links as influential factor to their use of psychoactive substances:

“My mother used to make alcohol at home , and we [siblings] used to sell it . She [mother] used to ask me to taste alcohol to find the strength of alcohol and later my body asked for a higher alcohol dose , and then I became an alcohol addict . ” [Male participant, 24 years, Indigenous, FGD].

iii) Lack of social acceptance.

The majority of the participants in IDI mentioned that their history of psychoactive substance use mean they were not accepted in society, even after they got treatment for addiction. These attitudes pushed some to relapse into addictive habits:

“After leaving the rehabilitation center it was difficult for me to adjust to society . They call names like : ‘jadhya’ (alcoholic) and ‘dhule’ (drug addict) . Even if I am trying to do something good , the family and society don’t trust me , which forced me get use drugs again . ” [Male participant, 30 years, FGD]. “If my friends and families had supported at that time (after returning from rehabilitation) , you [ researcher ] would not see me here [ rehabilitation center ] today again . ” [Male Participant, 34 years, FGD].

One of the IDI participants mentioned that she was maltreated (emotional abuse) by the family members which forced her to use psychoactive substances again after returning from rehabilitation.

“My husband has a foreign ID (as my father-in-law is a foreign soldier) and he left for a foreign country to strengthen our financial status . After he left , the family members of the husband-side started giving torture [verbal and physical abuse] to me in a different way , and this is why I get into drugs use again (brown sugar , nitrogen tablets) . ” [Female participant, Indigenous community, 22 years, IDI].

Few participants from FGD expressed that psychoactive substance users should be given a chance in society to work or share their stories which would dissuade other young Nepalese people to use psychoactive substances.

“People with history of drug use should get income generating opportunities in the community . But society and family do not trust drug users . They [ psychoactive substances users ] are always blamed for any wrong things if happen in community such as if someone stole anything , the community people first reach to drug users to check if they stole it . This forces us [users] to return to drugs” [Male participant, 28 years, FGD].

B. Individual factors

Many factors that operate at individual level impedes decision making process among youths, resulting their engagement in psychoactive substance use. Peer pressure, source of relief and financial challenges are sub-themes that explain individual factors related to psychoactive substance use.

i) Peer pressure.

Most participants from both FGD and IDI believed that friends and peer groups were a key factor in initial psychoactive substance use (particularly Marijuana, Cannabis and alcohol use). This included direct or indirect influence or pressure from friend circles for psychoactive substance use.

“I started with "Chang" [a local alcoholic drink] at the age of 15 during my school life , as I was part of the bad circle [psychoactive substance users] in my school . Later on , I became resistant to change and decided to use other drug use such as syringes , brown sugar . ” [Female participant, 22 years, IDI].

The majority of participants from the FGD and IDI (all age groups and genders) shared their experiences that friends encouraged them and put pressure on them to try marijuana and other drugs. The social influence from the user and the supportive friendship provided an environment that encouraged others to abuse psychoactive substances. One of the participants said-

“My friend circle motivated me a lot by giving examples like , look nothing happened to us . As they were taking the weed , nitrogen tablets , brown sugar for a long time , and life is a matter of enjoyment , and ultimately I got involved . ” [Male participant 23 years, Chhetri, FGD].

Some participants of FGDs and IDI said that friend circles played a key role in alcohol initiation, by highlighting the relationship with alcohol and culture. Most participants from ethnic groups mentioned that they started with homemade alcohol and later their curiosity to try other forms of psychoactive substances (weed, brown sugar) increased. One participant said-

“I got involved in drugs (weed) via my friend circle which was created at school . I started at the age of 12 . They pressured me showing ethnic relations to alcohol -Khana kei hudaina…jaat le deko yar [ Have it, it’s the gift given by your ethnicity, English translation ] and I felt it true and started taking it . ” [Male participant, 24 years, indigenous, FGD].

The majority of the participants from IDIs mentioned that their friends encouraged them to use psychoactive substances to get relief from stress.

“I asked for solutions with my friend , and they told me to take these drugs and will get relief from the tension . But , after getting into this (substance use) , it’s hard to withdraw . ” [Male participant, 23 years, Chhetri, FGD].

ii) Source of stress relief.

Youth used psychoactive substances as a source of relief in order to alleviate frustration and stress.

Most of the participants of FGDs expressed that they used psychoactive substances as a coping strategy to deal with stress caused because of the break-up in a relationship and family problems:

“I start using drugs to get relief from tension caused by study and financial hardship . ” [Male participant, 22 years, IDI].

A few participants said that they have seen people relaxed, and free of tension or negative feelings through the use of psychoactive substances, which motivated them to try substances:

“Psychoactive substance use gave me energy and a sense of belief that stress , and problems can be solved” . [Male Participant, 19 years, Brahmin, FGD].

iii) Financial challenges.

Most of the participants cited financial challenges as a pertinent factor behind psychoactive substance use. One participant expressed:

“We [my family] took a loan from someone in our community with an interest of 10% per month to build a home . We paid interest and huge amount but at last , he [loan giver] did not return our property . This put me in tension and to cope with that I started taking drugs . ” [Male Participant, 23 years, IDI].

Additionally, few participants described the financial challenges faced by Nepalese students in foreign countries increases the risk of drug abuse. One participant of IDI shared the following experience:

“I was in Australia and was not able to find a job and family could not support me financially as they already had loans and I could not cope up with the situations which forced me to involve in using drugs . ” [Male participant, 22 years, IDI].

C. Physical environment

The physical environment played a substantial role in shaping the attitudes and behaviors of individuals and influencing norms and values. In this context, two key themes emerged relating to the physical environment: the accessibility and availability of psychoactive substances in the surrounding environment, and the lack of monitoring and enforcements by authorities.

i) Accessibility and availability of psychoactive substances in the surrounding environment.

Participants identified the easy availability of psychoactive substances in the home, neighborhood, local markets, or near city areas where psychoactive substances like alcohol, cigarettes, marijuana and illegal drugs are available to youth. Participants said that this type of environment encourage youth to try psychoactive substances at first, which leads to sustained psychoactive substance use. Participants of FGDs mentioned that tobacco, alcohol, and substances like nitrogen tablets, brown sugar and marijuana were readily available in the local pharmacy and grocery shops (which is illegal in Nepal) and can be purchased very easily using peer network. One of the participants said:

“I started taking Nitrogen tablets in beginning , later on , brown sugar , opium . It is easily available in the Butwal markets . ” [Male participant, 19 years, Indigenous, FGD].

Similarly, one participant from IDI mentioned his experience of buying psychoactive substances even from pharmacy shops.

“Drugs are easily available from Butwal pharmacy , they [pharmacists] do everything for money . ” [Male participant, 21 years, IDI].

