Association between socioeconomic positions and overweight/obesity in rural Nepal.

Introduction: Obesity and its association with socioeconomic factors are well-established. However, the gradient of this relationship among rural populations in low- and middle-income countries such as Nepal is not fully understood. We sought to assess the association of socioeconomic factors (education, income, and employment status) with overweight/obesity. Methods: This cross-sectional study analyzed data from 260 participants aged ≥18 years and attending a rural health center in Dolakha, Nepal. Self-reported data on demographic, socioeconomic, and lifestyle factors was collected, and weight and height were measured for all the study participants. Those with a body mass index of <25 kg/m2 were regarded as non-overweight/obese and those with ≥25 kg/m2 were regarded as overweight/obese. Poisson regression models were used to estimate prevalence ratios and corresponding 95% confidence intervals to assess the association between socioeconomic factors and overweight/obesity. In addition, we assessed the effect of modification by age and gender to study the effect of socioeconomic factors on overweight/obesity. Results: The age-standardized prevalence of overweight/obesity was higher for individuals with higher education (23%) and high-income (32%) and those who were unemployed (42%). Compared to the low-income and no formal education groups, the prevalence ratio of overweight/ obesity was 1.69 and 2.27 times more for those belonging to the high-income and high school and above groups, respectively. No evidence of effect modification by gender and age was observed. Conclusions: Socioeconomic factors, education, and income were positively associated with overweight/obesity prevalence in rural Nepal. Further large studies using longitudinal settings are necessary to replicate our findings.

Measuring Environmental Justice in Real Time: A Pilot Study Using Digital Participatory Method in the Global South, Nepal.

Individuals' perceived fairness or justice beliefs are related to health in numerous ways. However, environment justice research to date has given little attention to perceived fairness of environmental exposures as experienced by individuals. This study explored the feasibility of a bottom-up digital participatory (via mobile phones) approach using ecological momentary assessment (EMA) to capture individuals' subjective experience of environmental exposures and the subjective evaluation of fairness by those affected in the context of Nepal. In total, 22 individuals participated in the study for 28 days. The results show high rates of study retention and adherence. Individuals' justice perception was found to vary within and between individuals, but also substantially depending on the types of environmental exposures. Nevertheless, the study indicates that uncertainties are inevitable as study design and timing may conflict participants' daily lives and priorities. The method allows us to consider multiple geographic contexts of individuals' everyday lives beyond residential environment. This pilot study proved the possibility to assess perceptions of environmental justice issues and demonstrated the necessary steps to using digital participatory method for assessing subjective perception of fairness of individuals.

Prioritizing Health-Sector Interventions for Noncommunicable Diseases and Injuries in Low- and Lower-Middle Income Countries: National NCDI Poverty Commissions.

Health sector priorities and interventions to prevent and manage noncommunicable diseases and injuries (NCDIs) in low- and lower-middle-income countries (LLMICs) have primarily adopted elements of the World Health Organization Global Action Plan for NCDs 2013-2020. However, there have been limited efforts in LLMICs to prioritize among conditions and health-sector interventions for NCDIs based on local epidemiology and contextually relevant risk factors or that incorporate the equitable distribution of health outcomes. The Lancet Commission on Reframing Noncommunicable Diseases and Injuries for the Poorest Billion supported national NCDI Poverty Commissions to define local NCDI epidemiology, determine an expanded set of priority NCDI conditions, and recommend cost-effective, equitable health-sector interventions. Fifteen national commissions and 1 state-level commission were established from 2016-2019. Six commissions completed the prioritization exercise and selected an average of 25 NCDI conditions; 15 conditions were selected by all commissions, including asthma, breast cancer, cervical cancer, diabetes mellitus type 1 and 2, epilepsy, hypertensive heart disease, intracerebral hemorrhage, ischemic heart disease, ischemic stroke, major depressive disorder, motor vehicle road injuries, rheumatic heart disease, sickle cell disorders, and subarachnoid hemorrhage. The commissions prioritized an average of 35 health-sector interventions based on cost-effectiveness, financial risk protection, and equity-enhancing rankings. The prioritized interventions were estimated to cost an additional US$4.70-US$13.70 per capita or approximately 9.7%-35.6% of current total health expenditure (0.6%-4.0% of current gross domestic product). Semistructured surveys and qualitative interviews of commission representatives demonstrated positive outcomes in several thematic areas, including understanding NCDIs of poverty, informing national planning and implementation of NCDI health-sector interventions, and improving governance and coordination for NCDIs. Overall, national NCDI Poverty Commissions provided a platform for evidence-based, locally driven determination of priorities within NCDIs.

