Social determinants of health and cardiometabolic risk factors in Nepal: A scoping review.

AIMS: Cardiometabolic risk factors are modifiable contributors to cardiometabolic disease and adverse outcomes. Cardiometabolic risk factors are emerging health concerns among adults in low and middle-income countries. The role of social determinants of health on cardiometa gaps. DATA SYNTHESIS: A comprehensive search was conducted in multiple databases: PubMed (MEDLINE), Web of Science (Clarivate), and CINAHL (EBSCO). Joanna Briggs Institute's (JBI) Scoping Review methodology and PRISMA extension for scoping reviews-SCRA guided this review. Forty-four cross-sectional studies published between 2010 and 2022 were eligible for this review. Men were more likely to have hypertension, while women were more likely to have obesity and abdominal obesity. Participants from marginalized caste/ethnicity, urban regions, and those with lower education, and greater wealth index had a greater likelihood of hypertension, dyslipidemia, and hyperglycemia; however, differences across these sociodemographic subgroups are narrowing. Smoking, harmful alcohol use, high salt intake, low fruit and vegetable intake, and sedentary lifestyles were associated with one or more cardiometabolic risk factors. Finally, one cardiometabolic risk factor increased the risk of others. CONCLUSIONS: Findings reflect that Nepal is at the intersection of rapid urbanization, nutritional transition, and socioeconomic shift. Future studies should take a multilevel approach to investigate the role of social determinants in increasing the cardiometabolic risk burden in Nepal.

Service Availability and Readiness of Primary Care Health Facilities Offering Hypertension Diagnosis Services in Wakiso District, Uganda, 2019.

INTRODUCTION: Hypertension is a growing burden in Uganda and other low- and middle-income countries. Appropriate diagnosis services are needed at primary care health facilities to identify, initiate treatment for, and manage hypertension. This study assessed service availability and readiness as well as facilitators and barriers in primary health care facilities for hypertension diagnosis services in Wakiso District, Uganda. METHODS: In July and August 2019, we conducted structured interviews at 77 randomly selected primary care health facilities in Wakiso District. We used an interviewer-administered health facility checklist modified from the World Health Organization's service availability and readiness assessment tool. We also conducted 13 key informant interviews with health workers and district-level managers. Readiness was measured by availability of functional diagnostic equipment, related supplies and tools, and health provider attributes. Service availability was measured by assessing hypertension diagnosis services. RESULTS: Most (86%; 66 of 77) health facilities offered hypertension diagnosis services and 84% (65 of 77) had digital blood pressure measuring devices; only 69% (53 of 77) had functional blood pressure measuring devices. Lower-level facilities lacked appropriate blood pressure cuffs for use across age groups: 92% (71 of 77) lacked pediatric cuffs and 52% (40 of 77) lacked alternative adult cuffs. Facilitators for diagnosing hypertension included partners that built health facility staff capacity and funds for purchasing hypertension diagnostic supplies; common barriers were nonfunctional equipment, delays in receiving training, and inadequate staffing. CONCLUSION: The results highlight the need for an adequate supply of devices, routine replacements or repairs, and frequent refresher training for health workers.

Effects of adding exercise to usual care in patients with either hypertension, type 2 diabetes or cardiovascular disease: a systematic review with meta-analysis and trial sequential analysis.

OBJECTIVE: To assess the beneficial and harmful effects of adding exercise to usual care for people with hypertension, type 2 diabetes mellitus and/or cardiovascular disease. DESIGN: Systematic review with meta-analysis and trial sequential analysis of randomised clinical trials. DATA SOURCES: The CENTRAL, MEDLINE, EMBASE, Science Citation Index Expanded on Web of Science and BIOSIS searched from inception to July 2020. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: We included all randomised clinical trials adding any form of trialist defined exercise to usual care versus usual care in participants with either hypertension, type 2 diabetes or cardiovascular disease irrespective of setting, publication status, year and language. OUTCOME AND MEASURES: The primary outcomes were all-cause mortality, serious adverse events and quality of life. DATA EXTRACTION AND SYNTHESIS: Five independent reviewers extracted data and assessed risk of bias in pairs. Our methodology was based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses, Grading of Recommendations Assessment, Development and Evaluation and Cochrane Risk of Bias-version 1. RESULTS: We included 950 trials, of which 248 trials randomising 21 633 participants reported on our predefined outcomes. All included trials were at high risk of bias. The major types of exercise reported were dynamic aerobic exercise (126/248 trials), dynamic resistance exercise (25/248 trials), and combined aerobic and resistance exercise (58/248 trials). The study participants were included due to cardiovascular diseases (189/248 trials), type 2 diabetes (41/248 trials) or hypertension (16/248 trials). The median intervention period was 3 months (IQR: 2-4 months) and the median follow-up period was 6 months (IQR: 3-8 months) after randomisation. Meta-analyses and trial sequential analyses showed evidence of a beneficial effect of adding exercise to usual care when assessing all-cause mortality (risk ratio (RR) 0.82; 95% CI 0.73 to 0.93; I2=0%, moderate certainty of evidence) and serious adverse events (RR 0.79; 95% CI 0.71 to 0.88; I2=0%, moderate certainty of evidence). We did not find evidence of a difference between trials from different economic regions, type of participants, type of exercise or duration of follow-up. Quality of life was assessed using several different tools, but the results generally showed that exercise improved quality of life, but the effect sizes were below our predefined minimal important difference. CONCLUSIONS: A short duration of any type of exercise seems to reduce the risk of all-cause mortality and serious adverse events in patients with either hypertension, type 2 diabetes or cardiovascular diseases. Exercise seems to have statistically significant effects on quality of life, but the effect sizes seem minimal. PROSPERO REGISTRATION NUMBER: CRD42019142313.