Participants from IDI and FGDs also stated that the accessibility of psychoactive substances at the nearby Indo-Nepal border facilitated adolescent initiation of psychoactive substances (such as Nitrogen tablets, brown sugar, cocaine, heroin). Over-the-counter medicine consumption is common in both rural and urban setting of Nepal because people can get medicines directly from unregulated non-pharmacist run registered/unregistered ‘drug shops’ similar to grocery shops. Some participants of IDIs and FGDs specifically referred to the availability and use of cough syrups (Phensedyl), Dendrites (adhesive synthetic product for footwear), fevicol glue (a synthetic adhesive used for woodworks) and sedatives like Nembutal, zolpidem and Seconal.

ii) Monitoring and enforcement.

Most of the participants in this study (in both FGDs and IDIs) believed that political bodies, local policemen, shopkeepers (particularly grocery stores), pharmacists and border personnel at the Indo-Nepal border enable environments that allow for the availability of psychoactive substances (including nitrogen tablets, brown sugar and heroin). Additionally, participants noted the role that authorities play in the drug smuggling process. One participant of IDI shared his experience who had seen some police officials involved in trading psychoactive substances and drug paraphernalia:

“Few policemen are also drug addicts , and they know the supply mechanism . Under [policemen] support drugs are available in the market . Besides policemen , there are many high-profile people in drug trading in Butwal . ” [Male Participant, 23 years, IDI].

A few of the participants from FGD mentioned that it was easy to escape from the police by giving bribes if they were caught in drug trafficking:

“I was caught once by the police but bribing police with was enough to escape from border . ” [Male participant, 26 years, FGD].

Most participants in IDI described that the inadequate monitoring of psychoactive substances in society such as public bars, pubs, restaurants, and sometimes brothels, where psychoactive substances were sold and used on site. Some of the participants of IDI also mentioned that adolescents and women from marginalized communities (Indigenous and Dalit community) were generally involved in the cross-border trafficking of drugs, as officials overlooked traffickers either because of their age or physical status (i.e., those who appeared poor and vulnerable were allowed to travel without checking).

“I used to wrap the drugs in the plastic and keep it inside the shoe insole so that police can’t find it . Using this technique , I transported drugs to Butwal . ” [Male participant, 22 years, Indigenous, IDI].

A small number of participants described taking risks to hide or transport drugs to be undetected. This included getting involved in trafficking psychoactive substances through swallowing small plastic pouches or mixing psychoactive substances with other large food items:

“I got into cross-border drug supply since the age of 7 years old . They [smugglers] trained me in swallowing brown sugar sachets in India . After crossing border (India-Nepal border) I excrete those sachets in Nepal through stool . This was the safest way to escape the border police . ” [Male participant, 11 years, Dalit Community, FGD].

D. Academic environment

The school environment also played a vital role in students’ lives. Youths spent a large amount of time in school among other fellow students and teachers. Participants from FGDs and IDI explicitly mentioned that failure to achieve good grades and lack of support from teachers was the primary reason to leave school and use psychoactive substances.

“Actually , in my case , the schoolteacher never supported me and used to give my example in the class . This guy [indicating participant ] is good for nothing , and he cannot do anything in the future . With all this , I opt out of school and later got involved in using drugs . ” [Male participant, 19 years, Indigenous, FGD]. “I was weak in study and my school friends suggested that using diazepam and morphine [pharmaceutical drugs] can improve concentration on the study . I used these drugs for sometimes and later it became too hard to withdraw [ stop drug use ] . ” [Male participant, 16 years, Chhetri, FGD].

E. Influence of media

Participants reported that digital media and television programs glamorized psychoactive substance use, which directly influenced especially, adolescents and adults to try psychoactive substances. Some participants in the FGDs mentioned the use of psychoactive substances by celebrities in movies or on social media pages, while some participants from IDIs said that their use of psychoactive substances (tobacco, alcohol, or marijuana) was to feel like an actor in a movie or television-serial. This copying practice was perceived as fun or exciting and led to the experimentation of psychoactive substances. In some cases, this led to sustained use of substances and abuse of psychoactive substances. One of the participants of FGD said, he used to have various non-prescribed medicines and available materials like dendrites (glue) to have fun and a good feeling, which turned him to be psychoactive substances abuser:

“ I used dendrites , mixed different medical drugs* . I used to try different pharmaceutical drugs to get in the mood . ” [Male Participants, 30 years, Indigenous, FGD].

* Note. Mixing of the liquid drugs used to treat kidney disease patients to get ‘a good kick’.

This study identified crucial socio-cultural, individual, physical environment, academic environments and the influence of media, as key fueling factors of psychoactive substance use among Nepalese youths of this study. Despite a small study group, consisting of 20 participants, this study presents a rich source of information on the factors that influence youth initiation and use of psychoactive substances in Nepal. This research reports on the experiences of youth who had been at rehabilitation centers (and some from a very young age). While this may be unique to the current sample, it will be important that future research explores whether these themes emerge in a sample of youth from the general population of Nepal. This research serves as an important starting point to better understand these behaviors and develop appropriate interventions to reduce the harm caused by use of psychoactive substances.

The findings of this study identified the family, culture, and societal environment, where the growth and development of individuals take place, as an initiating factor for psychoactive substance use among youth in Nepal. Parental separation, detachment from family members and poor parental supervision contribute to stress among adolescents, which encouraged them to use psychoactive substances. This finding is consistent with other research that found family environment as a determining factor for the engagement of youths in psychoactive substance handling and use [ 24 , 25 ]. Studies have also reported high use of psychoactive substances among adolescents who return from rehabilitation centres (due to peer pressure, family level conflict or adjustment within family, low self-confidence, and low acceptance by the society) [ 26 , 27 ]. However, given the cultural nuances identified in this cohort, future research should seek to better understand how these societal factors interact with each other, as well as other factors that shapes pathways to psychoactive substance use among Nepalese youths.

This study also found ethnicity as a key driver for psychoactive substance use among Nepalese youth. Prior research from India have highlighted that alcohol use among some indigenous communities is strongly connected to cultural rituals where part of alcohol is offered to the god and the remaining is consumed by the devotees as prasad (a devotional offering made to a god and later shared by devotee) [ 28 , 29 ]. The cultural acceptances of psychoactive substance use in some ethnic groups have previously documented in studies from Nepal [ 17 , 30 ]. However, previous studies from Nepal reported that the non-indigenous communities were more involved in psychoactive substance use compared to indigenous people [ 13 , 31 ]. This might be because of the cultural differences where one specific community culture provides a favorable environment for youth of other communities to use psychoactive substances such as alcohol, while these activities are less accepted in their own community.

It was perhaps no surprise that peer groups appeared to play a very influential role for the initiation and continued use of psychoactive substances, especially among youths, given previous studies conducted in Nepal and other countries showed the influence of peers to use psychoactive substances [ 32 – 35 ]. Since adolescents and youth share special bonding rituals with friends, it is easier to be influenced by the behaviors of friends and difficult to reject offers of psychoactive substance use [ 36 ]. In addition, the influence to use psychoactive substance from their peer circle can be explained by societal cognitive theory which highlights some of the factors like environment and others action play a vital role in behavioral change [ 37 ]. Also, studies have reported factors such as appreciation shown by peer circle can induce the psychoactive substance use [ 38 ].

