Heterogeneous genetic architectures of prostate cancer susceptibility in sub-Saharan Africa.

Men of African descent have the highest prostate cancer incidence and mortality rates, yet the genetic basis of prostate cancer in African men has been understudied. We used genomic data from 3,963 cases and 3,509 controls from Ghana, Nigeria, Senegal, South Africa and Uganda to infer ancestry-specific genetic architectures and fine-map disease associations. Fifteen independent associations at 8q24.21, 6q22.1 and 11q13.3 reached genome-wide significance, including four new associations. Intriguingly, multiple lead associations are private alleles, a pattern arising from recent mutations and the out-of-Africa bottleneck. These African-specific alleles contribute to haplotypes with odds ratios above 2.4. We found that the genetic architecture of prostate cancer differs across Africa, with effect size differences contributing more to this heterogeneity than allele frequency differences. Population genetic analyses reveal that African prostate cancer associations are largely governed by neutral evolution. Collectively, our findings emphasize the utility of conducting genetic studies that use diverse populations.

The Influence of Housing Status and Food Insecurity on a Behavioral HIV/STI Prevention Intervention for Black Women under Community Supervision in New York City: A Moderation Analysis.

Black women in community supervision programs (CSPs) are disproportionately affected by HIV and other sexually transmitted infections (STIs). A randomized controlled trial of a group intervention titled Empowering African-American Women on the Road to Health (E-WORTH) demonstrated effectiveness in reducing sexual risk behaviors and STI incidence among Black women in CSPs. This secondary analysis aimed to assess the moderating effects of housing status and food security on E-WORTH effectiveness in reducing sexual risk behaviors and cumulative incidence of STIs over a 12-month period which were found significant in the original trial among a sample of 351 Black women in CSPs in New York City who use drugs and/or engage in binge drinking who reported engaging in HIV risk behaviors or testing positive for HIV. We examined the moderating effects of housing stability, housing independence, and food insecurity on reducing cumulative STI incidence and number of unprotected sex acts using mixed-effects negative binomial regression and logistic regression models that controlled for age, high school education, employment status, and marital status. Findings indicate that the intervention effect was moderated by housing stability, but not housing independence or food security. Compared to the control group, E-WORTH participants who were housing insecure had 63% fewer acts of condomless sex. Our findings highlight the importance of interventions designed for women in CSPs that account for upstream determinants of health and include service linkages to basic needs provisions. Further research is needed to unpack the cumulative impacts of multiple experiences of poverty faced by this population.

Psychosocial and palliative care in African national cancer control plans: A qualitative study.

OBJECTIVE: Low and middle income countries of Africa account for a disproportionate amount of the global health burden of cancer. Providing patients access to psychosocial oncology and palliative care through policy structures such as the National Cancer Control Plans (NCCP) is essential to improving the care provided to patients and their families. The first phase of this study sought to determine the extent to which palliative care and psychosocial oncology were integrated in NCCPs in African countries. METHODS: A qualitative thematic analysis of the plans was used using Nvivo, with two-raters coding and continuous team discussions. Data were organized into an infographic map showing the coverage of themes across African countries. RESULTS: Fifty-eight NCCPs and NCD plans were analyzed in the 54 countries in Africa. The findings illustrate a lack of standardization across countries' NCCPs in addressing psychosocial oncology and palliative care themes. Certain areas presented good coverage across several plans, such as barriers to access, education, awareness, and health behaviors, coordination of care, families, caregivers and community involvement, and palliative care. Other themes presented low coverage, such as doctor-patient communication, mental health, bereavement, psychosocial care, survivorship care, and traditional medicine. CONCLUSIONS: One may consider further developing NCCP areas as they pertain to psychosocial oncology and palliative care to ensure their proper place on the policy agenda for a healthier Africa.

Leveraging systems science and design thinking to advance implementation science: moving toward a solution-oriented paradigm.