[Monitoring and evaluation platform for HEARTS in the Americas: improving population-based hypertension control programs in primary health carePlataforma de monitoramento e avaliação do programa HEARTS nas Américas: melhoria dos programas de controle da hipertensão de base populacional na atenção primária à saúde]. / Plataforma de monitoreo y evaluación para HEARTS en las Américas: hacia la mejora de los programas de control de la hipertensión a nivel poblacional en la atención primaria de salud.

HEARTS in the Americas is the Pan American Health Organization flagship program to accelerate the reduction of the cardiovascular disease (CVD) burden by improving hypertension control and CVD secondary prevention in primary health care. A monitoring and evaluation (M&E) platform is needed for program implementation, benchmarking, and informing policy-makers. This paper describes the conceptual bases of the HEARTS M&E platform including software design principles, contextualization of data collection modules, data structure, reporting, and visualization. The District Health Information Software 2 (DHIS2) web-based platform was chosen to implement aggregate data entry of CVD outcome, process, and structural risk factor indicators. In addition, PowerBI was chosen for data visualization and dashboarding for the analysis of performance and trends above the health care facility level. The development of this new information platform was focused on primary health care facility data entry, timely data reporting, visualizations, and ultimately active use of data to drive decision-making for equitable program implementation and improved quality of care. Additionally, lessons learnt and programmatic considerations were assessed through the experience of the M&E software development. Building political will and support is essential to developing and deploying a flexible platform in multiple countries which is contextually specific to the needs of various stakeholders and levels of the health care system. The HEARTS M&E platform supports program implementation and reveals structural and managerial limitations and care gaps. The HEARTS M&E platform will be central to monitoring and driving further population-level improvements in CVD and other noncommunicable disease-related health.

A iniciativa HEARTS nas Américas é o principal programa da Organização Pan-Americana da Saúde para acelerar a redução da carga de doenças cardiovasculares (DCV) por meio do melhoramento do controle da hipertensão e da prevenção secundária de DCV na atenção primária à saúde. Uma plataforma de monitoramento e avaliação (M&E, na sigla em inglês) é necessária para a implementação do programa, para fazer a avaliação comparativa e para informar os formuladores de políticas. Este documento descreve as bases conceituais da plataforma de M&E do HEARTS, incluindo princípios de design de software, contextualização dos módulos de coleta de dados, estrutura de dados, relatórios e visualização. A plataforma baseada na web do District Health Information Software 2 (DHIS2) foi escolhida para implementar a inserção de dados agregados de indicadores de fatores de risco estruturais, processos e desfechos de DCV. Além disso, o PowerBI foi escolhido para a visualização de dados e para fazer o dashboard da análise de desempenho e tendências para além do nível da unidade de saúde. O desenvolvimento desta nova plataforma de informações teve como foco a inserção de dados da unidade de atenção primária à saúde, a notificação oportuna de dados, visualizações e o uso ativo dos dados para orientar a tomada de decisões para a implementação equitativa do programa e a melhoria da qualidade do atendimento. Além disso, as lições aprendidas e as considerações programáticas foram avaliadas por meio da experiência do desenvolvimento do software de M&E. Fomentar vontade política e apoio é essencial para desenvolver e implantar uma plataforma flexível em vários países, que seja contextualmente específica para as necessidades das diferentes partes interessadas e níveis do sistema de saúde. A plataforma de M&E do HEARTS ampara a implementação do programa e revela limitações estruturais e gerenciais, bem como lacunas na atenção à saúde. A plataforma de M&E do HEARTS será central para monitorar e impulsionar mais melhorias no nível populacional em DCV e outras doenças não transmissíveis.

Simplified hypertension screening methods across 60 countries: An observational study.