This study also observed the use of psychoactive substance in relation to stress management. This supports other evidence that shows stressful events and traumatic exposure creates neurological shifting which may decrease behavioral control and accelerates the risk of maladaptive behavior [ 39 ]. This is also supported by other studies that found use of psychoactive substance as a source of relaxation and relief among students [ 36 , 40 ]. The financial status of the individual and family was found to be contributing factor to increased use of psychoactive substances. Low financial status and economic instability generates stress and acts as a stimulant of psychoactive substance initiation. A previous study reported interconnection between economic crisis and increased prevalence of psychoactive substance abuse, needle and syringe sharing [ 41 , 42 ]. Beside these, the misuse of having higher financial capability was also associated with the high connection with psychoactive substance user gangs and increased psychoactive substance use like alcohol, marijuana which is consistent with other studies [ 43 – 45 ].

Easy availability of psychoactive substances in local markets was identified as an enabling factor for use among youths. Readily available alcohol and tobacco in the household was the first choice of psychoactive substance among our study participants which was also reported in previous studies [ 17 , 46 ]. Misuse of pharmacological drugs was reported by many participants in the present study. Similarly, misuse of psychotropic drugs and the facilitation of over-the-counter drugs were found in other studies [ 47 ]. Furthermore, minor opiates and pain medicines (Temazepam, Flurazepam) were found to be commonly misused by healthcare students for getting kick [ 32 ]. In addition, poor monitoring of security personnel in the Nepal-India border aids to cross-border trafficking and easy availability of psychoactive substance in the local market [ 48 ]. Poor academic performance and grades cause stress among youth which increases risk of psychoactive substance use as a coping mechanism. Such students engage in psychoactive substance use with hope of gaining better scores and to get relief from the dissatisfaction caused by the poor academic achievements [ 36 , 49 , 50 ]. The present study showed academic pressure as an enabler for psychoactive substance abuse among youth and this highlights the importance of school/college-based intervention to improve study environment. This can be done by creating school policies to recognize students with high level of stress, inclusion of extra curriculum chapters such as stress management education, encouragement, good communication and motivation to the needy ones [ 51 ]. In addition, to minimize the psychological distress among students, incorporation of life and social skills training and problem-based learning skills in an academic curriculum which may help students to function independently and choose right decisions [ 52 ]. According to United Nations Office on Drugs and Crime, skills-based health education includes the interactive sessions by skilled teacher which helps in building personal and social abilities to deal with daily life circumstances that one faces [ 53 ].

The present study revealed the influence of media and celebrities in promoting psychoactive substance use among youth. Media often portrays psychoactive substances as a source of entertainment through role play which indirectly fosters psychoactive substance use [ 54 ]. It is highly likely that psychoactive substances use among youths increases when media artists publicly demonstrate drinking alcohol, smoking cigarette or using drugs to show aggressive behavior, cope with personal circumstances such as relationship break-up, financial challenges or demonstrate the power in their networks. Prior studies have demonstrated the role of media in promoting substance use among youth [ 55 , 56 ].

Youth who are involved in psychoactive substance use were found to be indulged with various unlawful behaviors such as involvement in vigorous and gang sex, criminal mischief and in burglary to collect money to have psychoactive substances [ 57 – 60 ].

Our findings suggest the need for interventions that deliver cultural friendly health literacy initiatives to be operated at different levels such as school, community, youth clubs to educate youths on the detrimental effects of using psychoactive substances and providing information on the available services to help them to get rid of psychoactive substance use. In addition, youth identified as at-risk should be supported through targeted activities that seek to identify and prevent factors that enable pathways to psychoactive substance use. We also suggest the need for strong implementation of policies that prohibit the psychoactive substances being sold to children below 18 years. Further, we suggest the need for national level research focusing on youth to understand the social and structural determinants of psychoactive substance use among Nepalese youths. The findings from such study may help the government of Nepal to develop policies and strategies to curb psychoactive substance use among the youths.

Strengths and limitations

Strengths of this study include that this is one of the first qualitative studies conducted in Nepal that seeks to understand the factors that influence psychoactive substance use initiation, rather than collecting survey data. This study also provides starting point for additional in-depth qualitative studies based on findings AND knowledge developed in this study. One of the key limitations of this study was a small study conducted within participants of one district from participants who were in rehabilitation centers, therefore the findings may not be generalizable to the broader population of the country. Another limitation is that we did not collect data from family and community members, teachers and other stakeholders who could have provided more insights on this research area.

This study explored multiple factors that influenced initiation and engagement in psychoactive substance use among young people in the Rupandehi district of Nepal. The findings from this study may assist policymakers to design multi-sectoral responses to prevent harm from psychoactive substance related issues among Nepalese youth. These preliminary findings suggest there is a need for additional research with multilevel stakeholders, such as youths, family members, schools and community based local organizations and police officials to better understand psychoactive substance consumption behaviors. Future work should seek to identify interventions that address these factors to reduce youth initiation and using psychoactive substances and preventing subsequent harms.

Acknowledgments

We thank all the participants and rehabilitation and treatment centers for their cooperation and support during the study. Sincere thank goes to Nepal Health Research Council for Research Grant and confirming the ethical approval for this study. We acknowledge Sakriya Sewa Samaj Rupandehi, Nepal for their kind cooperation and support throughout the study.

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• Open access
• Published: 11 January 2024

Exploring community insights on antimicrobial resistance in Nepal: a formative qualitative study

• Ayuska Parajuli 1 ,
• Lidis Garbovan 2 ,
• Basudev Bhattarai 1 ,
• Abriti Arjyal 1 ,
• Sushil Baral 1 ,
• Paul Cooke 2 ,
• Sophia Latham 3 ,
• Dani J. Barrington 4 ,
• Jessica Mitchell 5 &
• Rebecca King 5  

BMC Health Services Research volume  24 , Article number:  57 ( 2024 ) Cite this article

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Antimicrobial resistance (AMR) is the process by which microbes evolve mechanisms to survive the medicines designed to destroy them i.e. antimicrobials (AMs). Despite being a natural process, AMR is being hastened by the abuse of AMs. In context of Nepal, there is limited information on drivers of AMR and barriers in addressing it from a community perspective. This study explores the local language and terminology used around AMs in the community, commonly used AMs and reasons for their usage, how these AMs are sourced, and the perceived barriers to addressing AMR via One Health approach.

A phenomenological study design was utilized with applied qualitative research theoretically framed as pragmatism. Twelve in-depth interviews and informal discussions with a One Health focus, were purposively conducted with wide range of stakeholders and community resident of Kapilvastu municipality of Nepal during April 2022. The acquired data was analyzed manually via a thematic framework approach. The study obtained ethical approval from ethical review board of Nepal Health Research Council and University of Leeds.