Equity of geographical access to public health facilities in Nepal.

INTRODUCTION: Geographical accessibility is important against health equity, particularly for less developed countries as Nepal. It is important to identify the disparities in geographical accessibility to the three levels of public health facilities across Nepal, which has not been available. METHODS: Based on the up-to-date dataset of Nepal formal public health facilities in 2021, we measured the geographical accessibility by calculating the travel time to the nearest public health facility of three levels (ie, primary, secondary and tertiary) across Nepal at 1×1 km2 resolution under two travel modes: walking and motorised. Gini and Theil L index were used to assess the inequality. Potential locations of new facilities were identified for best improvement of geographical efficiency or equality. RESULTS: Both geographical accessibility and its equality were better under the motorised mode compared with the walking mode. If motorised transportation is available to everyone, the population coverage within 5 min to any public health facilities would be improved by 62.13%. The population-weighted average travel time was 17.91 min, 39.88 min and 69.23 min and the Gini coefficients 0.03, 0.18 and 0.42 to the nearest primary, secondary and tertiary facilities, respectively, under motorised mode. For primary facilities, low accessibility was found in the northern mountain belt; for secondary facilities, the accessibility decreased with increased distance from the district centres; and for tertiary facilities, low accessibility was found in most areas except the developed areas like zonal centres. The potential locations of new facilities differed for the three levels of facilities. Besides, the majority of inequalities of geographical accessibility were from within-province. CONCLUSION: The high-resolution geographical accessibility maps and the assessment of inequality provide valuable information for health resource allocation and health-related planning in Nepal.

Socioeconomic Status and Its Relation to Hypertension in Rural Nepal.

INTRODUCTION: Hypertension and its association with socioeconomic positions are well established. However, the gradient of these relationships and the mediating role of lifestyle factors among rural population in low- and middle-income countries such as Nepal are not fully understood. We sought to assess the association between socioeconomic factors (education, income, and employment status) and hypertension. Also, we assessed whether the effect of education and income level on hypertension was mediated by lifestyle factors. METHODS: This cross-sectional study was conducted among 260 participants aged ≥18 years attending a rural health center in Dolakha, Nepal. Self-reported data on demographic, socioeconomic, and lifestyle factors were collected, and blood pressure, weight, and height were measured for all study participants. Those with systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg or administrating high blood pressure-lowering medicines were regarded as hypertensives. Poisson regression models were used to estimate the prevalence ratios and corresponding 95% confidence intervals to assess the association between socioeconomic factors and hypertension. We explored mediation, using the medeff command in Stata for causal mediation analysis of nonlinear models. RESULTS: Of the 50 hypertensive participants, sixty percent were aware of their status. The age-standardized prevalence of hypertension was two times higher for those with higher education or high-income category. Compared to low-income and unemployed groups, the prevalence ratio of hypertension was 1.33 and 2.26 times more for those belonging to the high-income and employed groups, respectively. No evidence of mediation by lifestyle factors was observed between socioeconomic status and hypertension. CONCLUSIONS: Socioeconomic positions were positively associated with hypertension prevalence in rural Nepal. Further studies using longitudinal settings are necessary to validate our findings especially in low- and middle-income countries such as Nepal.

Health system gaps in cardiovascular disease prevention and management in Nepal.

