Neighborhood environment and quality of life of older adults in eastern Nepal: findings from a cross-sectional study.

INTRODUCTION: Quality of life (QoL) is a subjective measure reflecting individuals' evaluations based on their personal goals and values. While global research shows the role of neighborhood factors like ethnic diversity and socio-cultural dynamics on QoL, these are unexplored in the Nepali context. Therefore, this study examined the relationship between neighborhood environment and QoL among Nepali older adults in eastern Nepal. METHODS: This cross-sectional study involved 847 non-institutionalized older adults (aged ≥ 60 years) from two districts in eastern Nepal. QoL was evaluated using the 13-item brief Older People's Quality of Life questionnaire, where a mean score of < 3 indicated low/poor QoL. The neighborhood environment, conceptualized across three domains (demographic, socio-cultural, and built environment), included ethnic diversity, connections with family, friends, and neighbors, cultural ties, residential stability, and rurality. Their association with QoL was examined using multivariable logistic regression. RESULTS: Around 20% of older adults reported poor QoL. Higher ethnic diversity (adjusted Odds Ratio [aOR] = 0.12, 95% confidence interval [CI]: 0.04-0.36), moderate contact with family and relatives (aOR = 0.26, CI: 0.11-0.61), and high contact with neighbors (aOR = 0.09, CI: 0.03-0.21) were associated with lower odds of poor QoL. Conversely, high contact with friends (aOR = 2.29, CI: 1.30-4.04) and unstable residence (OR = 6.25, CI: 2.03-19.23) increased the odds of poor QoL. Additionally, among the covariates, chronic disease, tobacco use, unemployment, and lack of education were also significantly associated with poor QoL. CONCLUSION: Overall, the demographic environment, socio-cultural factors, and the built environment of the neighborhood influence QoL. Therefore, diversifying the neighborhood's ethnic composition, promoting social connections such as frequent contact with family, relatives, and neighbors, and ensuring residential stability can enhance the QoL of older adults.

Gut microbiome transition across a lifestyle gradient in Himalaya.

The composition of the gut microbiome in industrialized populations differs from those living traditional lifestyles. However, it has been difficult to separate the contributions of human genetic and geographic factors from lifestyle. Whether shifts away from the foraging lifestyle that characterize much of humanity's past influence the gut microbiome, and to what degree, remains unclear. Here, we characterize the stool bacterial composition of four Himalayan populations to investigate how the gut community changes in response to shifts in traditional human lifestyles. These groups led seminomadic hunting-gathering lifestyles until transitioning to varying levels of agricultural dependence upon farming. The Tharu began farming 250-300 years ago, the Raute and Raji transitioned 30-40 years ago, and the Chepang retain many aspects of a foraging lifestyle. We assess the contributions of dietary and environmental factors on their gut-associated microbes and find that differences in the lifestyles of Himalayan foragers and farmers are strongly correlated with microbial community variation. Furthermore, the gut microbiomes of all four traditional Himalayan populations are distinct from that of the Americans, indicating that industrialization may further exacerbate differences in the gut community. The Chepang foragers harbor an elevated abundance of taxa associated with foragers around the world. Conversely, the gut microbiomes of the populations that have transitioned to farming are more similar to those of Americans, with agricultural dependence and several associated lifestyle and environmental factors correlating with the extent of microbiome divergence from the foraging population. The gut microbiomes of Raute and Raji reveal an intermediate state between the Chepang and Tharu, indicating that divergence from a stereotypical foraging microbiome can occur within a single generation. Our results also show that environmental factors such as drinking water source and solid cooking fuel are significantly associated with the gut microbiome. Despite the pronounced differences in gut bacterial composition across populations, we found little differences in alpha diversity across lifestyles. These findings in genetically similar populations living in the same geographical region establish the key role of lifestyle in determining human gut microbiome composition and point to the next challenging steps of determining how large-scale gut microbiome reconfiguration impacts human biology.

Knowledge, attitudes and practices of South Asian immigrants in developed countries regarding oral cancer: an integrative review.