Nepali and Awadhi languages does not have specific words for AMs or AMR, which is understandable by the community people. Rather, community use full explanatory sentences. People use AMs but have incomplete knowledge about them and they have their own local words for these medicines. The knowledge and usage of AMs across human and animal health is impacted by socio-structural factors, limited Government regulation, inadequate supply of AMs in local government health facilities and the presence of various unregulated health providers that co-exist within the health system. Novel ideas such as the use of visual and smart technology, for instance mobile phones and social media exposure, can enable access to information about AMs and AMR.

This study shows that terminology that is understandable by the community referring to AMs and AMR in Nepali and Awadhi languages does not exist, but full explanatory sentences and colloquial names are used. Despite regular utilisation, communities have incomplete knowledge regarding AMs. Since, knowledge alone cannot improve behaviour, behavioural interventions are required to address AMR via community engagement to co-produce their own solutions.

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Introduction

Antimicrobial resistance (AMR) is the process by which microbes evolve mechanisms to survive the medicines designed to destroy them. AMR is one of the major global health threats of modern times, contributing to 1.27 million human deaths in 2019 alone [ 1 ]. AMR is considered a One Health challenge as it impacts on the health of humans, animal, plants, and the environment. The evolution of AMR in microbes in a natural process but is exacerbated by exposure to conditions which accelerate resistance such as antimicrobial medicines, climatic changes, and heavy metal pollution [ 2 , 3 , 4 , 5 ]. As such, AMR is truly a One Health challenge which requires multi-sectoral action. The World Health Organisation (WHO) Global Action Plan on AMR predicts that lower and middle income countries (LMICs) countries such as Nepal are set to bear the highest burden of drug resistant infections in the coming 30 years [ 6 ]. This was emphasised by Murray et al.’s work which showed the highest rates of AMR in Sub-Saharan Africa and Southeast Asia [ 1 ]. This is due to a combination of factors including population growth, poor water and sanitation hygiene (WASH), and unequal access to healthcare [ 7 , 8 , 9 ].

Nepal has seen huge population growth in the past 20 years, putting pressure on healthcare, waste disposal, and food production sectors. The infrastructure of the country lags behind its population boom with pressure on agricultural industries to provide for this growing number of people. Additionally, crowded settlements, a large rural population, recent natural disasters such as the 2015 earthquake, and poor sanitation mean Nepal has a higher prevalence of common diseases than other South-East Asia Region (SEAR) countries [ 10 , 11 , 12 ].

Antimicrobial (AM) usage to treat these and other ailments is not always regulated by healthcare providers [ 13 ]. In combination, these issues mean AM usage is liberal, for example antibiotics (ABs) may be used to treat simple respiratory symptoms in humans or used for growth promotion in livestock. Future pressures to increase food productivity leading to more intensive farming may drive pressure to use growth promoters more. Such misuse, combined with improper storage and disposal of AMs, is fuelling AMR in both urban and rural regions of Nepal [ 8 , 14 ].

Nepal is in its early stage of federalization where the new state architecture has three tiers of government – federal government, seven provincial governments and 753 local governments (municipalities), and the power and responsibilities are devolved to local governments [ 15 , 16 ]. In the new federal structure, health is one of the most decentralized sectors where basic health services fall under the exclusive functions of local government which have the authority to plan, operate, and manage their own health systems, so that health services can be brought closer to homes of residents. This can eventually narrow the gaps in health service access and utilization [ 15 , 16 ]. However, reports have shown limited institutional capacity to deliver these functions across the government, and lack of clarity and coherence between policies and devolved powers [ 17 ].

To successfully tackle the challenge of AMR in Nepal, we must first understand the scale and complexity of the problem. The core issue regarding AMR in Nepal is the very limited information on AMR at community level [ 18 ]. Hence, the aim of this paper is to explore local language and terminology used around AMs in the community, commonly used antimicrobials and reasons for their usage, how these antimicrobials are sourced, and the perceived barriers to addressing AMR via One Health approach.

This paper is a part of COSTAR (Community Solutions to AMR) project (2021–2023) [ 19 ]. This project seeks to co-create, implement, and robustly evaluate an innovative intervention that addresses the contextual drivers of AMR in Nepal (Kapilvastu) and Bangladesh. COSTAR is an interventional study, where community dialogue approach (CDA) is being co-created and implemented as an intervention in Nepal. This project has multiple components i.e., formative, intervention development, implementation of intervention and evaluation. The results of this formative qualitative analysis will support and inform various components, including intervention of the COSTAR project. This project will be accomplished through the One Health concept, which will rely on an infrastructure for knowledge exchange that will have an impact on national and global policy.

Methodology

Research design.

A phenomenological study design was carried out in this study with applied qualitative research theoretically framed as pragmatism [ 20 ]. The aim of the study is to explore specific themes to contribute to specific policy and practice recommendations as ‘actionable knowledge’ [ 21 ].

The methodology of the study is reported in line with the COREQ guidance [ 22 ], and a checklist is provided as (Additional file 1 ).

Study setting

This study was carried out as a preliminary formative work for the COSTAR project and its study site was Kapilvastu municipality which lies in Lumbini province of Nepal. It has population of around 88,874 with 43,998 males and 44,876 females [ 23 ]. This municipality is one of the plain (Terai) region in Mid-Western and shares open border with India. There is geographical, social, and cultural diversity in this municipality, which allows us to explore differences across various diversities.

Furthermore, the healthcare system for human and animal health is based on government and private health care facilities [ 17 ]. In Kapilvastu, government facilities include, basic health service centre, health posts, urban health clinic and district hospitals [ 15 , 24 , 25 ]. Similarly, private health facilities include local medicals, pharmacies, clinics, private hospitals whereas quacks and traditional healers are the informal health service providers [ 15 , 24 , 25 ] (Table  1 ). In the sector of animal health, animal service centre at ward level and veterinary hospital and Livestock Expert Centre at district level are the government service providers whereas agro-vet are the private service providers and lastly, traditional healers are informal service providers [ 15 , 24 , 25 ] (Table  2 ). Hence, these pluralism in local health system of Kapilvastu municipality, in addition to open border with India could have played an important role in misuse of antimicrobials as many people from this municipality visit the border side of India to seek medical care and over-the-counter medicines at low cost. Further, there is limited information available on the AMR related issues in plain (terai) regions of Nepal [ 24 , 25 ]. All these observations have been noticed while HERD implemented other health system related project in the same municipality by embedding into the local health system.

Data collection

The research team purposively conducted ten qualitative interviews and informal discussions with 12 adult participants. All were community residents and represented a range of stakeholders from one health perspectives (doctors, vets, etc.) within the local health system. People who did not provide consent and of age less than 18 years were not included in the study. To identify and purposively select the appropriate participants for the study, the research team coordinated with stakeholders from the health section of Kapilvastu Municipality and District Animal Health Office. Interviews were conducted with those who provided written informed consent by using guide which had separate set of questions for participants from different domains: human health, animal health and community members.

