If headache has any association with hypertension, it is negative. Evidence from a population-based study in Nepal.

BACKGROUND: Hypertension and headache disorders are major contributors to public ill health, linked by a long-standing but questionable belief that hypertension is a conspicuous cause of headache. In Nepal, where hypertension is common and often untreated, we assessed the substance of this belief, hypothesising that, should hypertension be a significant cause of headache, a clear positive association between these disorders would exist. METHODS: In a cross-sectional, nationwide study, trained health workers conducted face-to-face structured interviews, during unannounced home visits, with a representative sample of the Nepalese adult population (18-65 years). They applied standard diagnostic criteria for headache disorders and measured blood pressure digitally. Hypertension was defined as systolic pressure ≥140 and/or diastolic ≥90 mm Hg. RESULTS: Of 2,100 participants (59.0% female, mean age 36.4 ± 12.8 years), 317 (15.1%) had hypertension (41.0% female) and 1,794 (85.4%) had headache (61.6% female; 728 migraine, 863 tension-type headache, 161 headache on ≥15 days/month [mutually exclusive diagnoses]; 42 unclassified headaches).All headache collectively was less prevalent among hypertension cases (78.9%) than non-cases (86.6%; p = 0.001). A negative association between hypertension and all headache was demonstrated in bivariate analysis (odds ratio: 0.6 [95% Confidence interval: 0.4-0.8]; p < 0.001), but did not maintain significance in multivariate regression analysis (adjusted odds ratio: 0.8 [95% Confidence interval: 0.5-1.1]; p = 0.09). The findings were reflected, without significance, in each headache type. CONCLUSIONS: If any association exists between hypertension and headache disorders, it is negative. From the public-health perspective, headache disorders and hypertension are unrelated entities: they need distinct policies and programs for prevention, control and management.

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.

The burden of chronic respiratory diseases in adults in Nepal: A systematic review.

While chronic lung disease causes substantial global morbidity and mortality, global estimates have primarily been based on broad assumptions. Specific country data from low-income countries such as Nepal are limited. This review assessed primary evidence on chronic respiratory disease burden among adults in Nepal. A systematic search was performed in June 2019 (updated May 2020) for studies through nine databases. High levels of heterogeneity deemed a narrative synthesis appropriate. Among 27 eligible studies identified, most were low-moderate quality with cross-sectional and retrospective study design. Chronic lung diseases identified were chronic obstructive pulmonary disease (COPD), asthma, bronchiectasis and restrictive lung diseases. Studies were categorised as: (i) community-based, (ii) hospital-based and (iii) comorbidity-related and disease burden. Reported disease prevalence varied widely (COPD, 1.67-14.3%; asthma, 4.2-8.9%). The prevalence of airflow obstruction was higher among rural dwellers (15.8%) and those exposed to household air pollution from domestic biomass burning as opposed to liquid petroleum gas users (Odds Ratio: 2.06). Several comorbidities, including hypertension and diabetes mellitus added to the disease burden. The review shows limited literature on lung disease burden in Nepal. Publications varied in terms of overall quality. Good quality research studies with prospective cohorts related to respiratory conditions are required.

Nutritional and health status of children 15 months after integrated school garden, nutrition, and water, sanitation and hygiene interventions: a cluster-randomised controlled trial in Nepal.

BACKGROUND: It has been suggested that specific interventions delivered through the education sector in low- and middle-income countries might improve children's health and wellbeing. This cluster-randomised controlled trial aimed to evaluate the effects of a school garden programme and complementary nutrition, and water, sanitation and hygiene (WASH) interventions on children's health and nutritional status in two districts of Nepal. METHODS: The trial included 682 children aged 8-17 years from 12 schools. The schools were randomly allocated to one of three interventions: (a) school garden programme (SG; 4 schools, n = 172 children); (b) school garden programme with complementary WASH, health and nutrition interventions (SG+; 4 schools, n = 197 children); and (c) no specific intervention (control; 4 schools, n = 313 children). The same field and laboratory procedures were employed at the baseline (March 2015) and end-line (June 2016) surveys. Questionnaires were administered to evaluate WASH conditions at schools and households. Water quality was assessed using a Delagua kit. Dietary intake was determined using food frequency and 24-h recall questionnaire. Haemoglobin levels were measured using HemoCue digital device and used as a proxy for anaemia. Stool samples were subjected to a suite of copro-microscopic diagnostic methods for detection of intestinal protozoa and helminths. The changes in key indicators between the baseline and end-line surveys were analysed by mixed logistic and linear regression models. RESULTS: Stunting was slightly lowered in SG+ (19.9 to 18.3%; p = 0.92) and in the control (19.7 to 18.9%). Anaemia slightly decreased in SG+ (33.0 to 32.0%; p < 0.01) and markedly increased in the control (22.7 to 41.3%; p < 0.01), a minor decline was found in the control (43.9 to 42.4%). Handwashing with soap before eating strongly increased in SG+ (from 74.1 to 96.9%; p = 0.01, compared to control where only a slight increase was observed from 78.0 to 84.0%). A similar observation was made for handwashing after defecation (increase from 77.2 to 99.0% in SG+ versus 78.0 to 91.9% in control, p = 0.15). CONCLUSIONS: An integrated intervention consisting of school garden, WASH, nutrition and health components (SG+) increased children's fruit and vegetable consumption, decreased intestinal parasitic infections and improved hygiene behaviours. TRIAL REGISTRATION: ISRCTN17968589 (date assigned: 17 July 2015).