BACKGROUND: Cardiovascular diseases (CVDs) are the leading cause of deaths and disability in Nepal. Health systems can improve CVD health outcomes even in resource-limited settings by directing efforts to meet critical system gaps. This study aimed to identify Nepal's health systems gaps to prevent and manage CVDs. METHODS: We formed a task force composed of the government and non-government representatives and assessed health system performance across six building blocks: governance, service delivery, human resources, medical products, information system, and financing in terms of equity, access, coverage, efficiency, quality, safety and sustainability. We reviewed 125 national health policies, plans, strategies, guidelines, reports and websites and conducted 52 key informant interviews. We grouped notes from desk review and transcripts' codes into equity, access, coverage, efficiency, quality, safety and sustainability of the health system. RESULTS: National health insurance covers less than 10% of the population; and more than 50% of the health spending is out of pocket. The efficiency of CVDs prevention and management programs in Nepal is affected by the shortage of human resources, weak monitoring and supervision, and inadequate engagement of stakeholders. There are policies and strategies in place to ensure quality of care, however their implementation and supervision is weak. The total budget on health has been increasing over the past five years. However, the funding on CVDs is negligible. CONCLUSION: Governments at the federal, provincial and local levels should prioritize CVDs care and partner with non-government organizations to improve preventive and curative CVDs services.

Hypertension Care Coordination and Feasibility of Involving Female Community Health Volunteers in Hypertension Management in Kavre District, Nepal: A Qualitative Study.

Background: Hypertension and related complications are major contributors to morbidity and mortality in Nepal. Community health workers have been proposed as promising health cadres to meet the growing healthcare demand for non-communicable disease management in other developing countries. Objective: We aimed to explore existing workflows, needs and challenges for hypertension care coordination and to assess the feasibility of establishing a Female Community Health Volunteer (FCHV)-based hypertension management program in Kavre, Nepal. Design: We conducted one focus group discussion with eight FCHVs and twenty-three in-depth interviews with four FCHVs not attending FGD, nine individuals with hypertension, six health workers, and four health officials in two village development committees of Kavre District, Nepal. Applied thematic analysis was performed using NVivo 12. Results: Health literacy related to hypertension was low among both community members and FCHVs. Delay in treatment initiation and loss to follow-up were common patterns despite anti-hypertensive medication compliance. Major health system-related barriers included underutilization of primary healthcare institutions, communication gaps and lack of grass-roots level educational campaigns. Community pharmacies, monthly health camps and increasing governmental attention to NCDs were favorable for improving hypertension management. This study also supports that FCHVs should be provided with adequate training and financial incentives to promote hypertension education, screening and referral in their catchments. Conclusions: Barriers and facilitators identified in this study provide important implications for future hypertension management in Nepal. We recommend hypertension education and screening across Nepal at a grass-root level through FCHVs. Providing professional training and proper financial incentives for FCHVs are warranted. Highlights: Health literacy related to hypertension was low among both community members and Female Community Health Volunteers in Nepal.Delay in treatment initiation and loss to follow-up were common despite relatively high anti-hypertensive medication compliance.Health system-related barriers in research sites included underutilization of primary healthcare institutions, communication gaps, and lack of grass-roots level educational campaigns.Female Community Health Volunteers should be provided with adequate training and financial incentives to promote hypertension management.

NUrse-led COntinuum of care for people with Diabetes and prediabetes (NUCOD) in Nepal: study protocol for a cluster randomized controlled trial.

BACKGROUND: The purpose of this study will be to improve diabetes prevention, access to care and advocacy through a novel cost-effective nurse-led continuum of care approach that incorporates diabetes prevention, awareness, screening and management for low-income settings, and furthermore utilizes the endeavor to advocate for establishing a standard diabetes program in Nepal. METHODS: We will conduct a two-arm, parallel group, stratified cluster randomized controlled trial of the NUrse-led COntinuum of care for people with Diabetes (N1 = 200) and prediabetes (N2 = 1036) (NUCOD) program, with primary care centers (9 outreach centers and 17 government health posts) as a unit of randomization. The NUCOD program will be delivered through the trained diabetes nurses in the community to the intervention group and the outcomes will be compared with the usual treatment group at 6 and 12 months of the intervention. The primary outcome will be the change in glycated hemoglobin (HbA1c) level among diabetes individuals and progression to type 2 diabetes among prediabetes individuals, and implementation outcomes measured using the RE-AIM (reach, effectiveness, adoption, implementation and maintenance) framework. Outcomes will be analyzed on an intention-to-treat basis. DISCUSSION: The results of this trial will provide information about the effectiveness of the NUCOD program in improving clinical outcomes for diabetes and prediabetes individuals, and implementation outcomes for the organization. The continuum of care model can be used for the prevention and management of diabetes and other noncommunicable diseases within and beyond Nepal with similar context. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04131257. Registered on 18 October 2019.