BACKGROUND: Simplified blood pressure (BP) screening approaches have been proposed. However, evidence is limited to a few countries and has not documented the cardiovascular risk amongst missed hypertension cases, limiting the uptake of these simplified approaches. We quantified the proportion of missed, over-diagnosed, and consistently identified hypertension cases and the 10-year cardiovascular risk in these groups. METHODS AND FINDINGS: We used 60 WHO STEPS surveys (cross-sectional and nationally representative; n = 145,174) conducted in 60 countries in 6 world regions between 2004 and 2019. Nine simplified approaches were compared against the standard (average of the last 2 of 3 BP measurements). The 10-year cardiovascular risk was computed with the 2019 World Health Organization Cardiovascular Risk Charts. We used t tests to compare the cardiovascular risk between the missed and over-diagnosed cases and the consistent hypertension cases. We used Poisson multilevel regressions to identify risk factors for missed cases (adjusted for age, sex, body mass index, and 10-year cardiovascular risk). Across all countries, compared to the standard approach, the simplified approach that missed the fewest cases was using the second BP reading if the first BP reading was 130-145/80-95 mm Hg (5.62%); using only the second BP reading missed 5.82%. The simplified approach with the smallest over-diagnosis proportion was using the second BP reading if the first BP measurement was ≥140/90 mm Hg (3.03%). In many countries, cardiovascular risk was not significantly different between the missed and consistent hypertension groups, yet the mean was slightly lower amongst missed cases. Cardiovascular risk was positively associated with missed hypertension depending on the simplified approach. The main limitation of the work is the cross-sectional design. CONCLUSIONS: Simplified BP screening approaches seem to have low misdiagnosis rates, and cardiovascular risk could be lower amongst missed cases than amongst consistent hypertension cases. Simplified BP screening approaches could be included in large screening programmes and busy clinics.

Monitoring and evaluation platform for HEARTS in the Americas: improving population-based hypertension control programs in primary health care.

HEARTS in the Americas is the Pan American Health Organization flagship program to accelerate the reduction of the cardiovascular disease (CVD) burden by improving hypertension control and CVD secondary prevention in primary health care. A monitoring and evaluation (M&E) platform is needed for program implementation, benchmarking, and informing policy-makers. This paper describes the conceptual bases of the HEARTS M&E platform including software design principles, contextualization of data collection modules, data structure, reporting, and visualization. The District Health Information Software 2 (DHIS2) web-based platform was chosen to implement aggregate data entry of CVD outcome, process, and structural risk factor indicators. In addition, PowerBI was chosen for data visualization and dashboarding for the analysis of performance and trends above the health care facility level. The development of this new information platform was focused on primary health care facility data entry, timely data reporting, visualizations, and ultimately active use of data to drive decision-making for equitable program implementation and improved quality of care. Additionally, lessons learnt and programmatic considerations were assessed through the experience of the M&E software development. Building political will and support is essential to developing and deploying a flexible platform in multiple countries which is contextually specific to the needs of various stakeholders and levels of the health care system. The HEARTS M&E platform supports program implementation and reveals structural and managerial limitations and care gaps. The HEARTS M&E platform will be central to monitoring and driving further population-level improvements in CVD and other noncommunicable disease-related health.

HEARTS en las Américas es el programa insignia de la Organización Panamericana de la Salud para acelerar la reducción de la carga de enfermedades cardiovasculares (ECV) mediante la mejora del control de la hipertensión y la prevención secundaria de las ECV en la atención primaria de salud. Es necesaria una plataforma de monitoreo y evaluación (M&E) para ejecutar el programa, establecer puntos de referencia y notificar a los responsables de las políticas. En este artículo se describen las bases conceptuales de la plataforma HEARTS M&E, como los principios de diseño del software, la contextualización de los módulos de recopilación de datos, la estructura de los datos, la presentación de información y la visualización. Se escogió la plataforma web District Health Information Software 2 (DHIS2) para ejecutar el ingreso de los datos agregados de los indicadores de resultados, procesos y factores de riesgo estructurales de las ECV. Además, se eligió PowerBI para la visualización de datos y la elaboración del panel de control para el análisis del desempeño y las tendencias más allá del nivel de los centros de atención médica. El desarrollo de esta nueva plataforma de información se centró en el ingreso de datos de los centros de atención primaria de salud, la presentación oportuna de datos, las visualizaciones y, en última instancia, el uso activo de los datos para impulsar la toma de decisiones en la ejecución equitativa del programa y la mejora de calidad de la atención. Además, se evaluaron las enseñanzas extraídas y las consideraciones programáticas con la experiencia del desarrollo de software de M&E. Lograr el apoyo y la voluntad política es esencial para desarrollar y poner en marcha una plataforma flexible en múltiples países que sea contextualmente específica según las necesidades de las diversas partes interesadas y los niveles del sistema de atención de la salud. La plataforma HEARTS M&E brinda apoyo para la ejecución del programa y muestra las limitaciones estructurales y gerenciales, así como las brechas en la atención. Esta plataforma será fundamental para monitorear e impulsar nuevas mejoras a nivel de la población en lo que respecta a las ECV y otras enfermedades no transmisibles relacionadas.