Cross-Cultural Adaptation and Validation of the Nepali Version of the Pelvic Girdle Questionnaire.

OBJECTIVE: The purpose of this study was to translate, cross-culturally adapt, and assess the reliability and validity of the Pelvic Girdle Questionnaire (PGQ) in pregnant Nepalese women. METHODS: The cross-cultural adaptation process was conducted according to the Guillemin guidelines. Reliability and validity were assessed using cross-sectional design. The participants responded to questionnaires of sociodemographics, the Nepali version of the PGQ, the Oswestry Disability Index, the Patient-Specific Functional Scale, the 5-item version of the Edinburgh Depression Scale, and the Numerical Pain Rating Scale. The internal consistency was assessed with Cronbach's alpha. The test-retest reliability was calculated using the intraclass correlation coefficient and smallest detectable change. Construct validity was assessed by testing 9 a priori hypotheses that examine correlations between the PGQ activity and symptom subscales, and also among the PGQ subscales and Oswestry Disability Index, Numerical Pain Rating Scale, Patient-Specific Functional Scale, and 5-item version of the Edinburgh Depression Scale. Spearman and Pearson's correlation were used to assess the correlations. RESULTS: A sample of 111 pregnant women were included in the study. The Cronbach's alpha for the Nepali version of the total PGQ was good (α = 0.83), and the test-retest reliability was acceptable (ICC2.1, 0.72) with a measurement error of SDC95% 18.6 points. Seven of the 9 hypotheses found support, which confirms acceptable construct validity of the Nepali PGQ. CONCLUSION: The Nepali version of the PGQ is a reliable and valid tool for assessing pelvic girdle pain in pregnant Nepalese women.

Prevalence of geriatric depression in the Kavre district, Nepal: Findings from a cross sectional community survey.

BACKGROUND: The increasing elderly population worldwide is likely to increase mental health problems such as geriatric depression, which has mostly been studied in high-income countries. Similar studies are scarce in low-and-middle-income-countries like Nepal. METHODS: A cross-sectional, population-based, door-to-door survey was conducted in randomly selected rural and urban population clusters of the Kavre district, Nepal. Trained nurses (field interviewers) administered structured questionnaires that included a validated Nepali version of the Geriatric Depression Scale short form (GDS-15) for identifying geriatric depression among the elderly (≥60 years) participants (N = 460). Those scoring ≥6 on GDS-15 were considered depressed. Logistic regression analysis explored the associations of geriatric depression with regard to socio-demographic information, life style, family support and physical well-being. RESULTS: Of the total 460 selected elderly participants, 439 (95.4%) took part in the study. More than half of them were females (54.2%). The mean age was 70.9 (± 8.6) years. Approximately half (50.6%) were rural inhabitants, the majority (86.1%) were illiterate, and about three-fifths (60.1%) were living with their spouses. The gender-and-age adjusted prevalence of geriatric depression was 53.1%. Geriatric depression was significantly associated with rural habitation (AOR 1.6), illiteracy (AOR 2.1), limited time provided by families (AOR 1.8), and exposure to verbal and/or physical abuse (AOR 2.6). CONCLUSION: Geriatric depression is highly prevalent in Kavre, Nepal. The findings call for urgent prioritization of delivery of elderly mental health care services in the country.

High Rates of Enteric Fever Diagnosis and Lower Burden of Culture-Confirmed Disease in Peri-urban and Rural Nepal.

Background: In South Asia, data on enteric fever are sparse outside of urban areas. We characterized enteric fever diagnosis patterns and the burden of culture-confirmed cases in peri-urban and rural Nepal. Methods: We used national reports to estimate enteric fever diagnosis rates over 20 years (1994-2014) and conducted a prospective study of patients presenting with a >72-hour history of fever to 4 peri-urban and rural healthcare facilities (during August 2013-June 2016). We compared clinical characteristics of patients with culture-confirmed Salmonella Typhi or Paratyphi infection to those of patients without enteric fever. We used generalized additive models with logistic link functions to evaluate associations of age and population density with culture positivity. Results: National rates of enteric fever diagnosis were high, reaching 18.8 cases per 1000 during 2009-2014. We enrolled 4309 participants with acute febrile illness. Among those with a provisional clinical diagnosis, 55% (1334 of 2412) received a diagnosis of enteric fever; however, only 4.1% of these had culture-confirmed typhoidal Salmonella infection. Culture positivity was highest among young adults and was strongly associated with higher population density (P < .001). Conclusions: Enteric fever diagnosis rates were very high throughout Nepal, but in rural settings, few patients had culture-confirmed disease. Expanded surveillance may inform local enteric fever treatment and prevention strategies.