Many public health challenges are characterized by complexity that reflects the dynamic systems in which they occur. Such systems involve multiple interdependent factors, actors, and sectors that influence health, and are a primary driver of challenges of insufficient implementation, sustainment, and scale of evidence-based public health interventions. Implementation science frameworks have been developed to help embed evidence-based interventions in diverse settings and identify key factors that facilitate or hinder implementation. These frameworks are largely static in that they do not explain the nature and dynamics of interrelationships among the identified determinants, nor how those determinants might change over time. Furthermore, most implementation science frameworks are top-down, deterministic, and linear, leaving critical gaps in understanding of both how to intervene on determinants of successful implementation and how to scale evidence-based solutions. Design thinking and systems science offer methods for transforming this problem-oriented paradigm into one that is solution-oriented. This article describes these two approaches and how they can be integrated into implementation science strategies to promote implementation, sustainment, and scaling of public health innovation, ultimately resulting in transformative systems changes that improve population health.

Heterogeneous genetic architectures and evolutionary genomics of prostate cancer in Sub-Saharan Africa.

Men of African descent have the highest prostate cancer (CaP) incidence and mortality rates, yet the genetic basis of CaP in African men has been understudied. We used genomic data from 3,963 CaP cases and 3,509 controls recruited in Ghana, Nigeria, Senegal, South Africa, and Uganda, to infer ancestry-specific genetic architectures and fine-mapped disease associations. Fifteen independent associations at 8q24.21, 6q22.1, and 11q13.3 reached genome-wide significance, including four novel associations. Intriguingly, multiple lead SNPs are private alleles, a pattern arising from recent mutations and the out-of-Africa bottleneck. These African-specific alleles contribute to haplotypes with odds ratios above 2.4. We found that the genetic architecture of CaP differs across Africa, with effect size differences contributing more to this heterogeneity than allele frequency differences. Population genetic analyses reveal that African CaP associations are largely governed by neutral evolution. Collectively, our findings emphasize the utility of conducting genetic studies that use diverse populations.

Application of group model building in implementation research: A systematic review of the public health and healthcare literature.

BACKGROUND: Group model building is a process of engaging stakeholders in a participatory modeling process to elicit their perceptions of a problem and explore concepts regarding the origin, contributing factors, and potential solutions or interventions to a complex issue. Recently, it has emerged as a novel method for tackling complex, long-standing public health issues that traditional intervention models and frameworks cannot fully address. However, the extent to which group model building has resulted in the adoption of evidence-based practices, interventions, and policies for public health remains largely unstudied. The goal of this systematic review was to examine the public health and healthcare applications of GMB in the literature and outline how it has been used to foster implementation and dissemination of evidence-based interventions. METHODS: We searched PubMed, Web of Science, and other databases through August 2022 for studies related to public health or health care where GMB was cited as a main methodology. We did not eliminate studies based on language, location, or date of publication. Three reviewers independently extracted data on GMB session characteristics, model attributes, and dissemination formats and content. RESULTS: Seventy-two studies were included in the final review. Majority of GMB activities were in the fields of nutrition (n = 19, 26.4%), health care administration (n = 15, 20.8%), and environmental health (n = 12, 16.7%), and were conducted in the United States (n = 29, 40.3%) and Australia (n = 7, 9.7%). Twenty-three (31.9%) studies reported that GMB influenced implementation through policy change, intervention development, and community action plans; less than a third reported dissemination of the model outside journal publication. GMB was reported to have increased insight, facilitated consensus, and fostered communication among stakeholders. CONCLUSIONS: GMB is associated with tangible benefits to participants, including increased community engagement and development of systems solutions. Transdisciplinary stakeholder involvement and more rigorous evaluation and dissemination of GMB activities are recommended.

Pediatric Tracheostomy Emergency Readiness Assessment Tool: International Consensus Recommendations.

