Investigating the Aftershock of a Disaster: A Study of Health Service Utilization and Mental Health Symptoms in Post-Earthquake Nepal

1. In   the Methods section, it is unclear how alternate households in the transect   walk of the first household’s 0.5 km radius was selected until reaching 50.   More descriptions are needed. Were they randomly selected within the 0.5kn   radius? Or recruiting from those closest to the first household?

In each VDC, 50   households were selected using systematic random sampling. This was done by   selecting the first household closest to the city center and then every   alternate household in the 0.5 km radius until 50 individuals in each VDC   were included

2. Was   DASS translated to local languages by Social Science Baha in Nepal? What were   the languages? Were the questionnaires mainly completed by the respondents   themselves or with the help of the interviewers?

Yes it was translated into Nepali:  Please see page 6.  On page 5 see:  All surveys were translated to Nepali by SSB and surveys   were read by the trained researchers to the respondents to ensure   comprehension. 

3.Suggest   to standardize the percentages to be in 1 decimal place. 

This has been completed

4. 97%   of interviewees reported their house was damaged or destroyed. The intensity   between the two conditions could be quite different. Any separate percentages   for these?

This should actually be home destroyed.  This has been corrected on page 8

5. In   the Results section, are district hospitals considered as primary or   secondary care settings in Nepal? How are they compared with private   clinics/hospitals in term of size, manpower and quality? Some descriptions of   them, as well as female community health volunteers (FCHVs), can enhance   international readers’ understanding of the context in Nepal. Furthermore,   are there psychiatrists, psychologists, mental health nurses, social workers   and other counsellors in the district hospitals? Is mental health support   mainly by GPs, doctors in other specialists, general nurses and volunteers   there? It is unclear what type of health professionals the distressed consult   in hospitals. 

This   has been put earlier in the document on page three and four to lay the   framework for the results section.

6. One   minor point. The colors of the bars in figure 1 are a bit confusing as the   same colors are used for different items in the two questions, and vice   versa. 

We have omitted the figure to alleviate confusion. 

7. In   Table 4, some items under income columns are marked with NA. Are the   subsamples too small for analysis?

Yes, the subsamples are too small

1) In page 2, the authors described traditional healers, private pharmacies, and medical shops in Nepal. I understand that traditional healers and medical shops would be trained as healthcare providers.

But I assume the private pharmacies may have professional training and governmental certification or registration for their healthcare activities. How are the roles of the private pharmacies and medical shops different? 

In rural setting of Nepal (where this study was done) there is   not much difference in the private pharmacies and medical shops. Usually they   are run by the paramedics (in context of Nepal paramedics are professionals   who have received 1 to 3 years of medical studies, this includes Health   Assistants, Auxiliary Health Workers) who work in the government   health institutions ( as their business and using their skill/knowledge) as   in the health posts there are limited supply of medicine, most times   medicines are not available. So the paramedics running   these shops do have professional knowledge and certification to   prescribe medicines. In case of medicine shops selling natural herbs   (ayurvedic medicines) they don’t have such criteria. Now Nepal Government is   trying to regulate the paharmacies so it is compulsory for a person ta have   diploma in pharmacy (3 years) or a degree in pharmacy ( 4 years).  This has been described further in the   manuscript.

2) The last sentence of page 2 illustrates mental health post-disaster Nepal. Please describe more detailed information regarding the coordinated effort to address the mental health of survivors.

Who was assigned as the control tower, and what kind of psychosocial support subclusters were participated? What role did the mobile health clinics play? What school and community-based interventions, and public awareness initiatives were provided?

This has been added on page 4:  Mobile health clinics,   for example, offered temporary counseling and outreach to remote earthquake   affected regions. School and community-based interventions focused on   empowering parents to become involved in school activities, and training   teachers in positive discipline approaches to create a respectful and safe   learning environment. Awareness initiatives involved raising public awareness   on mental health issues and reducing stigma (19).

3) In page 4, the researchers developed healthcare access questions to identify types of

available health care, quality of services, and utilization. Please describe more details of the healthcare access questions. Were they Likert scales? If so, please provide the choice of options for each question. 

We have added the response set for each question.  Please note two questions were categorical,   two were Likert, and one was dichotomous (yes/no)

3) Review the manuscript as for typographer.

This has been done