A iniciativa HEARTS nas Américas é o principal programa da Organização Pan-Americana da Saúde para acelerar a redução da carga de doenças cardiovasculares (DCV) por meio do melhoramento do controle da hipertensão e da prevenção secundária de DCV na atenção primária à saúde. Uma plataforma de monitoramento e avaliação (M&E, na sigla em inglês) é necessária para a implementação do programa, para fazer a avaliação comparativa e para informar os formuladores de políticas. Este documento descreve as bases conceituais da plataforma de M&E do HEARTS, incluindo princípios de design de software, contextualização dos módulos de coleta de dados, estrutura de dados, relatórios e visualização. A plataforma baseada na web do District Health Information Software 2 (DHIS2) foi escolhida para implementar a inserção de dados agregados de indicadores de fatores de risco estruturais, processos e desfechos de DCV. Além disso, o PowerBI foi escolhido para a visualização de dados e para fazer o dashboard da análise de desempenho e tendências para além do nível da unidade de saúde. O desenvolvimento desta nova plataforma de informações teve como foco a inserção de dados da unidade de atenção primária à saúde, a notificação oportuna de dados, visualizações e o uso ativo dos dados para orientar a tomada de decisões para a implementação equitativa do programa e a melhoria da qualidade do atendimento. Além disso, as lições aprendidas e as considerações programáticas foram avaliadas por meio da experiência do desenvolvimento do software de M&E. Fomentar vontade política e apoio é essencial para desenvolver e implantar uma plataforma flexível em vários países, que seja contextualmente específica para as necessidades das diferentes partes interessadas e níveis do sistema de saúde. A plataforma de M&E do HEARTS ampara a implementação do programa e revela limitações estruturais e gerenciais, bem como lacunas na atenção à saúde. A plataforma de M&E do HEARTS será central para monitorar e impulsionar mais melhorias no nível populacional em DCV e outras doenças não transmissíveis.

Broad scale functional connectivity for Asian elephants in the Nepal-India transboundary region.

The Nepal-India transboundary region hosts one of Asia's most complex large mammal assemblages, including a small (but growing) population of Asian elephants (Elephas maximus). These elephants occur in four widespread and geographically disjunct subpopulations, and some of them undergo seasonal transboundary movements. We conducted a broad-scale evaluation of the amount and quality of elephant habitat available in the region and of functional landscape connectivity between and within subpopulations using Maxent, circuit theory, and least-cost path analysis. Habitat suitability was highly influenced by abiotic geographical factors (altitude and precipitation) and less by ecological factors (habitat heterogeneity, plant productivity) and human disturbance (distance to settlements). The region had a relatively small amount of high and optimal suitability habitat (12.6% out of 93,700 km2) but all subpopulations seem to be far from carrying capacity, suggesting ample potential for further population growth. Landscape connectivity was higher between and within the west and far-west subpopulations, which should be considered a single subpopulation. The central and ea st subpopulations, however, had low to very low between-subpopulation connectivity. Conservation priorities include maintaining the current connectivity in the west subpopulation and across the border in the east, and protecting high-quality habitats in eastern Nepal. Restoring connectivity between the central and other subpopulations is possible if the number of elephants continues growing, and it should be a long-term conservation aspiration. Maintaining and enhancing landscape connectivity in this region requires transboundary cooperation and coordination between Nepali and Indian authorities. If successful, it will bring considerable benefits for the conservation of elephants and other wildlife.

Effects of a health worker-led 3-month yoga intervention on blood pressure of hypertensive patients: a randomised controlled multicentre trial in the primary care setting.