Probable Exit Strategy Against COVID-19 of Low Resource Country like Nepal: Open Floor Discussion.

Lockdown is essential for containing the spread of SARS-CoV-2. It is the best measure to maintain extreme social distancing which has been effective in controlling the infection and saving lives. But they are causing huge loss economically, disrupting social life and causing distress around the world. Reopening too quickly or too boldly without a goal-oriented strategy could mean a second wave of infection as fierce or even worse as the first. The fundamentals of the virus remain the same - one infected person will, without a lockdown pass it onto three others on average. The consequences of lifting the lockdown are unforeseeable and the stakes are high. Due to the different spectrum of severity with same strain of virus and uncertainty of post lockdown era, lifting the lockdown will be a trial and error approach. Nevertheless, at some point the lockdown has to be lifted. The strategic approach would be innumerable testing, investigations, strong contact tracing, isolation and follow-up. In a low-income country like Nepal, this will mean negotiating a tricky balance between terminating the spread of SARS-CoV-2, and allowing people to recover their livelihoods before they slip into extreme poverty and anguish.

Metabolic Syndrome and Related Factors in Chinese Children and Adolescents: Analysis from a Chinese National Study.

AIMS: Metabolic syndrome (MetS) has become a worldwide epidemic; however, few studies have described its status in Chinese children. This study aimed to estimate MetS status and its associations with geography, economic development, birth weight, and parental education of Chinese children and adolescents. METHODS: Data were derived from 15,045 participants aged 7-18 years across seven Chinese provinces. Physical measurement and blood tests were conducted to assess the five classical MetS components described by the International Diabetes Federation, including abdominal obesity (the essential component), high blood pressure, low high-density cholesterol (HDL-C), high triglyceride, and elevated fasting glucose (FG). Logistic regression was adopted to explore possible associations between MetS and other factors. RESULTS: Overall, MetS prevalence was 2.3%, higher in males (2.8% vs. 1.7% in females), northern regions (3.1%), more developed regions (2.9%), and older participants (aged 16-18 years) (P＜0.05 for all). Among the five MetS components, abdominal obesity and low HDL-C level were most prevalent (21.8% and 14.4%), and 35.9% of the participants had at least one component. In logistic regression, MetS itself did not correlate with birth weight or parental education. High birth weight was positively correlated with abdominal obesity (odds ratio, 1.48) butnegatively associated with elevated FG (odds ratio, 0.49). Concusions: MetS itself was not common in Chinese children and adolescents, whereas its certain components were far more prevalent. Children from North China, more-developed areas, and at an older age were more likely to develop MetS. Strategies designed to prevent pediatric MetS in China should focus on prevalent components as well as its geographic and economic development predilections.

Stakeholder Engagement in Planning the Design of a National Needs Assessment for Cardiovascular Disease Prevention and Management in Nepal.

BACKGROUND: There is growing support for stakeholder engagement in health research, but the actual impact of such engagement has not been well established. OBJECTIVES: This paper describes the stakeholder engagement process and evaluation during the planning of the national needs assessment for cardiovascular disease in Nepal. METHODS: We used personal and professional networks to identify relevant stakeholders within the 7Ps framework (Patients and the Public, Providers, Purchasers, Payers, Public Policy Makers and Policy Advocates, Product Makers and the Principal Investigators) to develop a plan for assessing cardiovascular health needs in Nepal. We consulted 40 stakeholders through 2 meetings in small groups and a workshop in a large group to develop the study methods, conceptual framework, and stakeholder engagement process. We interviewed 33 stakeholders to receive feedback on the stakeholder engagement process. RESULTS: We engaged 80% of the targeted stakeholders through small group discussions and a workshop. Three of 5 recommendations from the small group discussion were aimed at improving the stakeholder engagement process and 2 were aimed to improve the research methods. Eleven of 27 recommendations from the workshop aimed to improve the research methods, 4 aimed to improve stakeholder engagement, and 2 helped to expand the scope of dissemination. Ten were irrelevant or could not be incorporated due to resource limitation. Most stakeholders noted that the workshop provided an open platform for a multisectoral group to colearn from one another and share ideas. Others highlighted that the discussion generated insights to enhance research by incorporating expertise and ideas from different perspectives. The major challenges discussed were about committing the time for engagement. CONCLUSIONS: The stakeholder engagement process positively affected the design of our research. This study provides important insights for future researchers that aim to engage stakeholders in national-level assessment programs in the health care system in the context of Nepal.