BACKGROUND: Oral cancer is a growing problem worldwide, with high incidence rates in South Asian countries. With increasing numbers of South Asian immigrants in developed countries, a possible rise in oral cancer cases is expected given the high prevalence in their source countries and the continued oral cancer risk behaviours of immigrants. The aim of this review is to synthesise existing evidence regarding knowledge, attitudes and practices of South Asian immigrants in developed countries regarding oral cancer. METHODS: Five electronic databases were systematically searched to identify original, English language articles focussing on oral cancer risk knowledge, attitudes and practices of South Asian immigrants in developed countries. All studies that met the following inclusion criteria were included: conducted among South Asian immigrants in developed countries; explored at least one study outcome (knowledge or attitudes or practices); used either qualitative, quantitative or mixed methods. No restrictions were placed on the publication date, quality and setting of the study. RESULTS: A total of 16 studies involving 4772 participants were reviewed. These studies were mainly conducted in the USA, UK, Italy and New Zealand between 1994 and 2018. Findings were categorised into themes of oral cancer knowledge, attitudes and practices. General lack of oral cancer risk knowledge (43-76%) among participants was reported. More than 50% people were found engaging in one or more oral cancer risk practices like smoking, betel quid/pan/gutka chewing. Some of the participants perceived betel quid/pan/gutka chewing habit good for their health (12-43.6%). CONCLUSION: This review has shown that oral cancer risk practices are prevalent among South Asian immigrants who possess limited knowledge and unfavourable attitude in this area. Culturally appropriate targeted interventions and strategies are needed to raise oral cancer awareness among South Asian communities in developed countries.

Breastfeeding practices within the first six months of age in mid-western and eastern regions of Nepal: a health facility-based cross-sectional study.

BACKGROUND: The World Health Organization recommends initiation of breastfeeding within 1 hour of birth and exclusive breastfeeding up to 6 months of age. Infant feeding practices, including suboptimal breastfeeding practices, are associated with stunting. Rate of stunting was highest in the Mid-western region and lowest in the Eastern region of Nepal. This study aimed to assess the breastfeeding practices in these two regions, as well as to identify factors associated with partial breastfeeding. METHODS: We conducted a health facility-based cross-sectional study in the Mid-western and Eastern regions of Nepal from December 2017 to May 2018. Investigators administered a pre-tested questionnaire among consecutive 574 mother-infant dyads at different levels of health facilities. We dichotomized the breastfeeding pattern to partial breastfeeding and full (exclusive or predominant) breastfeeding. We conducted multivariable logistic regression to identify factors associated with partial breastfeeding within 6 months of age. RESULTS: There were 574 infants included in the study, all of which received at least some breastfeeding. Only 23.2% of infants were exclusively breastfed until 6 months, with 28.2% predominantly breastfed and 48.6% partially breastfed. Partial breastfeeding rate was 52.3% in the Mid-western region and 44.4% in the Eastern region. Breastfeeding was initiated within an hour from birth in 67.2% of infants. One-quarter of infants were given pre-lacteal feed, honey being the commonest. Knowledge of the recommended duration of exclusive breastfeeding was inadequate in 16, and 65% of mothers reported breastfeeding problems in the first 6 months. Firstborn and low birth weight infants had a significantly higher rate of partial breastfeeding. Partial breastfeeding was also higher when infants were not breastfed within 1 hour from birth, mothers reported having breastfeeding-related problems or had inadequate knowledge of the duration of exclusive breastfeeding. CONCLUSION: Nearly half of the infants were fully breastfed at 6 months of age in Nepal. The rate of partial breastfeeding was higher with inadequate knowledge on duration of exclusive breastfeeding or late initiation of breastfeeding or perceived breastfeeding problems. Hence, programs should address knowledge and practice gaps in breastfeeding practices, particularly among mothers of low birth weight and firstborn infants.

Hemoglobin levels and anemia evaluation among pregnant women in the remote and rural high lands of mid-western Nepal: a hospital based study.