BACKGROUND: Hypertension control remains a major challenge globally. A recent systematic review suggested that yoga has beneficial effects on reducing blood pressure. However, the role of yoga in hypertension management in primary health care has received little attention, and no studies have evaluated the impact of a yoga program fully delivered by health care staff on hypertension. This study, therefore, assessed the effects of a health worker-led yoga intervention on blood pressure reduction among hypertensives patients in the primary care setting. METHODS: This was a multicentric, two-arm, randomised trial conducted among hypertensive patients in seven Ayurveda Health Centres in Nepal between March 2017 and June 2018. One hundred and twenty-one participants who were on or without medications were randomised to intervention (n = 61) and wait-list control (n = 60) groups using stratified block randomisation. Participants in the intervention arm received an intervention consisting of an initial five-day structured yoga training at the centres and then a further home-based practice of yoga for five days a week for the following 90 days. Both intervention and control groups also participated in a 2-h health education session. The primary outcome of this trial was systolic blood pressure at 90-day follow-up. Data were analysed on an intention-to-treat basis using linear mixed-effects regression models. RESULTS: We included all 121 study participants (intervention/control = 61/60) in the primary analysis (52.1% males; mean ± SD age = 47.8 ± 10.8 years). The difference in systolic blood pressure between the intervention group and the control group was - 7.66 mmHg (95% CI: - 10.4, - 4.93). For diastolic blood pressure, the difference was - 3.86 mmHg (95% CI: - 6.65, - 1.06). No adverse events were reported by the participants. CONCLUSIONS: A yoga program for hypertensive patients consisting of a five-day training in health centres and 90 days of practice at home is effective for reducing blood pressure. Significant benefits for hypertensive patients could be expected if such programmes would become a part of the standard treatment practice. TRIAL REGISTRATION: This trial was prospectively registered with the Clinical Trial Registry of India [ CTRI/2017/02/007822 ] on 10/02/2017.

May Measurement Month 2019: an analysis of blood pressure screening results from Nepal.

May Measurement Month (MMM) is a global initiative to screen high blood pressure (BP) in the community and increase awareness at the population level. High BP is the leading risk factor for mortality worldwide and in Nepal. This study presents the results of the 2019 MMM in Nepal. Opportunistic BP screening was conducted in 30 out of 77 districts across Nepal and aged ≥18 years at the community and public places. BP was measured three times in a seated position. A total of 74 205 individuals participated in the study, mean age 39.9 years, and 58% were male. BP measurements for the second and third readings were available for 69 292 (93.3%) individuals. The proportion of the population that were hypertensive was 27.5% (n = 20 429). Among those hypertensives, 46.3% were aware of their hypertensive status and of these, 37.5% were on antihypertensive medication. Only 54.3% of those on antihypertensive medication had their BP controlled. Of the community screened, those self reporting to have diabetes, current tobacco users, and current alcohol drinkers were 6.7%, 23.6%, and 31.9%, respectively; 20.6% of the participants were overweight, and 6.5% were obese. Since the first BP screening campaign, MMM 2017 in Nepal, the number of participants screened has largely increased over the years. MMM's success in Nepal is through a coordinated mobilization of trained health science students and volunteers in the communities. The Nepal MMM data demonstrates that large community-based BP screening campaigns are possible in low resource settings.

Prevalence and associated factors of hypertension among veterans of the Indian Gorkha regiments living in Pokhara Metropolitan City, Nepal.

BACKGROUND: Hypertension is a major preventable risk factor for cardiovascular disease. Occupational factors such as having served or serving in armed forces may be associated with hypertension. This study aimed to assess the prevalence and factors associated with hypertension among veterans of the Indian Gorkha army living in western Nepal. METHODS: A community-based cross-sectional study was conducted among the veterans living in the Pokhara metropolitan city. Data on blood pressure (BP), anthropometric measurements, and behavioral factors were collected by face-to-face interviews using the World Health Organization's non-communicable disease risk factor surveillance (STEPS) tool. Hypertension was defined as systolic blood pressure (BP) ≥ 140 mm Hg and/or diastolic BP of ≥ 90 mm Hg or currently on antihypertensive medication. RESULTS: The age-adjusted prevalence of hypertension was 66.2 % among the study participants (317). Mean systolic and diastolic blood pressure was 144.5 mmHg (± 18.3) and 89.3mmHg (± 16.0), respectively. Among the hypertensive participants, 67 % were aware of their disease, 90 % of them were under treatment, and 14 % of the individuals who received treatment had their hypertension under control. The proportion of smokers was 12.9 % and alcohol drinker was 86.1 %. One-fourth (25.9 %) of the participants had a family history of hypertension. Veterans aged 55-64 years had higher odds (AOR: 5.3; 95 % CI: 1.8-15.9; p = 0.003) of being associated with hypertension as compared to 35-44 years. Being a current alcohol drinker (AOR: 2.5; 95 % CI: 1.4-4.5; p = 0.003), overweight (AOR: 1.9; 95 % CI: 1.0-3.5; p = 0.04), obese (AOR: 3.1; 95 % CI: 1.1-8.3; p = 0.03) and family history of hypertension (AOR: 2.9; 95 % CI: 1.5-5.8; p = 0.002) were independently associated with hypertension. CONCLUSIONS: Hypertension was prevalent in retired Nepal veterans. Hypertension was associated with a number of modifiable lifestyle and behavioral factors. Our findings suggest the need for screening, education and management of Nepal veterans for hypertension.

Health-Related Quality of Life of People Living with COPD in a Semiurban Area of Western Nepal: A Community-Based Study.