The number of interviews were determined based on saturation of data during the time of data collection. The duration of the interviews ranged from 30 min to one hour. Data collection was done in April 2022. Characteristics of participants are presented in Table  3 .

The data were digitally recorded after securing the participants’ written consent. In addition to the recording, the research team (AP and BB) took field notes in Nepali that captured observations and informal discussions during the data collection period. All the interviews were conducted in Nepali. They were transcribed and then translated to English by well-trained translators fluent in Nepali and English, adhering to the transcription/translation guidelines of the organization, under the supervision of the core research team. For quality assurance, four translations and transcriptions were checked against the transcripts and audios respectively and corrections were made as needed.

For this study ethical approval was obtained from Nepal Health Research Council (NHRC) with reference number 3098 Ethical Review Board (ERB) protocol registration number 189/2021. The study also obtained approval from the University of Leeds, Faculty of Medicine, and the Health Ethical approval Board in February 2020 under the project name: MREC 20–034 – ‘Engaging communities to address antimicrobial resistance: Identifying contextualised and sustainable community-led solutions in low resource settings’, which was later named COSTAR.

Data analysis

The research team developed a codes, using both a priori and emergent codes in the analysis process. First, researchers (AP, BB and AA) generated an a priori code based on the objectives of the study and the questions in the interview schedule. Additionally, another researcher (LG) conducted a manual, thematic analysis of the coded interview transcripts [ 26 ] that enabled them to identify key sub-categories (subthemes) and categories (themes). Additional researchers (JM, SB) contributed to the data analysis process by offering suggestions on refining the themes and subthemes in iterative stages to generate clear and concise findings. The key themes and sub-themes generated via the data analysis are summarised in Table  4 .

It is important to state that the literal Nepali and Awadhi languages translation of the terms ‘antimicrobial’ and ‘antimicrobial resistance’ were not understood by the community, but rather a full sentence must be used to explain each term. The research team asked questions focused on ‘antimicrobials’ but the participants and service providers answered mostly referring to ‘antibiotics’. Hence, this is an important consideration and finding of our study. Additionally, antibiotics were the most identified type of antimicrobials during the conversations with community members. As such, data collectors often used the translational sentence for antibiotics as a way of supporting community members to understand the term antimicrobial. For these reasons, the findings section does discuss antibiotics specifically in many areas.

Theme I - Commonly used antimicrobials in human and animal health

Antibiotics (ab) and antimicrobials (am).

Service providers mentioned a range of commonly used antimicrobials (AM), particularly antibiotics, in the human and animal health systems (Tables  5 and 6 ). However, in this qualitative study we did not aim to quantify their use, but to explore the community’s own understanding of these medicines.

To contextualize the relative importance of these drugs, classification of antibiotic medicines is explained in Tables  5 and 6 with reference of WHO AWaRe classification [ 27 ]. All the drugs identified in Tables  5 and 6 are also mentioned in Nepal’s National List of Essential Medicines released by the [ 28 ] which means that they are regulated medicines by the Nepal Government and used by the service providers and the population.

Health service providers suggested that in most of the cases, drugs used to treat humans and animals are same by their generic names but differ by dosages. However, the dosage might vary as per the species of animals and some medicines also differ by their trade name.

“Some antibiotics which are used for human health problems, these medicines are also used in veterinary medicine with different doses and names. For example: penicillin is used in the dose of 4 lakhs to 5 lakhs (4 to 5 hundred thousand units = 250–313 mg) in human while for animals, doses of 20 lakhs to 40 lakhs (20 to 40 hundred thousand units = 1250–2500 mg) are used.” (P 2 – owner of local agro-vet).

They reported that Cefixime is the most used AB in the community.

“Cefixime is the cheapest antibiotic available in the market at present condition. [It is] the mostly used and misused antibiotic.” (P 5 - private clinic doctor).

Similarly, antifungal drug Fluconazole, are reportedly misused by the community due to their low cost. People understand Fluconazole as a medicine taken every week, which is cheaper than specific antifungal treatments.

“People go to pharmacy and ask for medicine for rashes with 50 rupees. It is also not the fault of pharmacist because a person may come with 50 rupees and ask for the anti- fungal drugs when other anti- fungal drugs are not found in 50 rupees. Fluconazole is the only drug which comes at 50 rupees.” (P 5 - private clinic doctor).

There are several concerns about the use of AMs. Commonly used AMs in this region are similar across human and animal sectors. This can allow resistant infections to develop and spread between species. In terms of framing community engagement messages, it is important to consider access to medicines and what is a realistic alternative for both providers and users. Focusing messages on prudent use of AMs for sick animals can limit AM use and the risk of AMR developing and spreading between species. It is promising that none of the ABs discussed here were on the WHO’s Reserve category of drugs, which should be protected for the treatment of multidrug resistant infections in humans.

Local terminology used by community to refer to antimicrobials

Community were not able to understand the literal Nepali and Awadhi translation of the word ‘antimicrobials’ and ‘antimicrobials resistance’. Hence it was essential to explore the local terminology used in the community when people seek health care services. The medicines listed in (Table  7 ) are different forms of AMs which are commonly understood by various colloquial names in the community. Different health workers from human health explained during interviews that community members do not understand the term ‘antimicrobial’ or ‘antibiotic’ but they usually refer to these groups of medicines with the specific local terminologies, and they think they should be used whenever they experience specific symptoms (Table  7 ).

“People ask for medicines of high dose if they want antibiotics. Some people ask for medicines of power which means antibiotics.” (P 5 – private clinic doctor).

Findings show that the terminology used locally for AMs is strongly impacted by the level of education and the type of health centre community members visit when they seek health support. If they go to a local health post to seek treatment, they tend to ask for specifically named medicines as shown in Table  7 . But if they go to clinics or private hospitals, it has been reported that they do not demand medicines or AMs when they see a doctor.

“Hill originated Brahmin/Chhetri people residing in Terai are more educated in comparison to other terai people . People other than hill originated Brahmin/Chhetri, directly ask for strong medicine, injection (antibiotics) etc. Hill originated Brahmin/Chhetri ask for medicine with low dose at first and if it does not work, then only, they will seek medicines of higher doses (antibiotics).” (P 5 – private clinic doctor).

Furthermore, the level of education and literacy that people have in this region has an impact on their health-seeking behaviour and knowledge of medicines such as AMs. Being able to read the name of the medicine and the required dose is difficult for those with low literacy levels and memorising such technical language is also not easy, hence the support of the health staff seems to be crucial in this case.

“Educated people can read the label, so they can understand but uneducated people may not know about anti-fungal, anti-helminthic medicines. They may understand the medicine but they may not know the name of the medicine.” (P 3 – local pharmacist).