OBJECTIVE: To achieve consensus on critical steps and create an assessment tool for actual and simulated pediatric tracheostomy emergencies that incorporates human and systems factors along with tracheostomy-specific steps. METHODS: A modified Delphi method was used. Using REDCap software, an instrument comprising 29 potential items was circulated to 171 tracheostomy and simulation experts. Consensus criteria were determined a priori with a goal of consolidating and ordering 15 to 25 final items. In the first round, items were rated as "keep" or "remove". In the second and third rounds, experts were asked to rate the importance of each item on a 9-point Likert scale. Items were refined in subsequent iterations based on analysis of results and respondents' comments. RESULTS: The response rates were 125/171 (73.1%) for the first round, 111/125 (88.8%) for the second round, and 109/125 (87.2%) for the third round. 133 comments were incorporated. Consensus (>60% participants scoring ≥8, or mean score >7.5) was reached on 22 items distributed across three domains. There were 12, 4, and 6 items in the domains of tracheostomy-specific steps, team and personnel factors, and equipment respectively. CONCLUSIONS: The resultant assessment tool can be used to assess both tracheostomy-specific steps as well as systems factors affecting hospital team response to simulated and clinical pediatric tracheostomy emergencies. The tool can also be used to guide debriefing discussions of both simulated and clinical emergencies, and to spur quality improvement initiatives. LEVEL OF EVIDENCE: 5 Laryngoscope, 133:3588-3601, 2023.

Dietary practices, physical activity and social determinants of non-communicable diseases in Nepal: A systemic analysis.

Unhealthy dietary habits and physical inactivity are major risk factors of non-communicable diseases (NCDs) globally. The objective of this paper was to describe the role of dietary practices and physical activity in the interaction of the social determinants of NCDs in Nepal, a developing economy. The study was a qualitative study design involving two districts in Nepal, whereby data was collected via key informant interviews (n = 63) and focus group discussions (n = 12). Thematic analysis of the qualitative data was performed, and a causal loop diagram was built to illustrate the dynamic interactions of the social determinants of NCDs based on the themes. The study also involved sense-making sessions with policy level and local stakeholders. Four key interacting themes emerged from the study describing current dietary and physical activity practices, influence of junk food, role of health system and socio-economic factors as root causes. While the current dietary and physical activity-related practices within communities were unhealthy, the broader determinants such as socio-economic circumstances and gender further fuelled such practices. The health system has potential to play a more effective role in the prevention of the behavioural and social determinants of NCDs.

Communicating bad news to patients and families in African oncology settings.

AIMS: To assess clinicians' self-reported knowledge of current policies in African oncology settings, of their personal communication practices around sharing bad news with patients, and to identify barriers to the sharing of serious news in these settings. METHODS: A cross-sectional study of cancer care providers in African oncology settings (N = 125) was conducted. Factor analysis was used to assess cross-cultural adaptation and uptake of an evidence-based protocol for disclosing bad news to patients with cancer and of providers' perceived barriers to disclosing bad news to patients with cancer. Analysis of Various (ANOVA) was used to assess strength of association with each dimension of these two measurement models by various categorical variables. RESULTS: Providers from Nigeria, Kenya, Ghana, and Rwanda represented 85% of survey respondents. Two independent, psychometrically reliable, multi-dimensional measurement models were derived to assess providers' personal communication practices and providers' perceived barriers to disclosing a cancer diagnosis. Forty percent (40%) of respondent nurses but only 20% of respondent physicians had had formal communications skills training. Approximately 20%-25% of respondent physicians and nurses reported having a consistent plan or strategy for communicating bad news to their cancer patients. CONCLUSIONS: Results show that effective communication about cancer diagnosis and prognosis requires an appreciation and clinical skill set that blends an understanding of cancer-related internalized stigmas harbored by patient and family, dilemmas posed by treatment affordability, and the need to navigate family wishes about cancer-related diagnoses in the context of African oncology settings. Findings underscore the need for culturally grounded communications research and program design.

Utilizing community engagement studios to inform clinical trial design at a Center of Excellence for Alzheimer's Disease.

Despite the disproportionate burden of Alzheimer's disease in older adults of color, the scientific community continues to grapple with underrepresentation of racial and ethnic minorities in clinical research. Our Center of Excellence for Alzheimer's Disease (CEAD) collaborated with a local community partner to conduct community engagement (CE) studios to effectively involve our community of diverse older adults in the early planning stages of a clinical trial. Given the COVID-19 pandemic, the in-person studio format was adapted to allow for virtual, real-time participation. Our objective is to describe the process and feasibility of conducting virtual CE studios in an older adult population. Ninety percent of participants were non-Hispanic Black community-dwelling woman aged 60 years and older. The overall background and proposed clinical trial design was presented to the participants who then made recommendations regarding potential recruitment strategies, the use of culturally relevant language to describe the study, and logistical recommendations to improve participation and retention among community members. Our CEAD successfully conducted virtual CE studios during the COVID-19 pandemic, by partnering with a community-based organization, to engage community stakeholders about clinical trial design. CEADs are in a unique position to implement CE studios to better support patient access to clinical trials.