Chronic Obstructive Pulmonary Disease (COPD) is a major cause of morbidity and mortality in Nepal. It is a progressive lung disease and has a significant impact on the quality of life of patients. Health-related quality of life (HRQOL) reflects the health- and disease-related facets of quality of life. Limited studies have assessed the impact of COPD on HRQOL and associated factors in Nepal. This study is based on a cross-sectional household survey data from a semiurban area of Western Nepal. A validated Nepali version of St George's Respiratory Questionnaire (SGRQ) was used to measure the HRQOL. COPD was defined together with post-bronchodilator airflow obstruction and the presence of respiratory symptoms. Post-bronchodilator airflow obstruction was defined as Forced Expiratory Volume in 1st second (FEV1) to Forced Vital Capacity (FVC) ratio < 0.70. COPD was diagnosed in 122 participants, and their median (IQR) total score of HRQOL was 40 (26 - 69); the score of symptoms, activity, and impact area were 53 (37 - 74), 57 (36 - 86), and 26 (13 - 62), respectively. The overall HRQOL was significantly different in terms of age, occupational status, physical activity, and comorbidities. Disease severity and the presence of respiratory symptoms had a significant difference in HRQOL (p = 0.0001). Appropriate measures to improve conditions and addressing the associated factors like respiratory symptoms and enhancing physical activity are necessary and important.

Factors affecting the fruit and vegetable intake in Nepal and its association with history of self-reported major cardiovascular events.

BACKGROUND: The World Health Organization recommends consumption of a minimum of 400 g of fruits and vegetables per day for prevention of cardiovascular disease. Low fruit and vegetable intake is associated with an increased risk of stroke by 11% and ischemic heart disease by 31%. The present study aims to explore factors affecting the fruit and vegetable intake in Nepal and its association with history of self-reported major cardiovascular events (myocardial infarction and stroke). METHOD: Data for this cross-sectional study were collected as part of the study "Community Based Management of Hypertension in Nepal" initiated in the Lekhnath Municipality in 2013. Demographic and nutrition information were collected using the WHO STEPwise approach to a surveillance tool. Descriptive statistics identified the frequency and percentage of fruit and vegetable intake. A Chi-square test examined the association between fruit and vegetable intake and history of self-reported cardiovascular events, socio-demographic and cardiovascular risk factors. Binary logistic regression analysis identified odds ratio with 95% confidence intervals between fruit and vegetable intake and history of self-reported cardiovascular events. RESULTS: The mean and median intake of fruits and vegetables were 3.3 ± 0.79 and 3 servings respectively. Of the 2815 respondents, 2% (59) reported having a history of major cardiovascular events. The adjusted odds of having a history of major cardiovascular events was 2.22 (95%CI, 1.06-4.66) for those who consumed < 3 servings compared to those who consumed ≥3 servings of fruits and vegetables a day. CONCLUSION: The respondents who consumed < 3 servings of fruits and vegetables a day had higher odds of a history of major cardiovascular events in comparison to those who consumed ≥3 servings. This finding may carry a policy recommendation for those settings where the current recommendation of having ≥5 servings of fruits and vegetables a day is not possible. Our findings also suggest that surviving a major cardiovascular event was not enough in itself to modify nutritional intake. As many Nepali consumes low amount of fruits and vegetables, appropriate measures should be taken to increase this consumption to prevent cardiovascular morbidity and mortality.

Prevalence and incidence of oral cancer in low- and middle-income countries: A scoping review.

INTRODUCTION: Oral cancer is common cancer in many low- and middle-income countries (LMICs) with a low five-year survival rate. It is among the four most common types of cancer in South East Asia region. In South-Central Asia, lip and oral cavity cancer is the second most common cancer according to the specific cancer types. METHODS: This scoping review intended to investigate published studies on the current prevalence and incidence of oral cancer in LMICs. The review was conducted applying the search words "Oral Cancer" and "Mouth neoplasm" as the Medical Subject Heading (MeSH) major topic and "Epidemiology" and ("prevalence" OR "incidence") as the MeSH subheading; the search was supplemented by cross-references. Included studies met the following criteria: original studies, reporting of prevalence or incidence rates, population-based studies, studies in English language and studies involving humans. RESULTS: The sample sizes ranged from 486 to 101,761 with 213,572 persons included. Buccal mucosa is one of the most common sites of oral cancer, associated with the widespread exposure to chewing tobacco. The incidence is likely to rise in the region where gutkha, pan masala, pan-tobacco and various other forms of chewing tobacco are popular. CONCLUSION: This review contributes to useful information on prevalence and incidence estimates of oral cancer in LMICs.

Pesticide exposure and diabetes mellitus in a semi-urban Nepali population: a cross-sectional study.

