Effect of exercise on functional capacity and body weight for people with hypertension, type 2 diabetes, or cardiovascular disease: a systematic review with meta-analysis and trial sequential analysis.

BACKGROUND: Hypertension, type 2 diabetes, and cardiovascular disease affect the activities of daily living at varying degree. While the effects of aerobic exercise on functional capacity are well-documented, the extent of change for different types of exercise in these chronic conditions remains unexplored. Additionally, there is conflicting evidence regarding the role of exercise in reducing body weight. METHODS: We conducted systematic review with meta-analysis and trial sequential analysis and searched various databases from inception to July 2020. We included randomised clinical trials adding any form of trialist defined exercise to usual care versus usual care in people with either hypertension, type 2 diabetes, and/or cardiovascular disease irrespective of setting, publication status, year, and language. The outcomes assessed were i) functional capacity assessed through different scales separately i.e., Maximal Oxygen Uptake (VO2max), 6-min walk test (6MWT), 10-m walk test (10MWT), and ii) body weight. RESULTS: We included 950 studies out of which 444 trials randomising 20,098 participants reported on various functional outcomes (355 trials) and body weight (169 trials). The median follow-up was 3 months (Interquartile ranges (IQR): 2.25 to 6). Exercise added to the usual care, improved VO2max (Mean Difference (MD):2.72 ml/kg/min; 95% Confidence Interval (CI) 2.38 to 3.06; p < 0.01; I2 = 96%), 6MWT (MD: 42.5 m; 95%CI 34.95 to 50.06; p < 0.01; I2 = 96%), and 10MWT (MD: 0.06 m/s; 95%CI 0.03 to 0.10; p < 0.01; I2 = 93%). Dynamic aerobic and resistance exercise showed a consistent improvement across various functional outcomes, whereas body-mind therapies (MD: 3.23 ml/kg/min; 95%CI 1.97 to 4.49, p < 0.01) seemed especially beneficial for VO2max and inspiratory muscle training (MD: 59.32 m; 95%CI 33.84 to 84.80; p < 0.01) for 6MWT. Exercise yielded significant reduction in body weight for people with hypertension (MD: -1.45 kg; 95%CI -2.47 to -0.43; p < 0.01), and type 2 diabetes (MD: -1.53 kg; 95%CI -2.19 to -0.87; p < 0.01) but not for cardiovascular disease with most pronounced for combined exercise (MD: -1.73 kg; 95%CI -3.08 to -0.39; p < 0.05). The very low certainty of evidence warrants cautious interpretations of the results. CONCLUSION: Exercise seemed to improve functional capacity for people with hypertension, type 2 diabetes, and/or cardiovascular disease but the effectiveness seems to vary with different forms of exercise. The potentially superior improvement in VO2max and 6MWT by body-mind therapies and inspiratory muscle training calls for further exploration. Additionally, prescribing exercise for the sole purpose of losing weight may be a potential strategy for people with hypertension and type 2 diabetes. The extent of improvement in functional capacity and body weight reduction differed with different exercise regimens hence personalised exercise prescriptions tailored to individual needs may be of importance. PROSPERO REGISTRATION: PROSPERO registration number: CRD42019142313.

Lifestyle management of hypertension: International Society of Hypertension position paper endorsed by the World Hypertension League and European Society of Hypertension.

Hypertension, defined as persistently elevated systolic blood pressure (SBP) >140 mmHg and/or diastolic blood pressure (DBP) at least 90 mmHg (International Society of Hypertension guidelines), affects over 1.5 billion people worldwide. Hypertension is associated with increased risk of cardiovascular disease (CVD) events (e.g. coronary heart disease, heart failure and stroke) and death. An international panel of experts convened by the International Society of Hypertension College of Experts compiled lifestyle management recommendations as first-line strategy to prevent and control hypertension in adulthood. We also recommend that lifestyle changes be continued even when blood pressure-lowering medications are prescribed. Specific recommendations based on literature evidence are summarized with advice to start these measures early in life, including maintaining a healthy body weight, increased levels of different types of physical activity, healthy eating and drinking, avoidance and cessation of smoking and alcohol use, management of stress and sleep levels. We also discuss the relevance of specific approaches including consumption of sodium, potassium, sugar, fibre, coffee, tea, intermittent fasting as well as integrated strategies to implement these recommendations using, for example, behaviour change-related technologies and digital tools.

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.

Burden and risk factors of chronic respiratory diseases in Nepal, 1990-2019: An analysis of the global burden of diseases study.

