The role of tobacco and alcohol use in the interaction of social determinants of non-communicable diseases in Nepal: a systems perspective.

BACKGROUND: Tobacco and alcohol use are major behavioural risks in developing countries like Nepal, which are contributing to a rapid increase in non-communicable diseases (NCDs). This causal relationship is further complicated by the multi-level social determinants such as socio-political context, socio-economic factors and health systems. The systems approach has potential to facilitate understanding of such complex causal mechanisms. The objective of this paper is to describe the role of tobacco and alcohol use in the interaction of social determinants of NCDs in Nepal. METHOD: The study adopted a qualitative study design guided by the Systemic Intervention methodology. The study involved key informant interviews (n = 63) and focus group discussions (n = 12) at different levels (national, district and/or community) and was informed by the adapted Social Determinants of Health Framework. The data analysis involved case study-based thematic analysis using framework approach and development of causal loop diagrams. The study also involved three sense-making sessions with key stakeholders. RESULTS: Three key themes and causal loop diagrams emerged from the data analysis. Widespread availability of tobacco and alcohol products contributed to the use and addiction of tobacco and alcohol. Low focus on primary prevention by health systems and political influence of tobacco and alcohol industries were the major contributors to the problem. Gender and socio-economic status of families/communities were identified as key social determinants of tobacco and alcohol use. CONCLUSION: Tobacco and alcohol use facilitated interaction of the social determinants of NCDs in the context of Nepal. Socio-economic status of families was both driver and outcome of tobacco and alcohol use. Health system actions to prevent NCDs were delayed mainly due to lack of system insights and commercial influence. A multi-sectoral response led by the health system is urgently needed.

Cardio-metabolic disease risk factors among South Asian labour migrants to the Middle East: a scoping review and policy analysis.

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

Non-communicable disease prevention in Nepal: systemic challenges and future directions.

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

Social determinants of common metabolic risk factors (high blood pressure, high blood sugar, high body mass index and high waist-hip ratio) of major non-communicable diseases in South Asia region: a systematic review protocol.

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

Low birth weight at term and its determinants in a tertiary hospital of Nepal: a case-control study.

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

Factors associated with place of delivery in rural Nepal.

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