BACKGROUND: Anemia though is a major risk factor for unfavorable pregnancy outcomes; no previous studies have yet described the hemoglobin (Hb) concentrations and anemia prevalence among pregnant women of remote mid western highlands of Nepal where the aggravating factors that increase the risk of anemia are very common. In addition, the physiological adaptive Hb rise to altitude was considered in the study while evaluating anemia. Thus, our primary objectives were to study the hemoglobin levels and prevalence of anemia among pregnant women of Jumla and its adjoining districts, and to assess the potential associations of hemoglobin and anemia with women's characteristics. METHODS: The study was conducted in 319 singleton term non-smoker pregnant women who visited to the teaching hospital for delivery. Their blood samples were tested for Hb and related sociodemographic information was collected. One-way analysis of variance (ANOVA) and independent t-test were used to compare the mean Hb levels. Multiple linear regression model and multiple logistic regression model were used to assess the association of Hb level and anemia with pregnant women's characteristics. The prevalence of anemia was calculated based on the altitude and pregnancy-adjusted Hb cut off value for anemia [{11+ adjustment factor (1.3)} gm./dl]. RESULTS: The overall mean hemoglobin concentration was (13.497 ± 1.64) gm/dl, ranging from 8 to 19.20 g/dl. The pregnant women Hb level showed significant association with their age (Coeff = 0.059; 95% CI: 0.011, 0.106; p = 0.015) and parity (Coeff = - 0.21; 95% CI: - 0.382, - 0.038; p = 0.017). The overall prevalence of anemia in the study population was 17.9% (57/319), which varied with age, parity and ethnicity. The disadvantaged Janajatis were more likely (OR = 4.615, 95% CI: 1.48, 14.35, p = 0.008) to have anemia compared to upper cast group. CONCLUSION: The mean Hb concentration was high and prevalence rate of anemia was low among pregnant women in karnali zone compared to average Nepali pregnant women. Women's age and parity were significant predictors of Hb level. Ethnicity, however, was associated with the occurrence of anemia.

Women's bargaining power and child feeding in Nepal: Linkages through nutrition information.

Women's intra-household bargaining power is an important determinant of child nutritional status, but there is limited evidence on how it relates to infant and young child feeding (IYCF) practices. We conducted a cross-sectional analysis using 2012 baseline data from the impact evaluation of Suaahara, a multisectoral programme in Nepal, focusing on households with children 0-23 months (n = 1787). We examined if women's bargaining power was related to exposure to IYCF information and if exposure to IYCF information was in turn associated with improved IYCF practices: early initiation of breastfeeding, exclusive breastfeeding, minimum meal frequency and dietary diversity. Bargaining power consisted of four domains: (i) ownership and control of assets; (ii) social participation; (iii) workload; and (iv) household decision-making control and were primarily measured using additive scales. We used generalized structural equation modelling to examine if exposure to IYCF information mediated the relationship between the bargaining domains and the four IYCF practices, separately. Social participation was positively associated with exposure to IYCF information (ß = 0.266, P < .001), which in turn was related to early initiation (ß = 0.241, P = .001). We obtained similar results for the relationship between social participation and dietary diversity. Decision-making control was directly associated with exclusive breastfeeding (ß = 0.350, P = .036). No domains were associated with minimum meal frequency. Different domains of women's bargaining power may relate to exposure to nutrition information and IYCF behaviours. Understanding specific domains of bargaining power is critical to developing interventions that can effectively address gender-related issues that underlie child nutrition outcomes.

Heat Stress Impacts on Cardiac Mortality in Nepali Migrant Workers in Qatar.