OBJECTIVE: Epidemiological studies suggest exposure to pesticides to be related to risk of diabetes mellitus. The objective of the present study was to assess the association between pesticide use and diabetes mellitus in a semi-urban population in Nepal. METHODS: We conducted a nested cross-sectional study on pesticides and diabetes mellitus in a population-based cohort from the former Lekhnath Municipality, Nepal. 2643 persons were invited, and 2310 persons participated (response rate 87.4%). All participants were tested for fasting plasma glucose. Diabetes mellitus was defined as either fasting plasma glucose (FPG) ≥ 7.0 mmol/L (126 mg/dL) or self-reported diagnosis of diabetes mellitus. Exposure to pesticides was determined by questionnaire. For the exposed persons, three exposure metrics (years of exposure, weeks of exposure per year and hours of exposure per week) were categorized and used to model exposure-response relationships. RESULTS: Although 62% of participants reported to be exposed to pesticides, the frequency and intensity of pesticide usage was low. Contrary to our hypothesis, we found lower odds of diabetes mellitus among persons reporting any pesticide use compared to those reporting no use of pesticides-adjusted odds ratio with 95% CI = 0.68 [0.52; 0.90]. However, we found no clear exposure-response relationships between pesticide exposure and neither diabetes mellitus nor FPG, and few and inconsistent associations were seen between pesticide exposure and symptoms of acute pesticide intoxication. CONCLUSIONS: The apparently lower odds of diabetes mellitus among pesticide-exposed persons in this population are probably due to residual confounding. Our results do not seem to support an association between pesticide exposure and diabetes mellitus in this low-exposed population dominated by subsistence farmers, although results should be interpreted with caution in light of the study limitations.

Mid-upper arm circumference as an indicator of underweight in adults: a cross-sectional study from Nepal.

BACKGROUND: Undernourished people have an increased risk of premature mortality from both infectious and non-communicable diseases. Aside from screening purposes, assessment of nutritional status is a useful tool in management and evaluation of various chronic diseases. Body-Mass-Index (BMI) is today the most commonly used marker of nutritional status however, this method presents a challenge in many low resource settings and immobile patients. Mid-upper arm circumference (MUAC) is another anthropometric measure that requires minimal equipment and little training. So far, MUAC cutoffs for undernutrition are well established in children < 5 years but there is still no consensus for a specific cutoff in adults. The objective of this study was to compare MUAC with BMI and suggest a MUAC cut-off corresponding to a BMI of 18.5 kg/m2 to identify underweight in adults. METHODS: A cross-sectional study was conducted at two urban public hospitals in Nepal. The following variables where collected: MUAC, weight, height, sex, age and self-reported medical history. EXCLUSION CRITERIA: < 19 years of age, pregnancy and oedema. Sensitivity and specificity for a MUAC value corresponding to BMI < 18.5 was calculated. ROC analysis was performed for male and female as well as Pearson's correlation of MUAC and BMI. RESULTS: A total of 302 people between 18 and 86 years of age, 197 women and 105 men, were included. Of these, 90 people suffered from rheumatic heart disease. MUAC was highly correlated with BMI in both women r = 0.889 and men r = 0.846. Best statistically derived MUAC cutoff corresponding to a BMI < 18.5 kg/m2 was 24.5 cm (Youdens Index = 0.75; sensitivity 92.86; specificity 82.48), with high predictive value (AUROCC> 0.9). The setting based optimal MUAC cutoff was also 24.5 cm. No considerable variation was found in sex- and disease specific subgroups. CONCLUSION: MUAC is strongly correlated with BMI in adults in Nepal. For simplicity, a MUAC of 24.5 cm is the optimal statistically and setting based cutoff in both women and men to identify underweight (BMI < 18.5 kg/m2).

May Measurement Month 2018: an analysis of blood pressure screening results from Nepal.

Raised blood pressure (BP) is a leading risk factor for mortality globally and in Nepal. May Measurement Month (MMM) is a global initiative aimed at screening for hypertension and raising awareness on high BP worldwide. This study provides the results of the 2018 MMM (MMM18) in Nepal. An opportunistic cross-sectional survey of volunteers aged ≥18 years was carried out in May 2018 nationwide. The standard MMM protocol was followed for BP measurement, the definition of hypertension, and statistical analysis. The campaign was publicized through various social media for recruiting volunteers and inviting participation. A total of 15 561 (58.7% male) from 35 districts of Nepal were screened in MMM18, of which 4 321 (27.8%) had hypertension. A total of 2 633 (19.0%) of 13 873 individuals who were not on antihypertensive treatment were found to be hypertensive. Of those on medication, 799 (47.4%) had uncontrolled BP. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were significantly higher in people on antihypertensive treatment, smokers, and alcohol drinkers compared with those who were not on antihypertensive treatment, smokers, and alcohol drinkers, respectively. Likewise, SBP and DBP steadily increased across increasing body mass index categories. MMM18 was the largest BP screening campaign undertaken in Nepal. MMM has highlighted the importance of a periodic public health program at the national level to increase awareness on hypertension detection and control rate, and thus, the prevention of cardiovascular diseases.