Mediation Analyses of the Role of Apathy on Motoric Cognitive Outcomes.

Recent literature indicates that apathy is associated with poor cognitive and functional outcomes in older adults, including motoric cognitive risk syndrome (MCR), a predementia syndrome. However, the underlying biological pathway is unknown. The objectives of this study were to (1) examine the cross-sectional associations between inflammatory cytokines (Interleukin 6 (IL-6) and C-Reactive Protein (CRP)) and apathy and (2) explore the direct and indirect relationships of apathy and motoric cognitive outcomes as it relates to important cognitive risk factors. N = 347 older adults (≥65 years old) enrolled in the Central Control of Mobility in Aging Study (CCMA). Linear and logic regression models showed that IL-6, but not CRP was significantly associated with apathy adjusted for age, gender, and years of education (ß = 0.037, 95% CI: 0.002-0.072, p = 0.04). Apathy was associated with a slower gait velocity (ß = -14.45, 95% CI: -24.89-4.01, p = 0.01). Mediation analyses demonstrated that IL-6 modestly mediates the relationship between apathy and gait velocity, while apathy mediated the relationships between dysphoria and multimorbidity and gait velocity. Overall, our findings indicate that apathy may be an early predictor of motoric cognitive decline. Inflammation plays a modest role, but the underlying biology of apathy warrants further investigation.

Intersectional Stigma and Prevention Among Gay, Bisexual, and Same Gender-Loving Men in New York City, 2020: System Dynamics Models.

Objectives. To create causal loop diagrams that characterize intersectional stigma experiences among Black, gay, bisexual, same gender-loving, and other men who have sex with men and to identify intervention targets to reduce stigma and increase testing and prevention access. Methods. Between January and July 2020, we conducted focus groups and in-depth interviews with 80 expert informants in New York City, which were transcribed, coded, and analyzed. These qualitative insights were developed iteratively, visualized, and validated in a causal loop diagram (CLD) using Vensim software. Results. The CLD revealed 3 key feedback loops-medical mistrust and HIV transmission, serosorting and marginalization of Black and gay individuals, and family support and internalized homophobia-that contribute to intersectional HIV and related stigmas, homophobia, and systemic racism. On the basis of these results, we designed 2 novel intervention components to integrate into an existing community-level anti-HIV stigma and homophobia intervention. Conclusions. HIV stigma, systemic racism, and homophobia work via feedback loops to reduce access to and uptake of HIV testing, prevention, and treatment. Public Health Implications. The CLD method yielded unique insights into reciprocal feedback structures that, if broken, could interrupt stigmatization and discrimination cycles that impede testing and prevention uptake. (Am J Public Health. 2022;112(S4):S444-S451. https://doi.org/10.2105/AJPH.2022.306725).

Explorations of the Role of Digital Technology in HIV-Related Implementation Research: Case Comparisons of Five Ending the HIV Epidemic Supplement Awards.

INTRODUCTION: The use of digital technology in HIV-related interventions and implementation strategies is increasing. Whether the use of technology is to directly improve patient outcomes (ie, part of the intervention) or as part of the strategy to implement interventions has important implications. In this article, we present 5 case studies of projects that feature the use of technology in HIV-related implementation research to identify and describe challenges specific to technology-based implementation research about study design, outcome measurement, implementing in an evolving technology landscape, and equity. METHODS: For each case study, we identified the technological components, classified the components as intervention or implementation strategy, and identified implications for measuring performance and ensuring equity. The Exploration, Preparation, Implementation, and Sustainment framework was used to identify the research stage of each project. RESULTS: Technology is being leveraged across a diverse array of implementation strategies to promote Ending the HIV Epidemic in the United States. The case studies were primarily in the exploration and preparation phases of implementation, yet technology played a different role in each project- developing educational materials, mass media to recruit participants or distribute evidence-based campaigns, providing training, guiding tailoring, and implementing novel methods to democratize intervention development. DISCUSSION: Technology can play multiple roles in HIV-related implementation research projects, including serving as the intervention, being leveraged within implementation strategies, or both. We identified multiple considerations across projects that should be taken into account when measuring success and planning for equitable and sustained impact.