BACKGROUND: Qatar is a major destination country for Nepali migrant workers (NMWs; main age range 25-35 years) in the construction trade. These 120,000+ NMWs are exposed to various occupational hazards, including excessive heat, and 3-4 workers die each week. Our study aimed to show whether heat exposure caused deaths. METHODS: The worker population and mortality data of NMWs were retrieved from government institutions in Nepal. Heat exposure was assessed by monthly estimates of daily wet bulb globe temperature (WBGT), for in-shade conditions, from data collected at the Doha weather station from 2009 to 2017. Working in the sun during the middle of the day would add 2-3°C to the in-shade WBGT values. Daily deaths and their causes were obtained from the records of the Foreign Employment Promotion Board (FEPB) in Nepal, 2009-2017. Interviews with returning NMWs about their working conditions and the impacts of these conditions added information. The association between the heat variable and mortality was tested with standard statistical methods. RESULTS: The average annual death rate for NMWs in Qatar was 150 deaths/100,000. According to interviews, the majority of NMWs were found working in high WBGT (>31°C) each working day during hot months. The major cause of these deaths was recorded as cardiovascular problems (cardiovascular disease; CVD). Unfortunately, the causes of death were poorly described, and many deaths were listed as "cardiac arrest." We included these deaths in the broader category of "cardiovascular causes." There was a strong correlation between average monthly afternoon heat levels (WBGT) and CVD mortality. It is likely that a large proportion of these CVD deaths during hot months were due to serious heat stroke. Global studies show that approximately 15% of deaths in the age group 25-35 years are due to CVD causes. However, in this NMW population, the figures were 22% during the cool season and 58% during the hot season. CONCLUSIONS: The increased CVD mortality during hot periods is most likely due to severe heat stress. As many as 200 of the 571 CVD deaths during 2009-2017 could have been prevented if effective heat protection had been implemented as a part of local occupational health and safety programs. There is an urgent need for protection against such heat effects among NMWs, and rising temperatures from ongoing climate change are further increasing the health risks. Cause of death records for workers dying in hot conditions should be more precise than "cardiac arrest."

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).

Psychological morbidity in Nepali cross-border migrants in India: a community based cross-sectional study.

BACKGROUND: Since Nepali cross-border migrants can freely enter, work and stay in India, they are largely undocumented. The majority is involved in semi-skilled or unskilled jobs with limited labour rights and social security, a fact which predisposes them to psychological distress. We aimed to assess the prevalence of and factors associated with psychological morbidity among Nepali migrants upon their return from India. METHODS: A community based cross-sectional study was conducted in six districts of Nepal between September 2017 and February 2018. A total of 751 participants who had worked at least six months in India and returned to Nepal were interviewed from 24 randomly selected clusters. The General Health Questionnaire (GHQ)-12 was used to measure the psychological morbidity. Data were analysed using Poisson regression analysis. RESULTS: The majority was younger than 35 years (64.1%), male (96.7%), married (81.8%), had at least a primary education (66.6%), and belonged to Dalit, Janajati and religious minorities (53.7%). The prevalence of psychological morbidity was 13.5% (CI: 11.2-16.1%). Participants aged 45 years and above (adjusted prevalence ratio (aPR) = 2.74), from the Terai (aPR = 3.29), a religious minority (aPR = 3.64), who received no sick leave (aPR = 2.4), with existing health problems (aPR = 2.0) and having difficulty in accessing health care (aPR = 1.88) were more likely than others to exhibit a psychological morbidity. CONCLUSION: This study demonstrated that psychological morbidity was prevalent in the study participants and varied significantly with individual characteristics, work conditions and health. Multifaceted approaches including psychological counselling for returnees and protection of labour and health rights in the workplace are recommended to help reduce psychological morbidity.

Differences in prevalence of diabetes among immigrants to Canada from South Asian countries.

AIMS: The prevalence of diabetes is high in South Asians migrants. However, most previous research has studied South Asians as a collective whole. The aim of this study was to examine diabetes prevalence among immigrants from five South Asian countries living in Ontario, Canada. METHODS: Population-based health care and immigration databases were used to compare crude and adjusted diabetes prevalence on 1 January 2012 between immigrants to Ontario from different South Asians countries and the non-immigrant population. The prevalence of diabetes was also stratified by various sociodemographic factors. RESULTS: There were 431 765 first-generation South Asian immigrants; 68 440 (crude prevalence of 15.9%) of whom had a diagnosis of diabetes. After standardization for age, sex and income, diabetes prevalence was highest among South Asians from Sri Lanka (26.8%) followed by Bangladesh (22.2%), Pakistan (19.6%), India (18.3%) and Nepal (16.5%) in comparison with the non-immigrant population (11.6%). Increased prevalence was evident among men compared with women in each country of South Asia. Sociodemographic indicators including income, education, English proficiency and refugee status were associated with increased prevalence of diabetes in specific populations from South Asia. CONCLUSION: Striking differences in the prevalence of diabetes are evident among immigrants from different countries of South Asia. Awareness of the heterogeneity will help in recognizing priorities for the delivery of primary care for specific South Asian migrant populations with a range of settlement needs that also encompass social determinants of health.