The findings stress that there exists some differences in educational status of people belonging to different ethnicities. However, religion and ethnicity alone have a minimum role to play in influencing AM knowledge. Geographically, people belonging to similar culture and mindsets live together in the same community. People living in same community share common culture, social norms and values, beliefs and thoughts. Hence, it is rather the education and the community they live in contribute to shaping behaviours towards AM:

“There is not much difference in terms of religions and ethnicity but there are many differences in terms of education. For example: in ward no. x, people are educated with higher level degrees in terms of qualification. There, people consult with doctors before using antibiotics. Practice of people depends on education and the environment, but it does not depend on religion and ethnicity.” (P 5 - private clinic doctor).

Our findings show that Kapilvastu community members have their own working terminology for different medicines that fall under the category of AMs. They also recognise several common AB and antifungal medicines by name, but they do not know the word ‘antibiotic’ or ‘antimicrobials’. However, they have been using these medicines. This has implications for the design of AMR interventions aimed at engaging with the community, as it suggests a working knowledge of antimicrobials is present but incomplete.

Anecdotal conversations with an agro-vet reveal that in the case of agriculture, insecticides and pesticides are commonly used. However, as discussions progressed, the use of insecticide appeared to refer to the treatment of viral and bacterial infections by spraying streptomycin, which is actually an antibiotic. Indeed, agro-vets struggled to name AMs other than ‘streptomycin’ suggesting that knowledge of AMs in this sector is limited and could be driving misuse. This also shows misunderstanding of terminologies and drugs among service providers as well.

Theme II - General practice of consuming AMs

Health behaviour and socio-structural factors.

The health-seeking behaviour for human health in the community starts with visiting the nearest health services available in the area. The findings highlight that this is impacted by the level of education and knowledge people have, their age and their geographical setting. For instance, participants reported that those who are educated and live in urban areas go directly to the hospital, while those living in rural areas go to a medical store first:

“The reason for these differences in priorities of health services is due to education. Here [urban], people are educated so they don’t go to medical store directly while they face health problem. They go to hospital first. In village areas, they don’t have much knowledge, so they go to hospital only at the last stage.” (P 12 - Female community health volunteer).

Also, knowledge of AMs is more associated with young people who are assumed by the community to be more educated. This is likely to be aided by more information available on mobile phones and young people being thought to be more likely and able to search for such information.

When engaging in AM usage behaviour, people also consider ‘money and distance’ to the health post. For these reasons, in rural areas, they tend to first purchase and use ABs from a pharmacy or medical which is closer to their homes and if this does not work, then they visit a nearby health centre for assessment and further treatment.

“People take antibiotics first and if antibiotics do not work, then they come here [health facilities]. There is a medical (drug store with or without checkup facility) in every two villages…. There are two factors like money and distance. To save these factors, people first visit the local medical store and if it does not work there, then only they come to our clinic.” (P 5 –private clinic doctor).

The health behaviour in the community is, to some extent, also impacted by people’s beliefs in traditional healers which are part of the informal health system. Traditional healing is the practice of culturally and spiritually healing illness via dhami/jhankris and gurus [ 29 ].

“People also have religious belief. They go for traditional healing along with medical practices.” (P 5, urban clinic doctor).

Similarly, people make use of the informal services from ‘quack’ (fake) doctors, especially in the border area with India. Community members informally termed them as ‘Bangali doctors’ as they were originally from the state of West Bengal, India.

“Like in the border area, there are availability of quack doctor as well. These doctors give injections which contains steroids, so it works a little faster, so people have high trust on them.” (P 6 – health assistant).

Participants also reported that in case of minor health issues they tend to use home remedies, consume fresh food and fruits, and ensure a clean-living environment This suggests that they tend to follow a pluralistic health system including the use of home remedies and non-medical prescriptions.

Furthermore, structural factors at the level of supply in the local government health facility, such as not having enough stock to provide patients with a full dose, impact on peoples’ AM usage, which then leads to community members not completing a full AM dose. It is important to specify that the lack of stock was an issue specific to government health facilities, which provides AM to people free of cost.

“People come and we give them the dose for three days. We also have to look at the stock. We cannot give medicine dose for seven days because we have to give medicines for other people as well.” ( P2 – health worker at the health post).

For animal health, there are limited facilities to carry out culture tests on animals. Furthermore, service providers and community members mentioned that, in a place like Nepal, where people cannot afford health services for themselves, it is not feasible to carry out culture and antibiotic sensitivity tests for animals and the long waiting time for a test result may out-turn the death of an animal.

“We do not have any tests. We do not have X- ray service, ultrasound, pathology service, etc. The diagnosis all depends on our prediction. An antibiotic is prescribed in a village, and if that antibiotic does not work, then the animal is taken to the market or Taulihawa district hospital (district level veterinary hospital and Livestock Expert Centre).” (P 1 – owner of local agro-vet).

Differences between knowledge and practice

In the case of human health, some of the community members mentioned they are aware of the importance of taking a full dose of AMs and they practice it accordingly, by following the advice of the doctor although they may not know the names of the medicines. They also share their knowledge with others in the rural community to take the complete AM dose as prescribed.

“I do not leave any medicines. I take medicines to full doses. I teach other people as well about the importance of taking full course of antibiotics.” (P 10 – rural community member).

However, positive individual practices do not appear to translate into norms at the collective level, as participants reported different patterns in community practices on AM use and not being able to get a complete dose from health providers.

“I cannot say the same about other people in this community. They go to the clinic or pharmacy and tell about their illness. They consume the medicine provided by the pharmacist. If the medicine has proven to work for them, they visit the pharmacy next time when they get sick and ask for it again. Sometimes, they also tell the pharmacy: “please give me the medicine for two days as my illness got cured in two days last time, so no need for a complete course”. And the pharmacy also complies with their demands.” (P 10 – rural community member).

This quote suggests that it may be difficult for the pharmacist to sell a full course, particularly if the patient has experience of a short dose working before. Hence it becomes difficult to change these learnt behaviours and also it may not be clear if all pharmacists have the knowledge required to do that. However, assessing the knowledge of pharmacists or health workers was beyond the objectives of this study.

Similarly, in agriculture and animal husbandry individuals tend to purchase a short course of AMs rather than completing a full dose. Thus, clear similarities appear between the (mis)use of AMs in human and animal health.

“ Yes, I tell them about the required doses of antibiotics, but they do not take the required doses. They just take one to two doses of medicines and if necessary, then next day, they come to take medicines. Many people do not take medicines after one to two doses. Very less people take the full doses of medicines ” (P 1 – owner of local agro-vet).