Background and Aims: Chronic respiratory diseases (CRDs) substantially contribute to morbidity and mortality globally and in Nepal. However, there is a paucity of evidence on the trend and the burden of CRDs in Nepal. This study reports the trend of the burden and contribution of major risk factors to CRDs in Nepal from 1990 to 2019. Methods: This study is an observational study using publicly available data from Global Burden of Disease 2019 estimations for Nepal. The age-standardized and age-specific prevalence, incidence, mortality, disability-adjusted life years (DALYs), and risk factors for CRDs in Nepal were extracted to measure the burden and its trend. The data are presented as percentages or as rates per 100,000 population. Results: The age-standardized incidence rate of CRDs in Nepal in 2019 was 913.6 per 100,000 (95% uncertainty interval [UI]: 828.7-1000.1), which was an increase of 7.7% from 848.6 per 100,000 (95% UI: 780.2-918.2) in 1990. However, the age-standardized prevalence rate [4453/100,000 (4234.2-4671.8) in 1990; 4457.1/100,000 (4255.2-4666.8) in 2019] was almost stagnant. Most CRDs attributed to deaths and DALYs were due to chronic obstructive pulmonary disease. Conclusions: Air pollution and smoking are the main risk factors for DALYs due to CRDs in Nepal. This surging burden of the incidence rate of CRDs in Nepal calls for more effective actions to curb the risk factors and diseases.

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 / Monitoring and evaluation platform for HEARTS in the Americas: improving population-based hypertension control programs in primary health care / Plataforma de monitoramento e avaliação do programa HEARTS nas Américas: melhoria dos programas de controle da hipertensão de base populacional na atenção primária à saúde

RESUMEN 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 de M&E de HEARTS, 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 del programa con equidad 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 de M&E de HEARTS 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.

ABSTRACT 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.

RESUMO 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.

Effect of a female community health volunteer-delivered intervention to increase cervical cancer screening uptake in Nepal: a cluster randomized controlled trial.

This study aimed to assess the effect of Female Community Health Volunteer (FCHV)-delivered intervention to increase cervical cancer screening uptake among Nepalese women. A community-based, open-label, 2-group, cluster randomized controlled trial (CRCT) was conducted in a semi-urban setting in Western Nepal. Fourteen clusters (1:1) were randomly assigned to the intervention group, which received a 12-month intervention delivered by FCHVs or the control group (usual care). Between April and June 2019, 690 women aged 30-60 years were recruited for CRCT during the baseline survey. A follow-up assessment was conducted after the completion of the 12 months intervention. The primary outcome was the change in cervical cancer screening from baseline to 12-month follow-up. Of 690 women, 646 women completed the trial. 254 women in the intervention group and 385 women in the control group were included in the primary outcome analysis. There was a significant increase in cervical cancer screening uptake in the intervention group [relative risk (RR), 1.48; 95 % confidence interval (CI) 1.32, 1.66; P < 0.01)], compared to the control group. The secondary outcome was the change in median knowledge score among women that increased from 2 [interquartile range (IQR) 1-4] (baseline) to 6 [IQR 3-9] (follow-up) in the intervention group. However, the median knowledge score remained almost the same among women in the control group 2 [IQR 1-5] to 3 [IQR 2-5]. Our study findings reported that an FCHV-delivered intervention significantly increased cervical cancer screening uptake among women living in a semi-urban setting in Nepal. Trial registration: ClinicalTrials.gov NCT03808064.

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.

Socio-demographic and lifestyle factors associated with hypertension in Nigeria: results from a country-wide survey.

With the rising prevalence of hypertension, especially in Africa, understanding the dynamics of socio-demographic and lifestyle factors is key in managing hypertension. To address existing gaps in evidence of these factors, this study was carried out. A cross-sectional survey using a modified WHO STEPS questionnaire was conducted among 3782 adult Nigerians selected from an urban and a rural community in one state in each of the six Nigerian regions. Among participants, 56.3% were women, 65.8% were married, 52.5% resided in rural areas, and 33.9% had tertiary education. Mean ages (SD) were 53.1 ± 13.6 years and 39.2 ± 15.0 years among hypertensive persons and their normotensive counterparts respectively. On lifestyle, 30.7% had low physical activity, 4.1% consumed tobacco currently, and 35.4% consumed alcohol currently. In comparison to unmarried status, being married (OR = 1.88, 95% CI: 1.41-2.50) or widowed (OR = 1.57, 95% CI: 1.05-2.36) was significantly associated with hypertension, compared with never married. Compared with no formal education, primary (OR = 1.44, 95% CI: 1.12-1.85), secondary (OR = 1.37, 95% CI: 1.04-1.81), and tertiary education (OR = 2.02, 95% CI: 1.57-2.60) were associated with hypertension. Low physical activity (OR = 1.23, 95% CI: 1.05-1.42), alcohol consumption, (OR = 1.18, 95% CI: 1.02-1.37), and unemployment status (OR = 1.42; 95% CI: 1.07-1.88) were also associated with hypertension. Our study indicates an association of socio-demographic and lifestyle factors with hypertension, hence, there is a need for counselling, health education and policy formulation and implementation targeting these factors to prevent and control hypertension.