A survey of health problems of Nepalese female migrants workers in the Middle-East and Malaysia.

BACKGROUND: Nepal is a key supplier of labour for countries in the Middle East, India and Malaysia. As many more men than women leave Nepal to work abroad, female migrant workers are a minority and very much under-researched. The aim of the study was to explore the health problems of female Nepalese migrants working in the Middle-East and Malaysia. METHODS: The study was conducted among 1010 women who were registered as migrant returnees at an organisation called Pourakhi Nepal. Secondary data were extracted from the records of the organisation covering the five-year period of July 2009 to July 2014. RESULTS: The 1010 participants were aged 14 to 51 with a median age of 31 (IQR: 38-25) years. A quarter of respondents (24%) reported having experienced health problems while in the country of employment. Fever, severe illness and accidents were the most common health problems reported. Working for unlimited periods of time and not being able to change one's place of work were independently associated with a greater likelihood of health problems. Logistic regression shows that migrant women who are illiterate [OR = 1.56, 95% CI: 1.02 to 2.38, p = 0.042], who had changed their workplace [OR = 1.63, 95% CI: 1.14 to 2.32, p = 0.007], who worked unlimited periods of time [OR = 1.64, 95% CI: 1.44 to 1.93, p = 0.020], had been severely maltreated or tortured in the workplace [OR = 1.84, 95% CI: 1.15 to 2.92, p = 0.010], were not being paid on time [OR = 2.38, 95% CI: 1.60 to 3.55, p = 0.038] and migrant women who had family problems at home [OR = 3.48, CI 95%: 1.22 to 9.98, p = 0.020] were significantly associated with health problems in their host country in the Middle East. CONCLUSION: Female migrant workers face various work-related health risks, which are often related to exploitation. The Government of Nepal should initiate awareness campaigns about health risks and rights in relation to health care services in the host countries. Recruiting agencies/employers should provide information on health risks and training for preventive measures. Raising awareness among female migrant workers can make a change in their working lives.

Suicide in Nepal: Qualitative Findings from a Modified Case-Series Psychological Autopsy Investigation of Suicide Deaths.

South Asia accounts for the majority of the world's suicide deaths, but typical psychiatric or surveillance-based research approaches are limited due to incomplete vital surveillance. Despite rich anthropological scholarship in the region, such work has not been used to address public health gaps in surveillance and nor inform prevention programs designed based on surveillance data. Our goal was to leverage useful strategies from both public health and anthropological approaches to provide rich narrative reconstructions of suicide events, told by family members or loved ones of the deceased, to further contextualize the circumstances of suicide. Specifically, we sought to untangle socio-cultural and structural patterns in suicide cases to better inform systems-level surveillance strategies and salient community-level suicide prevention opportunities. Using a mixed-methods psychological autopsy approach for cross-cultural research (MPAC) in both urban and rural Nepal, 39 suicide deaths were examined. MPAC was used to document antecedent events, characteristics of persons completing suicide, and perceived drivers of each suicide. Patterns across suicide cases include (1) lack of education (72% of cases); (2) life stressors such as poverty (54%), violence (61.1%), migrant labor (33% of men), and family disputes often resulting in isolation or shame (56.4%); (3) family histories of suicidal behavior (62%), with the majority involving an immediate family member; (4) gender differences: female suicides were attributed to hopeless situations, such as spousal abuse, with high degrees of social stigma. In contrast, male suicides were most commonly associated with drinking and resulted from internalized stigma, such as financial failure or an inability to provide for their family; (5) justifications for suicide were attributions to 'fate' and personality characteristics such as 'stubbornness' and 'egoism'; (5) power dynamics and available agency precluded some families from disputing the death as a suicide and also had implications for the condemnation or justification of particular suicides. Importantly, only 1 out of 3 men and 1 out of 6 women had any communication to family members about suicidal ideation prior to completion. Findings illustrate the importance of MPAC methods for capturing cultural narratives evoked after completed suicides, recognizing culturally salient warning signs, and identifying potential barriers to disclosure and justice seeking by families. These findings elucidate how suicide narratives are structured by family members and reveal public health opportunities for creating or supplementing mortality surveillance, intervening in higher risk populations such as survivors of suicide, and encouraging disclosure.