Using participatory system dynamics learning to support Ryan White Planning Council priority setting and resource allocations.

The Ryan White CARE Act provides federal dollars supporting low income people living with HIV/AIDS (PLWH). Regional Ryan White Planning Councils (RWPC) are responsible for setting priorities and deciding CARE Act fund allocations, using local data to identify greatest need. However, RWPC are challenged with interpreting complex epidemiological, service utilization, and community needs data to inform priority setting and resource allocations. We piloted system dynamics (SD) learning, using a validated HIV care continuum SD simulation model calibrated to one northeastern U.S. Ryan White funding area. The pilot applied systems thinking to understand the complex HIV care continuum and to simulate and compare outcomes of various resource allocation decisions. Three scripted workshops provided opportunities to learn the SD modeling process and simulation tool, simulate various resource allocations, and compare population health outcomes. Mixed methods evaluation documented the SD modeling process, member responses to the modeling sessions, and attitudes regarding benefits and limitations of SD modeling for RWPC decision-making. Despite high member turnover and complexity of the SD model, members could understand the simulation model and propose strategies to seek greatest improvements in HIV care retention, viral suppression, and reduced infections. Findings suggests the value of SD modeling to assist RWPC decisions.

What Predicts a Clinical Discussion About PrEP? Results From Analysis of a U.S. National Cohort of HIV-Vulnerable Sexual and Gender Minorities.

HIV-outcome inequities remain prevalent in the U.S. Medical providers (MPs) are gatekeepers of PrEP, and understanding the dynamics of PrEP assessments is of major interest for public health. We analyzed data from Together 5000, an internet-based U.S. national cohort of sexual and gender minority (SGM) individuals aged 16-49 years and at risk for HIV. Among those eligible for PrEP uptake (n = 6264), we modeled predictors of discussing PrEP with an MP. A third (31%) of participants had spoken to a MP about PrEP. Among those who spoke to a MP, 45% suggested they would initiate PrEP; this outcome was more common among participants older than 24. With a persistent stagnant uptake nationwide, new opportunities to influence PrEP uptake must be explored. An attractive less targeted space is the medical office, specifically ways to support an initial and continued discussion about PrEP between MPs and their patients.

Social Determinants of Health Screening by Preclinical Medical Students During the COVID-19 Pandemic: Service-Based Learning Case Study.

BACKGROUND: The inclusion of social determinants of health is mandated for undergraduate medical education. However, little is known about how to prepare preclinical students for real-world screening and referrals for addressing social determinants of health. OBJECTIVE: This pilot project's objective was to evaluate the feasibility of using a real-world, service-based learning approach for training preclinical students to assess social needs and make relevant referrals via the electronic medical record during the COVID-19 pandemic (May to June 2020). METHODS: This project was designed to address an acute community service need and to teach preclinical, second-year medical student volunteers (n=11) how to assess social needs and make referrals by using the 10-item Social Determinants of Health Screening Questionnaire in the electronic health record (EHR; Epic platform; Epic Systems Corporation). Third-year medical student volunteers (n=3), who had completed 6 clinical rotations, led the 2-hour skills development orientation and were available for ongoing mentoring and peer support. All student-patient communication was conducted by telephone, and bilingual (English and Spanish) students called the patients who preferred to communicate in Spanish. We analyzed EHR data extracted from Epic to evaluate screening and data extracted from REDCap (Research Electronic Data Capture; Vanderbilt University) to evaluate community health workers' notes. We elicited feedback from the participating preclinical students to evaluate the future use of this community-based service learning approach in our preclinical curriculum. RESULTS: The preclinical students completed 45 screening interviews. Of the 45 screened patients, 20 (44%) screened positive for at least 1 social need. Almost all of these patients (19/20, 95%) were referred to the community health worker. Half (8/16, 50%) of the patients who had consultations with the community health worker were connected with a relevant social service resource. The preclinical students indicated that project participation increased their ability to assess social needs and make needed EHR referrals. Food insecurity was the most common social need. CONCLUSIONS: Practical exposure to social needs assessment has the potential to help preclinical medical students develop the ability to address social concerns prior to entering clinical clerkships in their third year of medical school. The students can also become familiar with the EHR prior to entering third-year clerkships. Physicians, who are aware of social needs and have the electronic medical record tools and staff resources needed to act, can create workflows to make social needs assessments and services integral components of health care. Research studies and quality improvement initiatives need to investigate how to integrate screening for social needs and connecting patients to the appropriate social services into routine primary care procedures.