Knowledge, attitude, preventive practices and utilization of cervical cancer screening among women in Nepal: a community-based cross-sectional study.

BACKGROUND: Cervical cancer continues to be a global public health concern and a leading cause of cancer deaths among Nepalese women. In spite of the availability of screening and treatment services in Nepal, the utilization of screening has been low. This study investigated knowledge, attitude, preventive practices and utilization of cervical cancer screening among women in a semi-urban area of Pokhara Metropolitan City of Nepal. METHODS: A community-based cross-sectional survey was carried out among 729 women 30-60 years of age, between April and June 2019. Participants were selected by systematic random sampling, and a door-to-door home visit was conducted for data collection. A pretested interviewer-administered Nepali questionnaire was used to collect information on sociodemographic variables, knowledge, attitude and preventive practices regarding cervical cancer screening. RESULTS: The mean age of the participants was 45.9 years (SD ±7.7); the majority were married (86.7%). Among the participants, 44.9% were ever screened for cervical cancer. However, only 10.4% of participants received timely repeated screening for cervical cancer. The median knowledge score achieved by participants was 2.0 [interquartile range (IQR) 1-4] on a scale of maximum score 36, the median attitude score was 31.0 (IQR 29-32) on a scale of 40 and the median preventive practice score was 3.0 (IQR 3-4) on a scale of five. CONCLUSION: This study showed low knowledge and low utilization of cervical cancer screening among women in Nepal. We recommend a community-based educational intervention to educate and empower women to increase knowledge and utilization of cervical cancer screening.

Monitoring and evaluation platform for HEARTS in the Americas: improving population-based hypertension control programs in primary health care / 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 / Plataforma de monitoramento e avaliação do programa HEARTS nas Américas: melhoria dos programas de controle da hipertensão de base populacional na atenção primária à saúde

ABSTRACT 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.

RESUMEN 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.

RESUMO 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.

Community-based intervention for prevention and management of chronic obstructive pulmonary disease in Nepal (COBIN-P trial): study protocol for a cluster-randomized controlled trial.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is one of the leading causes of death worldwide and the commonest of non-communicable diseases (NCDs) in Nepal. Risk factors like indoor and outdoor air pollution, a high prevalence of smoking, and the lack of awareness of COPD make it a serious public health concern. However, no attempt has been made in Nepal to estimate its burden and address the disease at the community level. METHOD: This study aims to evaluate the effect of a community-based health educational intervention administered by Female Community Health Volunteers (FCHVs) on the prevention and management of COPD. An open-label, two-group, community-based, cluster-randomized controlled trial will be implemented in the semi-urban area of Pokhara Metropolitan city (former Lekhnath Municipality) located in the Kaski district of Nepal. The estimated sample size of the intervention will be 1143. The unit of randomization is the ward (administrative unit) of the study area. The follow-up survey will be conducted immediately after 12 months of FCHVs-led interventions. The difference in the rate of decline of forced expiratory volume in 1 s (FEV1) and FEV1/FVC (forced vital capacity) ratio are the primary outcomes and the change in the proportion of modifiable risk factors of COPD, health-related quality of life scores, and change in knowledge of COPD will be secondary outcomes. DISCUSSION: This study will estimate the burden of COPD, the magnitude of risk factors and generate evidence to mobilize community health workers for COPD prevention and management at the community level in Nepal. TRIAL REGISTRATION: ClinicalTrials.gov NCT03797768 . Registered on January 9, 2019.

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.

Effectiveness of a Female Community Health Volunteer-Delivered Intervention in Reducing Blood Glucose Among Adults With Type 2 Diabetes: An Open-Label, Cluster Randomized Clinical Trial.