One of the agro-vet participants reported that the Government has been providing training on good agriculture and animal husbandry practice to the farmers. However, trainings are reportedly scarce and considered inadequate since only those who are licensed to carry out animal husbandry or agriculture can participate in such events. This means that those who want to participate may not be able to join the session because of the eligibility criteria (i.e. need to be licensed). The agro-vet reported that people take part in these trainings mostly for financial purpose, to get the allowance provided by the Government. On the other hand, those who get the chance to participate may not be interested in it.

“There are not many trainings available. Some trainings are organized once or twice in a year, and when trainings are organized, we just go to the program to take allowance. We just do some introduction and take little information.” (P 2 – owner of local agro-vet).

Social media information and visual aids

Service providers, particularly health workers from health post and agro-vet, shared their observations about how community members use smart technology, namely mobile phones to facilitate conversation with health professionals for example by taking pictures of medicines.

“ Most of the people do not have enough information about antibiotics but they have mobile phone. So, they click the pictures of medicines which they are using and bring the pictures to us [veterinary practice] for medicines.” (P 1 – owner of local agro-vet).

Our findings point to novel ideas such as the use of technology, namely mobile phones to counteract the lack of awareness of AM usage impacted by the structural factors discussed earlier. Via their phones, young people have access to the internet and social media sites, such as YouTube, regardless of their social status. Such social media exposure can enable access to information about AM usage.

Similarly, when researchers asked the participants for suggestions on how to engage with community members in further studies, and how to ask questions about ABs in a way that could be understood at the community level, respondents pointed to potential future activities supported by visual aids. They suggested, for example, showing pictures of commonly used medicine packages to community members to help them better engage in a discussion about the usage of AM.

Theme III - preliminary assessment of AMR drivers

The misuse and over-use of ams.

Participants reported regular misuse of AMs, specifically ABs, in the community as a key driver of AMR in both human and animal health. This behaviour is driven by the community members’ wish to recover fast from an illness and by the practices of health staff who give ABs on demand in an attempt to cure patients faster.

“In the case of private medical store, people also demand antibiotics by themselves. Medical personnel also usually give antibiotics to solve the health problems faster.” (P1 6 – health worker) .

Directly linked with the misuse of ABs is their availability without prescription which may lead to over-use. This was amplified during the Covid-19 pandemic, when one type of AB was prescribed for Covid-19 related symptoms. A clear example of misuse as COVID-19 is viral, not a bacterial infection.

“There is availability of antibiotics everywhere. Anyone is giving and prescribing antibiotic. In COVID-19, Ceftriaxone was used so widely in this area that this medicine became scarce. Ceftriaxone costs 35 rupees but during COVID-19, Ceftriaxone was not found even at 100 rupees.” (P 5 – urban clinic doctor).

In case of animal health, fast growth of poultry and other animals that encourages quick financial gains, have been reported as one of the key reasons for AMR in the community. This type of behaviour is common regardless of knowledge about the negative consequences that it entails.

People are giving hormonal medicines to chickens to raise them faster which have consequently negative effects on ourselves.

“ Now-a-days, farmers have also been educated. They have studied poultry, fisheries, etc. But there is misuse of antibiotics as well. ” (P 2 – owner of local agro-vet).

Lack of regulatory mechanisms and policies on AMR

According to the stakeholders, such as official from district animal health office, private clinic doctors and agro-vet staff, the use of AMs and specifically ABs is not sufficiently regulated at the national level, hence community members can purchase and misuse AMs, as they are easily available.

“ There are no proper policies about who can use the antibiotics and who cannot. Antibiotics are available everywhere and anyone is using antibiotic randomly without standard treatment protocol.” (P 5 –private clinic doctor).

The lack of enforced law mechanisms for AM usage also applies to animal health and agriculture. Findings suggest that community members working in this sphere engage in commerce with medicines that are not subject to sufficient quality checks and registered health practices. This is an important point also in the context of the geographical border with India which allows for people and goods to move easily between the two countries.

“ People also go to border of India to buy medicines. …People also use unregistered medicines. Some people sell medicines which are not registered by Department of Drug Division. People who are selling agricultural products are also selling medicines which belong to unregistered medical practices. There are not much quality control and regulation mechanism.” (P 2 – owner of local agro-vet).

Furthermore participants reported misuse of licenses by people who do not have the required education and whose misconduct for business purposes has not been penalized. Hence stricter law enforcement in this domain has been strongly recommended.

“Many people who have not even studied one word are also running veterinary clinic by misusing the license of other people. People have done business of crores (millions) without having authority. Authorized organizations of government should check and measure such misconducts.” (P 2 – owner of local agro-vet).

Lack of awareness about AMR and AM disposal behaviours at community level

Disposal of AMs has often been related to a lack of awareness, about AMR and appropriate use of AMs in human and animal health.

“People are not educated and aware about antibiotics and antibiotic resistance. People do not even know that they are using antibiotics randomly… It is not their fault.” (P 5 –private clinic doctor).

The disposal of AMs is not regulated and not penalised, hence there is no specific reported practice followed at the community level. Some people and pharmacies dispose waste medicines in garbage collection sites or dustbin or open spaces.

“In this community, wastes such as (used) sanitary pads, and medical wastes are thrown in an open area. The pharmacy across this road throws waste quite carelessly in the open environment. They are careless because they are not aware of the adverse consequences of such practices.” (P 11 – community resident).

In terms of animal health, participants highlighted that some of the agro-vets take back the remaining medicines such as ABs, vitamins and other supplementary medicines that come in solid form if they are returned with the payment of bills, which suggests positive behaviour.

This study explored local terminology used in the community to refer antimicrobials including antibiotics. Although community people did not always understand the term ‘antimicrobials’ or ‘antibiotics’ they did utilize a variety of colloquial words regarding drug use linked to specific symptoms. This contextual recognition of medication is similar were the findings of another study conducted in Congo [ 30 ]. Health seeking behaviours of community people are constrained by various socio-structural factors such as low physician to patient ratios (1:1724), lack of supply in government health facilities, lack of affordability of healthcare services, as shown in other Nepal-based studies [ 10 , 31 ]. These factors indicate that most people in Nepal rely on other service providers like, drug dispensers (medical and pharmacies), quacks and traditional practitioners [ 10 , 32 ], which is also evidenced by our study.

This pluralism in health system have been one of the reasons for inappropriate use of antimicrobials in Nepal [ 25 ]. For example, in community practice of both human and animal health sectors, prescription is not required to dispense AMs in Nepal and this can promote inappropriate use of AMs, as evidenced in our study. The wider literature clearly shows that AMR is driven by complex intersections around accessibility and availability of AMs, especially ABs. This includes over-the-counter (OTC) and prescription sales, irrational use, failure to follow the prescribed course of ABs as well as a lack of an effective AMR surveillance [ 7 , 24 , 25 , 33 ]. Other studies conducted in Nepal indicate that animal health experts have little control over AMs and there are limited surveillance strategies and data to capture the AMs use and AMR risks in Nepal [ 34 ]. Hence, co-existence of a pluralism in health system of Nepal and other countries calls for greater collaboration between the formal and informal healing systems in order to promote appropriate use of AMs by regulating standard treatment protocol [ 24 , 25 , 27 ].