Barriers and facilitators to cervical cancer screening uptake among women in Nepal - a qualitative study.

The global incidence of cervical cancer is approximately 570,000 cases and 311,000 deaths annually. Almost 90% of cervical cancer deaths occur in low and middle income countries. Screening is the most effective tool in prevention, early diagnosis, and treatment of cervical cancer. Nepal has no national cervical cancer screening programme, and data from 2003 showed that only 2.8% of Nepalese women had ever been screened. We conducted a qualitative study to obtain better insight into barriers and facilitators to cervical cancer screening among women in Nepal to generate data to inform interventions. In February 2019, four focus group discussions with previously screened and non-screened women, and Female Community Health Volunteers and four in-depth interviews with health workers were conducted in Pokhara Metropolitan City. Semi-structured interview guides were used, interviews were audio-recorded, transcribed verbatim, and analyzed using grounded theory approach with open coding. This resulted in five main themes: 1) lack of husband's support for screening, 2) prevalent stigma and discrimination, 3) lack of awareness about screening options, 4) getting screened, and 5) health care providers. We encourage policymakers and stakeholders apply these findings to improve awareness, access to information, and better screening services in Nepal.

Alcohol consumption pattern in western Nepal: findings from the COBIN baseline survey.

BACKGROUND: Harmful use of alcohol is a global public health problem. Differences in alcohol consumption patterns may add valuable information to the design of public health interventions to prevent excessive use of alcohol, which is yet missing in Nepal. Hence, the purpose of the study is to determine the prevalence, patterns of alcohol consumption and socio-economic correlates of lifetime alcohol consumption and binge drinking in the semi-urban area of Pokhara Municipality. METHODS: The cross-sectional data used in this study were collected as part of the COBIN study to understand alcohol consumption patterns and frequency and to determine correlates of lifetime alcohol consumption and binge drinking in the semi-urban area of Pokhara Municipality, Nepal. RESULTS: Out of 2815 study participants, 35.6% had ever used alcohol in their lifetime (Male 67.2% and Female 18.9%). Among 571 respondents who drank alcohol within the past 30 days, 77.1% male, and 46.9% female reported binge drinking behaviour. On average, males consumed 8.8 ± 0.3 standard alcohol drinks on one occasion, while females consumed only 4.4 ± 0.3 alcoholic drinks. Male (OR = 16; 95% CI: 12.1-21.1), older adults (OR = 1.5; 95% CI: 1.2-1.7) and people belonging to disadvantaged ethnic group (OR = 6.1; 95% CI: 4.9-6.3) had higher odds of lifetime alcohol consumption than their respective counterparts. Whereas, male (OR = 7.9; 95% CI: 4.3-14.6), having higher educational status and agriculture as the occupation had higher odds of binge drinking. CONCLUSION: Alcohol consumption frequency was significantly higher among males than females in Western Nepal. Although national program and policies should recommend reducing alcohol consumption in general, targeted interventions are needed for males aged 45-65 years of age and certain ethnic groups (Dalit and Janajati).

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.

May Measurement Month 2017: an analysis of blood pressure screening results in Nepal-South Asia.

Hypertension is the leading risk factor of mortality in Nepal accounting for ∼33 000 deaths in 2016. However, more than 50% of the hypertensive patients are unaware of their status. We participated in the May Measurement Month 2017 (MMM17) project initiated worldwide by the International Society of Hypertension to raise the awareness on the importance of blood pressure (BP) screening. In this paper, we discuss the screening results of MMM17 in Nepal. An opportunistic cross-sectional survey of volunteers aged ≥18 years was carried out in May 2017 following the standard MMM protocol. Data were collected from 18 screening sites in 7 districts covering 5 provinces. Screenings were conducted either in health facilities, public places, or participants' homes. Trained volunteers with health science background and female community health volunteers were mobilized to take part in the screening. A total of 5972 individuals were screened and of 5968 participants, for whom a mean of the 2nd and 3rd readings was available, 1456 (24.4%) participants had hypertension; 908 (16.8%) of those not receiving treatment were hypertensive; and 248 (45.2%) of those being treated had uncontrolled BP. MMM17 is the first nationwide BP screening campaign undertaken in Nepal. Given the suboptimal treatment and control rates identified in the study, there is a strong imperative to scale up hypertension prevention, screening, and management programmes. These results suggest that opportunistic screening can identify significant numbers with hypertension. Mobilization of existing volunteer networks and support of community stakeholders, would be necessary to improve the overall impact and sustainability of future screening programmes.