Importance: Female community health volunteers (FCHVs) are frontline community health workers who have been a valuable resource in improving public health outcomes in Nepal, but their value is understudied in diabetes care. Objective: To assess whether an FCHV-delivered intervention is associated with reduced blood glucose levels among adults with type 2 diabetes. Design, Setting, and Participants: This community-based, open-label, 2-group, cluster randomized clinical trial with a 12-month delayed control group design was conducted in 14 clusters of a semiurban setting in Western Nepal. A total of 244 adults with type 2 diabetes were recruited between November 2016 and April 2017. The follow-up assessment was conducted at 12 months after enrollment. Data analysis was performed from January to February 2019. Interventions: Seven clusters were randomized to the FCHV-delivered intervention in which 20 FCHVs provided home visits 3 times a year (once every 4 months) for health promotion counseling and blood glucose monitoring. If participants had blood glucose levels of 126 mg/dL or higher, the FCHVs referred them to the nearest health facility, and if participants were taking antihyperglycemic medication, they were followed up by the FCHVs for adherence to their medication. Seven clusters were randomized to usual care (control group). Main Outcomes and Measures: The primary outcome was the change in mean fasting blood glucose from baseline to 12-month follow-up. Secondary outcomes included changes in mean systolic blood pressure, mean diastolic blood pressure, mean body mass index, percentage change in the proportion of low physical activity, harmful alcohol consumption, current smoking, low fruit and vegetable intake, and antihyperglycemic medication status. Results: Of 244 participants, 120 women (56.6%) and 92 men (43.4%) completed the trial. At baseline, the mean (SD) age was 51.71 (8.77) years; 127 participants were in the intervention group, and 117 participants were in the control group (usual care). At baseline, the mean (SD) fasting blood glucose level was 156.06 (44.48) mg/dL (158.48 [45.50] mg/dL in the intervention group and 153.43 [43.39] mg/dL in the control group). At 12-month follow-up, the mean fasting blood glucose decreased by 22.86 mg/dL in the intervention group, whereas it increased by 7.38 mg/dL in the control group. The mean reduction was 27.90 mg/dL greater with the intervention (95% CI, -37.62 to -18.18 mg/dL; P < .001). In secondary outcome analyses, there was a greater decline in mean systolic blood pressure in the intervention group than in the control group (-5.40 mm Hg; 95% CI, -8.88 to -1.92 mm Hg; P = .002). There was detectable difference in the intake of antihyperglycemic medication between the groups (relative risk, 1.35; 95% CI, 1.1 to 1.74; P = .02). Conclusions and Relevance: These findings suggest that an FCHV-delivered intervention is associated with reduced blood glucose levels among adults with type 2 diabetes in a low-resource setting in Nepal. Trial Registration: ClinicalTrials.gov Identifier: NCT03304158.

Community-based intervention for cervical cancer screening uptake in a semi-urban area of Pokhara Metropolitan, Nepal (COBIN-C): study protocol for a cluster-randomized controlled trial.

BACKGROUND: Previous studies suggest that health intervention designed to increase cervical cancer screening has been effective to reduce cervical cancer incidence and mortality. The aim of this study is to determine the effect of a home-based health education intervention for increasing cervical cancer screening uptake delivered by trained female community health volunteers (FCHVs), a category of community health worker in Nepal. METHODS: A community-based, open-label, two-armed, cluster-randomized trial [seven clusters (geographical wards) randomized for the intervention, and seven for the control arm]. The participants are recruited from a population-based survey with a sample size of 884. Based on population proportion size, 277 women will be recruited for the intervention group and 413 women recruited for the control group. A 12-month community-based health education intervention will be administered mobilizing the FCHVs, based on the Health Belief Model. The primary outcome measure of the study will be the difference in percentage of cervical cancer screening uptake between the two study arms. The primary outcomes will be modeled by using mixed-effect logistic regression analysis. DISCUSSION: COBIN-C is the first study investigating the effect of a community-based health education intervention by FCHVs on increasing cervical cancer screening uptake among women in Nepal. The purpose of this study is to develop and implement a home-based, culturally sensitive program to increase cervical cancer screening coverage at the community level. TRIAL REGISTRATION: ClinicalTrials.gov NCT03808064 . Registered on January 14, 2019.

Prevalence of Chronic Obstructive Pulmonary Disease and its Associated Factors in Nepal: Findings from a Community-based Household Survey.