Furthermore, our study indicates that the education and location (urban/rural) of people influenced their knowledge and practice of AMs usage. This is widely supported by other research conducted in Nepal [ 33 ]. In addition, education and awareness about AMs use varied among different ethnic groups residing in Kapilvastu municipality. For example, hill-originating Brahmin/Chhetri were more aware in comparison to other ethnic groups residing in the same area. This variation in educational status is supported by further analysis of National Demographic Health Survey, Nepal [ 35 ]. This study shows that lack of awareness about AM and AMR at the community level, including both consumer and supplier is also related to inappropriate disposal practice of AMs.

It is recognized throughout the literature that knowledge alone is often not enough to change behaviours in general [ 24 ], and specifically around AM use and AMR in low resource settings. Reports show that District Drug Administration of Nepal conducts several AMR activities around personnel training and drug quality surveillance in Nepal [ 28 ]. For instance, they developed a community pharmacy training module focused on drug prescription and distribution for community pharmacy which includes an AMR awareness component [ 17 ]. However, our study shows that, in practice, community drug dispensers do not dispense complete dose of AMs to the people due to different types of structural barriers (such as people’s inability to purchase full course of drugs, lack of awareness about need to purchase full course).

This practice is further followed by limited specific regulations that prevent community members from buying AMs over the counter. Literature suggests, practice of drug dispensers in Nepal is largely unregulated and they have poor compliance with good pharmacy practice [ 24 ]. This study have similar findings in case of animal health. Literature suggests, there is no active surveillance in the animal health sector in Nepal [ 17 ]. Moreover, there is easy import of food, animals and meat from the open border with India and there is no specific mechanism for testing these products for AMR [ 17 ].

Conclusions

This study shows that the local term for AMs and AMR in Nepali and Awadhi languages does not exist, but full explanatory sentences and nick names for different AMs are used. People have been using it but have incomplete knowledge about AMs. The knowledge and usage of AMs across human and animal health is impacted by socio-structural factors, lack of government regulation and lack of supply in local government health facilities and the challenges of various unregulated health providers that co-exist within the health system.

Despite the progress made in improving AMR awareness at the policy and global level and via National Actions Plans in LMICs, critical gaps remain [ 36 ]. Hence, a different more creative approach might be required to tackle this challenge beyond knowledge provision. Using social media for raising awareness on AMR in the context of increased use of mobiles in LMICs is an opportunity for dissemination of information that is faster and cheaper than traditional methods and can reach larger audiences in short period of time [ 37 ]. This could be taken further, for instance by creating online games with a learning objective on AMR for school children [ 37 ].

Furthermore, behaviour change is a key objective of the global action plan on AMR, but many countries lack the support needed to achieve this objective. There is a lack of academic research on AMR in Nepal regarding the behavioural interventions that can help address the problem [ 17 ]. However, it has been acknowledged that awareness-raising approaches alone at community level are not sufficient to create meaningful behaviour change on issues such as inappropriate use of AMs [ 38 , 39 , 40 ]. Thus, communities must be engaged and encouraged to co-produce their own solutions [ 38 , 39 , 40 ]. Our formative qualitative study is an important tool that contributes to filling in this gap by providing contextual information on AMs use and AMR drivers. This then lays the ground for developing AMR interventions co-produced by communities to achieve behavioural changes.

Limitations

In this study we were not able to purposively sample certain types of people who might have provided useful perspectives on our topic, especially the ‘quack’ doctors and traditional healers. However, the participants spoke about them during the interviews, adding to the richness of our findings and showing the importance and the challenges of the informal, unregulated health system in Nepal, which currently co-exists as a part of the healthcare system.

We are also aware and we reported that the terms AB, AM and AMR could not be directly translated from English into the local languages due to the linguistic differences. The term ‘antimicrobials’ was not clearly conceptually differentiated by participants from the local pharmacies and agro-vet in most cases. Nonetheless, they have used antifungals to treat various related infections. Furthermore, the term antimicrobial is not as common as the term antibiotic in the community. Hence, most of the transcript quotes refer to antibiotics.

Data availability

All data generated or analysed during this study are included in this published article and its additional file 2 .

Abbreviations

Antibiotics

Antimicrobials

• Antimicrobial resistance

Community solutions to antimicrobial resistance

Ethical review board

Female community health volunteer

Lower- and middle-income countries

Nepal Health Research Council

Over the counter

South-East Asia Region

Water sanitation and hygiene

World Health Organization

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Acknowledgements

The authors would like to thank the communities and local stakeholders of Kapilvastu municipality who were part of this research in Nepal.

This study was funded by the Medical Research Council, United Kingdom, under the grant ID: MR/T029676/1. The funder of this study had no role in the study’s design or conduct, data collection, analysis or interpretation of results, writing of the paper, or decision to submit for publication.

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AP, AA, BB, JM, and SB designed the study, BB and AP collected the data, BP transcribed the semi-structured interviews, AP, BB, AA, JM, and SB contributed to writing the findings and the analysis. AP and LG led the paper writing process, the analysis and discussion and reviewed the paper. LG prepared the manuscript for submission. Several other authors had oversight of the study and the paper review process. SL was responsible for the animal health component, PC and DB contributed to reviewing the paper. RK oversaw the study and contributed to the paper review. All authors reviewed the manuscript and agreed with its final version.

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Parajuli, A., Garbovan, L., Bhattarai, B. et al. Exploring community insights on antimicrobial resistance in Nepal: a formative qualitative study. BMC Health Serv Res 24 , 57 (2024). https://doi.org/10.1186/s12913-023-10470-2

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Academic Dishonesty Within Higher Education in Nepal: An Examination of Students’ Exam Cheating

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The problem of academic dishonesty in general and exam cheating in particular, has been ubiquitous in schools, colleges, and universities around the world. This paper reports on the findings from teachers’ and students’ experiences and perceptions of exam cheating at Nepali schools, colleges, and universities. In so doing, the paper highlights the challenges of maintaining academic integrity in Nepali education systems. Based on qualitative research design, the study data were collected by employing semi-structured interviews with the teachers and the students. Findings from the study indicated that over-emphasized value given to marks/grades and the nature of exam questions among others were the predominant factors. Our findings contribute to the practical understanding that academic institutions in Nepal have largely failed to communicate the value of academic honesty and integrity to the students of all levels of education despite the increasing prevalence of exam cheating. Therefore, exam cheating requires urgent attention from academic institutions, educators, and education leaders to educate students about the long-term educational and social values of academic honesty and integrity.

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Ghimire, S.N., Bhattarai, U. & Baral, R.K. Academic Dishonesty Within Higher Education in Nepal: An Examination of Students’ Exam Cheating. J Acad Ethics (2023). https://doi.org/10.1007/s10805-023-09486-4

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