Food system dynamics structuring nutrition equity in racialized urban neighborhoods.

BACKGROUND: The food system is a social determinant of health and a leverage point for reducing diet-related racial inequities. Yet, food system interventions have not resulted in sustained improvement in dietary outcomes for underrepresented minorities living in neighborhoods with a history of disinvestment. Research is needed to illuminate the dynamics structuring food systems in racialized neighborhoods to inform intervention development. OBJECTIVES: To conduct participatory research examining the complexity and inequity of food systems in historically redlined neighborhoods to identify feedback mechanisms to leverage in efforts to transform system outcomes for racial equity. METHODS: We conducted a mixed-methods study in Cleveland, Ohio, USA from 2018 to 2021 using participatory system dynamic modeling with 30 academic and community partners, in-depth qualitative interviews with 22 key stakeholders, and public convenings with 250 local food policy council affiliates. Data were synthesized into causal loop diagrams depicting feedback mechanisms reinforcing or balancing neighborhood-level food system dynamics. RESULTS: We identified 10 feedback mechanisms structuring nutrition equity, which was identified as a meta-goal for food systems in racialized neighborhoods. Feedback mechanisms were organized in 3 domains: 1) meeting basic food needs with dignity (i.e., side hustle, government benefits, emergency food assistance, stigma, and stereotypes); 2) local food supply and demand dynamics (i.e., healthy food retail, job security, food culture, and norms); and 3) community empowerment and food sovereignty (i.e., community power, urban agriculture, risk of gentrification). Five exogenous factors moderate feedback dynamics: neighborhood crisis, neighborhood investments, household costs, government benefit funding, and voter participation. CONCLUSIONS: We identified nutrition equity as an overarching goal for local food systems, which reflects a state of having freedom, agency, and dignity in food traditions resulting in people and communities healthy in body, mind, and spirit. It is a transformative goal designed to spur system-level interventions that further racial equity through improved local food system dynamics.

Physical activity and stress management during COVID-19: a longitudinal survey study.

OBJECTIVE: Physical activity (PA) during COVID-19 shelter-in-place (SIP) may offset stress. This study examined associations between PA, stress and stress management strategies during SIP. DESIGN AND MAIN OUTCOME MEASURES: Participants (N = 990) from a cohort of Northern California adults completed surveys during early SIP (3/23/20-4/2/20) and mid-SIP (4/24/20-5/8/20). Participants self-reported past-month PA (meeting vs. not meeting guidelines), changes in stress (decreased/unchanged vs. increased) and use (yes/no) of 10 stress management strategies. We tested differences in mid-SIP stress and stress management strategies by PA, and differences in mid-SIP stress by stress management strategies. RESULTS: Compared to participants inactive at mid-SIP, active participants reported less stress (AOR = 0.60 [0.45, 0.81]). Active participants were more likely to manage stress using outdoor PA, indoor PA, yoga/meditation/prayer, gardening, and reading (AORs > 1.42), and less likely to sleep (AOR = 0.65 [0.48, 0.89]) or eat ([AOR = 0.48 [0.35, 0.66]) more. Managing stress using outdoor PA, indoor PA or reading was associated with lower stress; managing stress using TV/movies, sleeping or eating was associated with increased stress (ps < 0.05). CONCLUSIONS: Meeting PA guidelines during SIP was associated with less stress. Inactive participants reported greater sleeping and eating to cope; active participants used active stress management strategies. Engagement in physically active stress management was associated with lower stress.

Individual and community experience of rising burden of non-communicable diseases in two case districts of Nepal: a qualitative exploration.

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