Background: Despite chronic obstructive pulmonary disease (COPD) being the commonest non-communicable disease in Nepal, there is limited research evidence estimating the spirometry-based burden of COPD. This study aims to estimate the prevalence of COPD and its correlates through a community-based survey in Pokhara Metropolitan City, a semi-urban area of Western Nepal. Methods: A cross-sectional household survey was conducted among 1459 adults ≥40 years. COPD was defined according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria as a post-bronchodilator ratio of forced expiratory volume in 1st second (FEV1) to forced vital capacity (FVC) <0.70 with the presence of symptoms. COPD was also defined by the lower limit of normal (LLN) threshold - FEV1/FVC < LLN cut-off values with the presence of symptoms. Study participants were interviewed about sociodemographic and behavioural characteristics and respiratory symptoms. Descriptive statistics and logistic regression analysis were applied. Results: Spirometry reports were acceptable in 1438 participants. The mean age of the participants was 55 (±10) years, and, 54% were female. The prevalence of GOLD-defined COPD was 8.5% (95% CI: 7.1-10.0) and based on the LLN threshold of 5.4% (95% CI: 4.2-6.6). The multivariate logistic regression showed that increasing age, low body mass index, illiterate, current or former smoker, and biomass fuel smoke increased the odds of COPD in both the definitions. Conclusion: COPD is highly prevalent at community level and often underdiagnosed. Strategies aiming at early diagnosis and treatment of COPD, especially for the elderly, illiterate, and reducing exposure to smoking and biomass fuel smoke and childhood lung infection could be effective.

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.

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 2019: The Global Blood Pressure Screening Campaign of the International Society of Hypertension.

Elevated blood pressure remains the single biggest risk factor contributing to the global burden of disease and mortality. May Measurement Month is an annual global screening campaign aiming to improve awareness of blood pressure at the individual and population level. Adults (≥18 years) recruited through opportunistic sampling were screened at sites in 92 countries during May 2019. Ideally, 3 blood pressure readings were measured for each participant, and data on lifestyle factors and comorbidities were collected. Hypertension was defined as a systolic blood pressure ≥140 mm Hg, or a diastolic blood pressure ≥90 mm Hg (mean of the second and third readings) or taking antihypertensive medication. When necessary, multiple imputation was used to estimate participants' mean blood pressure. Mixed-effects models were used to evaluate associations between blood pressure and participant characteristics. Of 1 508 130 screenees 482 273 (32.0%) had never had a blood pressure measurement before and 513 337 (34.0%) had hypertension, of whom 58.7% were aware, and 54.7% were on antihypertensive medication. Of those on medication, 57.8% were controlled to <140/90 mm Hg, and 28.9% to <130/80 mm Hg. Of all those with hypertension, 31.7% were controlled to <140/90 mm Hg, and 350 825 (23.3%) participants had untreated or inadequately treated hypertension. Of those taking antihypertensive medication, half were taking only a single drug, and 25% reported using aspirin inappropriately. This survey is the largest ever synchronized and standardized contemporary compilation of global blood pressure data. This campaign is needed as a temporary substitute for systematic blood pressure screening in many countries worldwide.

Study, Design, and Rationale of Noncommunicable Diseases in Nepal (NCD Nepal) Study: A Community-Based Prospective Epidemiological and Implementation Study in Rural Nepal.

BACKGROUND: Noncommunicable diseases (NCDs) are the leading causes of deaths globally. Currently, there are limited high-quality data on the epidemiology and usefulness of community-based screening and treatment of NCDs in low-to-middle-income countries (LMIC), like Nepal. We describe the protocol of a community-based, longitudinal epidemiological study of screening and management of NCDs in rural Nepal. METHODS: We organize monthly mobile health clinics to screen NCDs among 40- to 75-year-old residents from municipal subdivision wards 3, 4, 6, and 7 of Ghorahi submetropolitan city, Dang, Nepal (approximately 406 km west of the capital, Kathmandu). We estimate a total of 7052 eligible participants. After obtaining informed consent, trained personnel will collect sociodemographic and lifestyle data, medical, medication, and family history using validated questionnaires, plus anthropometric measures and capillary glucose levels. We will screen for hypertension, diabetes, obesity, dyslipidemia, tobacco and alcohol use, self-reported physical activity, dietary habits, cardiovascular disease, stroke, chronic lung disease, cancer, and chronic kidney disease. We will also check hemoglobin A1C, lipid panel, serum creatinine, sodium, potassium, urine dipstick, and urine albumin-to-creatinine ratio in high-risk participants. We will offer lifestyle counseling, pharmacotherapy or refer to higher level care, where appropriate; routinely follow participants with NCDs for continuity of care; and follow individuals without NCDs but with elevated glucose, prehypertension or other risk factors every year, and those without risk factors every 2 years. We will monitor participants in the community to reduce attrition and to track all-cause and disease-specific mortality. DISCUSSION: Understanding the community burden of NCDs in resource-limited setting and testing effectiveness of community-based screening and management of NCDs will provide insights to develop national policy to address NCD burden in LMIC like Nepal.

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.