Ethnic Variations of Blood Groups in a Medical College of Eastern Nepal.

Background Red blood cells contain antigens in its membrane which are inherited according to Mendelian law. ABO and Rhesus blood group systems are considered the most important blood group systems for clinical procedures, blood transfusion, organ transplantation, anthropological study and medico-legal purposes. Determination of ABO and Rhesus blood groups and its frequency distribution in a multiethnic country like Nepal is important for effective management of blood banks, safe blood transfusion services. The trend of blood groups and its ethnic distributions in the eastern part of Nepal is still unknown. Objective To find the distribution of blood groups among the subjects of different ethnic groups of eastern Nepal. Method A cross-sectional perspective study was carried out among the subjects visited in the laboratory of Nobel Medical College, Biratnagar, Nepal for a period of one year from August 1, 2015 to July 30, 2016. Result The 11,960 subjects were included in the present study, among which 5012 were males and 6948 were females. The study revealed that in ABO system, blood group distribution was 34.80% O, 28.66% A, 27.66% B and 6.89% AB. With regard to Rh blood group system, Rhesus +ve was 96.79% and Rhesus -ve was 3.21%. O blood group dominant ethnic groups were Brahmin, Bhujel, Biswakarma, Shah, Gurung, Marwari, Magar, Mahato, Mandal, Newar, Sanyasi, Tamang, Terai Brahmin and Yadav. Similarly, blood group A dominant ethnic groups were Chhetri, Dhimal, Limbu, Rai and Muslim. Howerver, blood group B was dominant in ethnic groups, namely Biswakarma, Rajput, Satar and Tharu. Conclusion The frequency distribution pattern of ABO blood group was observed as O > A> B > AB and in Rhesus system, Rhesus +ve > Rhesus -ve. Variation in blood groups distribution was observed in various ethnic groups.

Evaluation of Measles-Mumps-Rubella Vaccination Among Newly Arrived Refugees.

OBJECTIVES: To assess US availability and use of measles-mumps-rubella (MMR) vaccination documentation for refugees vaccinated overseas. METHODS: We selected 1500 refugee records from 14 states from March 2013 through July 2015 to determine whether overseas vaccination records were available at the US postarrival health assessment and integrated into the Advisory Committee on Immunization Practices schedule. We assessed number of doses, dosing interval, and contraindications. RESULTS: Twelve of 14 (85.7%) states provided data on 1118 (74.5%) refugees. Overseas records for 972 (86.9%) refugees were available, most from the Centers for Disease Control and Prevention's Electronic Disease Notification system (66.9%). Most refugees (829; 85.3%) were assessed appropriately for MMR vaccination; 37 (3.8%) should have received MMR vaccine but did not; 106 (10.9%) did not need the MMR vaccine but were vaccinated. CONCLUSIONS: Overseas documentation was available at most clinics, and MMR vaccinations typically were given when needed. Further collaboration between refugee health clinics and state immunization information systems would improve accessibility of vaccination documentation.

High-risk human papillomavirus infection and abnormal cervical cytology among Nepali and Bhutanese refugee women living in eastern Nepal.