Geographical heterogeneity and inequality of access to improved drinking water supply and sanitation in Nepal.

BACKGROUND: Per United Nations' Sustainable Development Goals, Nepal is aspiring to achieve universal and equitable access to safe and affordable drinking water and provide access to adequate and equitable sanitation for all by 2030. For these goals to be accomplished, it is important to understand the country's geographical heterogeneity and inequality of access to its drinking-water supply and sanitation (WSS) so that resource allocation and disease control can be optimized. We aimed 1) to estimate spatial heterogeneity of access to improved WSS among the overall Nepalese population at a high resolution; 2) to explore inequality within and between relevant Nepalese administrative levels; and 3) to identify the specific administrative areas in greatest need of policy attention. METHODS: We extracted cluster-sample data on the use of the water supply and sanitation that included 10,826 surveyed households from the 2011 Nepal Demographic and Health Survey, then used a Gaussian kernel density estimation with adaptive bandwidths to estimate the distribution of access to improved WSS conditions over a grid at 1 × 1 km. The Gini coefficient was calculated for the measurement of inequality in the distribution of improved WSS; the Theil L measure and Theil T index were applied to account for the decomposition of inequality. RESULTS: 57% of Nepalese had access to improved sanitation (range: 18.1% in Mahottari to 100% in Kathmandu) and 92% to drinking-water (range: 41.7% in Doti to 100% in Bara). The most unequal districts in Gini coefficient among improved sanitation were Saptari, Sindhuli, Banke, Bajura and Achham (range: 0.276 to 0.316); and Sankhuwasabha, Arghakhanchi, Gulmi, Bhojpur, Kathmandu (range: 0.110 to 0.137) among improved drinking-water. Both the Theil L and Theil T showed that within-province inequality was substantially greater than between-province inequality; while within-district inequality was less than between-district inequality. The inequality of several districts was higher than what is calculated by regression of the Gini coefficient and our estimates. CONCLUSIONS: This study showed considerable geographical heterogeneity and inequality not evidenced in previous national statistics. Our findings may be useful in prioritizing resources to reduce inequality and expand the coverage of improved water supply and sanitation in Nepal.

Barriers and facilitators of diabetes services in Nepal: a qualitative evaluation.

For the past three decades, the burden of diabetes in Nepal has been steadily increasing, with an estimated 3% annual increase since the year 2000. Although the burden is increasing, the methods of addressing the challenge have remained largely unchanged. This study sought to assess the current state of diabetes services provided by health facilities and to identify the major barriers that people with diabetes commonly face in Nepal. For this qualitative study, we selected five health facilities of varying levels and locations. At each site, we employed three unique methods: a process evaluation of the diabetes treatment and prevention services available, in-depth interviews with patients and focus group discussions with community members without diabetes. We used thematic analysis to analyse the data. Our findings were organized into the five categories of the Ecological Model: Individual, Interpersonal, Organizational, Community and Public Policy. Sub-optimal knowledge and behaviors of patients often contributed to poor diabetes management, especially related to diet control, physical activity and initiation of drug treatment. Social support was often lacking. Organizational challenges included health provider shortages, long wait times, high patient loads and minimal time available to spend with patients, often resulting in incomprehensive care. Public policy challenges include limited services in rural settings and financial burden. The scarcity of financial and human resources for health in Nepal often results in the inability of the current healthcare system to provide comprehensive prevention and management services for chronic diseases. A multilevel, coordinated approach is necessary to address these concerns. In the short-term, adding community-based supplementary solutions outside of the traditional hospital-based model could help to increase access to affordable services.

Telephone management of severe wasp stings in rural Nepal: a case report.

We describe a young woman from a rural village in Nepal who suffered multiple wasp and hornet stings. She collapsed and was managed by a telephone consultation between a village health worker and a hospital specialist. The patient recovered fully. Not only was the telephone consultation efficient in terms of cost savings from avoided hospital treatment, but it was also effective since, with conventional care, there was a strong possibility that the patient would have died on her way to hospital. This case illustrates the potential for telephone-delivered rural care and management in emergency situations.