What are we hoping to achieve in Nepal in terms of psychology in cleft care?

This is a complex question - one that doesn’t come with a single, neat answer. But that, in itself, reflects the ethos of our work: to understand, to adapt, and to support; not to impose.

In low- and middle-income countries (LMICs) like Nepal, access to specialist psychological services within cleft care is often limited or non-existent. Yet psychological wellbeing remains a vital part of the cleft journey, not just for individuals with a cleft but also for their families. Our goal is not to address clinical mental health problems per se, but to support the overall psychological wellbeing of those affected.

Crucially, this isn’t about exporting UK models of care. It’s about respectfully engaging with local teams, learning from their practices, and supporting them in finding sustainable, culturally appropriate ways to weave psychological support into the fabric of their existing roles.

What does the Nepali team need – and what are we offering?

In Nepal, much of our psychological input has involved working alongside the cleft team, especially the ‘peripheral nurses’ who serve as community health workers. These nurses already juggle an impressive range of responsibilities: from feeding support and surgical prep to speech therapy, dental hygiene, and broader developmental surveillance. Many are also acutely aware of the emotional challenges faced by families and are eager to do more.

We’ve provided teaching and facilitated conversations around key concepts such as:

• Parental adjustment to a cleft diagnosis
• Coping with surgery and appearance changes
• Managing stigma, prejudice, and difficult questions
• Building self-esteem and confidence in young people

We’re also working with the team to incorporate these themes into day-to-day care. Some examples include:

• Psychoeducation: Developing culturally relevant resources, such as booklets explaining what to expect after a baby is born with a cleft, or guiding older children through upcoming procedures.
• Informal psychological support: Encouraging the nurses to ask open-ended questions about emotional wellbeing and to signpost support options, whether from within families or the broader community.
• Peer support: Building on existing WhatsApp groups and integrating emotional wellbeing themes into community-based “speech camps.”
• Child development tools: Collaborating on the introduction of the Ages and Stages Questionnaire (ASQ), including efforts to translate and culturally adapt the Social and Emotional subscale into Nepali.

What Does Success Look Like?

Measuring success in psychological care, particularly in contexts without clinical psychologists, is inherently difficult. Even in the UK, there's no single metric that defines psychological wellbeing for people with cleft. Instead, psychologists typically use tailored assessments and follow-up interventions.

In Nepal, we’re taking a more pragmatic approach, focusing on what can be realistically implemented. For example:

• Collecting informal feedback from participants before and after group activities or camps.
• Using tools like the ASQ to gather data about early development and wellbeing.
• Involving the team in research and audit projects so they can identify needs within their population and monitor the effectiveness of their efforts.

In the future, we hope to support the team in creating basic outcome measures for psychological initiatives, developed in collaboration, guided by local insight, and adapted to context.

A Respectful Partnership

Everything we do in Nepal stems from a single core principle: partnership. This is not about prescribing solutions but supporting teams to make informed, culturally appropriate decisions. It’s about offering ideas, sharing resources, and co-developing approaches that feel right for them.

This collaboration is still evolving and we have much to learn. But if we can support the Nepali cleft team to embed psychological awareness into their work, using their own voices, values, and structures, then we will consider that a real success.

Written in discussion with Dr Kate le Maréchal, Consultant Clinical Psychologist

Head of Service for Evelina London Cleft Service