BACKGROUND: Cervical cancer is the leading cause of cancer morbidity and mortality among women in Nepal and Bhutan. Data on high-risk human papillomavirus (HR-HPV) infection and cervical abnormalities among Nepali and Bhutanese women are sparse. The objectives of this study were to assess and compare the prevalence of HR-HPV infection and cervical abnormalities among Nepali and Bhutanese women living in Jhapa District in eastern Nepal; and examine the risk factors for HR-HPV infection and cervical abnormalities in those women. METHODS: Study participants were recruited from a women's health camp organized by NFCC-International, a Nepal-based non-governmental organization, in 2014. Consenting participants were administered a demographic and health questionnaire and cervico-vaginal specimens collected. Both self-collected and clinician-collected cervico-vaginal specimens were tested for HR-HPV infection. Cytologic exam was performed on clinician-collected samples and cervical cytology results were categorized according to the Bethesda classification. A participant was classified as a Bhutanese if they were either born in Bhutan or currently lived in one of the United Nations administered Bhutanese refugee camps in Jhapa; otherwise, the participant was classified as a Nepali. RESULTS: Of the 647 study participants, 15.9% were Bhutanese women living in refugee camps and the overall age (± standard deviation) was 38.8 ± 8.2 years. The prevalence of HR-HPV infection was 8.9% and abnormal cervical cytology was 7.1% respectively, with no significant difference in HR-HPV positivity (p = 0.399) or abnormal cervical cytology (p = 0.698) between Nepali and Bhutanese women. Compared to women whose husbands had not migrated for employment, women whose husbands had migrated outside of the district had 3.30 times (95% Confidence Interval [CI]: 1.13-9.64) the odds of being HR-HPV positive and women whose husbands had migrated outside the country had 2.92 times (95% CI: 1.32-6.49) the odds of having abnormal cervical cytology. CONCLUSIONS: HR-HPV positivity and abnormal cervical cytology were similar among Nepali and Bhutanese women. Husbands migrating for employment within or outside the country was a significant risk factor for high-risk HPV infection and cervical cytology, indicating the important role spousal behavior may play in HR-HPV acquisition and cervical abnormalities among these women.

Maternal and neonatal service usage and determinants in fragile and conflict-affected situations: a systematic review of Asia and the Middle-East.

BACKGROUND: Fragile and conflict-affected situations (FCS) in Asia and the Middle-East contribute significantly to global maternal and neonatal deaths. This systematic review explored maternal and neonatal health (MNH) services usage and determinants in FCS in Asia and the Middle-East to inform policy on health service provision in these challenging settings. METHODS: This systematic review was conducted using a standardised protocol. Pubmed, Embase, Web of Science, and selected development agency websites were searched for studies meeting inclusion criteria. Studies were assessed for methodological quality using an adapted evaluation tool. Qualitative and quantitative data were synthesized and pooled odds ratios generated for meta-analysis of service-usage determinants. RESULTS: Of 18 eligible peer-reviewed studies, eight were from Nepal, four from Afghanistan, and two each from Iraq, Yemen, and the Palestinian Territories. Fragile situations provide limited evidence on emergency obstetric care, postnatal care, and newborn services. Usage of MNH services was low in all FCS, irrespective of economic growth level. Demand-side determinants of service-usage were transportation, female education, autonomy, health awareness, and ability-to-pay. Supply-side determinants included service availability and quality, existence of community health-workers, costs, and informal payments in health facilities. Evidence is particularly sparse on MNH in acute crises, and remains limited in fragile situations generally. CONCLUSIONS: Findings emphasize that poor MNH status in FCS is a leading contributor to the burden of maternal and neonatal ill-health in Asia and the Middle-East. Essential services for skilled birth attendance and emergency obstetric, newborn, and postnatal care require improvement in FCS. FCS require additional resources and policy attention to address the barriers to appropriate MNH care. Authors discuss the 'targeted policy approach for vulnerable groups' as a means of addressing MNH service usage inequities.

Perceived impact of Nepalese food and food culture in diabetes.

Consuming a healthy diet forms an important component of diabetes management; however, adhering to a healthy diet is challenging. Dietary behaviour is often guided by socio-cultural, environmental and emotional factors, and not necessarily by physical and nutritional needs. This study explored Nepalese patients' perceptions of the impact of diet, diet management requirement for diabetes and how Nepalese food culture in particular influenced diet management. Interviews were conducted with Nepalese participants with type 2 diabetes in Sydney and Kathmandu; and data was thematically analysed. Diet was recognized as a cause of, and a key treatment modality, in diabetes. Besides doctors, participants in Nepal received a large amount of dietary information from the community. Dietary changes formed a major component of lifestyle modifications adopted after diagnosis, and mostly consisted of removal of foods with added sugar and foods with high total sugar content from the diet, and a reduction in overall quantity of foods consumed. Perceived dietary restriction requirements created social and emotional discomfort to patients. Most participants perceived the Nepalese food culture as a barrier to effective diet management. Meals high in carbohydrates, limited food choices, and food preparation methods were identified as barriers, particularly in Nepal. In Australia, participants reported greater availability and easier access to appropriate food, and healthier cooking options. The socio-cultural aspects of food behaviour, mainly, food practices during social events were identified as significant barriers. Although diet was acknowledged as an important component of diabetes care, and most adopted changes in their diet post-diagnosis, effective and sustained changes were difficult to achieve. Future public health campaigns and education strategies should focus on improving diet knowledge, awareness of food options for diabetes, and effective dietary management.

Perceptions of Cervical Cancer Screening, Screening Behavior, and Post-Migration Living Difficulties Among Bhutanese-Nepali Refugee Women in the United States.

Bhutanese-Nepali refugees are one of the largest refugee groups to be resettled in the U.S. in the past decade. Cervical cancer is a leading cause of cancer disparity in this population, yet screening rates are suboptimal. Nepali-speaking interviewers administered a community health needs questionnaire to a convenience sample of Bhutanese-Nepali refugees in a Midwestern city between July to October of 2015. Descriptive statistics were used to describe socio-demographic characteristics, Pap smear beliefs, post-migration living difficulties, and screening status. Differences in Pap test uptake between groups were tested using t test and Chi square statistics. Of the 97 female participants, 44.3% reported ever having had a Pap smear. Screening rates were lowest among women who did not know English at all. Most women had positive perceptions of Pap smears (80%) and 44.4% had received a Pap test recommendation from their healthcare provider, family, or friends. Pap testing was significantly higher among those who had positive perceptions (58.3 vs. 11.1% for women of negative perception, p = 0.01) and those who had received a recommendation (87.5 vs. 18.6% for women who had no recommendations, p < 0.001). Significant predictors of having a Pap smear were having a healthcare provider/family/friends recommendation (OR 65.3, 95% CI 11.4-373.3) and greater number of post-migration living difficulties (OR 1.18, 95% CI 1.02-1.37). The results of this study have important implications for the development of cervical cancer prevention programs targeting Bhutanese-Nepali refugees. Providing cancer prevention interventions early in the resettlement process could impact Pap test uptake in this population.

The Assessment and Sustainable Management of Sickle Cell Disease in the Indigenous Tharu Population of Nepal.

Sickle cell disease is an inherited hemoglobinopathy associated with significant morbidity and mortality. Reports suggest a high sickle cell disease burden among the indigenous Tharu population of Nepal, who for centuries have inhabited regions where malaria is endemic. Unfortunately, health care resources are limited and often inaccessible for Tharu individuals suffering from sickle cell disease. We conducted a large-scale screening effort to estimate the prevalence of Hb S (HBB: c.20A>T) among the Tharu population and delivered community-based education sessions to increase sickle cell disease awareness. A total of 2899 Tharu individuals aged 6 months to 40 years in the rural district of Dang in Western Nepal were screened using a sickling test, of whom, 271 [9.3%; 95% confidence interval (95% CI): 8.3-10.4%] screened positive for Hb S. Those who screened positive were offered diagnostic gel electrophoresis testing. Of the 133 individuals who underwent diagnostic testing, 75.9% (n = 101) were confirmed to be Hb AS heterozygotes, 4.5% (n = 6) were confirmed to be Hb SS homozygotes and 19.5% (n = 26) were false positives. These findings support a large burden of sickle cell disease among the Tharu population and highlight the importance of appropriate resource allocation and management. With a positive predictive value of 80.0% (95% CI: 73.0-87.0%), the sickling test in conjunction with raising local sickle cell disease awareness may be a simple and sustainable way to promote access to health resources.