Reproducibility and relative validity of food group intake in a food frequency questionnaire developed for Nepalese diet.

We developed a food frequency questionnaire (FFQ) designed to measure the dietary practices of adult Nepalese. The present study examined the validity and reproducibility of the FFQ. To evaluate the reproducibility of the FFQ, 116 subjects completed two 115-item FFQ across a four-month interval. Six 24-h dietary recalls were collected (1 each month) to assess the validity of the FFQ. Seven major food groups and 23 subgroups were clustered from the FFQ based on macronutrient composition. Spearman correlation coefficients evaluating reproducibility for all food groups were greater than 0.5, with the exceptions of oil. The correlations varied from 0.41 (oil) to 0.81 (vegetables). All crude spearman coefficients for validity were greater than 0.5 except for dairy products, pizzas/pastas and sausage/burgers. The FFQ was found to be reliable and valid for ranking the intake of food groups for Nepalese dietary intake.

Estimating prevalence and burden of major disorders of the brain in Nepal: cultural, geographic, logistic and philosophical issues of methodology.

BACKGROUND: Headache, anxiety and depression are major disorders of the brain in terms of their prevalence and the burdens and costs they impose on society. Nationwide population-based studies of these disorders are necessary to inform health policy but, in research-naïve and resource-poor countries such as Nepal, a host of methodological problems are encountered: cultural, geographic, logistic and philosophical. METHODS: Expert consensus was sought among researchers from different professional and cultural backgrounds in planning and conceptualizing an epidemiological study and adapting established methods to the special situation and circumstances of Nepal. RESULTS: The methodological problems were sorted into different themes: study design; climate; geography, access and transport; sociocultural issues; safety of interviewers. Each of these was dealt with separately, and their inter-relationships explored, in finding solutions that were sometimes pragmatic. A cross-sectional questionnaire-based study, with teams of interviewers visiting households across the three physiographic divisions (with extremes in altitude) in each of the five development regions of the country, would enable national sampling with sociocultural representativeness. However, the study instruments and interviews would be in Nepali only. Transport and access challenges were considerable, and their solutions combined travel by air, bus, river and foot, with allowances for rain-damaged roads, collapsed bridges and cancelled scheduled flights. The monsoon would render many routes impassable, and therefore set an absolute time limitation. Engaging participants willingly in the enquiry would be the key to success, and several tactics would be employed to enhance the success of this, most importantly enlisting the support of local community volunteers in each study site. CONCLUSION: Anticipating problems in advance of investing substantial resources in a large nationwide epidemiological study in Nepal was a sensible precaution. The difficulties could be resolved or circumvented without expected compromise in scientific quality. Expert consensus was an effective means of achieving this outcome.

Estimating the prevalence and burden of major disorders of the brain in Nepal: methodology of a nationwide population-based study.

BACKGROUND: The major disorders of the brain (MDBs), in terms of their prevalence and the burdens of ill health, disability and financial cost that they impose on individuals and society, are headache, depression and anxiety. No population-based studies have been conducted in Nepal. AIM: Our purpose was to assess the prevalence and burden attributable to MDBs in Nepal in order to inform health policy. Here we report the methodology. METHODS: The unusual sociocultural diversity and extreme geographical variation of the country required adaptation of standard methodology. We ran pre-pilot and pilot studies before embarking on the main study. The study design was cross-sectional. The population of interest were adults aged 18-65 years who were Nepali speaking and living in Nepal. We selected, employed and trained groups of interviewers to visit randomly selected households by cold-calling. Households were selected from 15 representative districts out of 75 in the country through multistage cluster sampling. One participant was selected randomly from each household. We used structured questionnaires (the HARDSHIP questionnaire, Hospital Anxiety and Depression Scale, and Eysenck Personality Questionnaire -Neuroticism), culturally adapted and translated into Nepali. We recorded blood pressure, weight, height and waist circumference, and altitude of each household. We implemented various quality-assurances measures. RESULTS: We completed the survey in one month, prior to onset of the monsoon. Among 2,210 selected households, all were contacted, 2,109 were eligible for the study and, from these, 2,100 adults participated. The participation rate was 99.6%. CONCLUSION: Standard methodology was successfully applied in Nepal, with some adaptations. The sociocultural and extraordinary geographic diversity were challenging, but did not require us to compromise the scientific quality of the study.

Effect of knowledge and perception on adherence to iron and folate supplementation during pregnancy in Kathmandu, Nepal.

BACKGROUND: Adherence to iron and folate supplementation during pregnancy is considered key to prevention and control of iron deficiency anemia. Nepal-like other developing countries-faces problems with adherence vis-a-vis iron/folate supplementation. OBJECTIVE: This descriptive survey aimed to assess the effect ofknowledge and perception ofpregnant women on adherence to iron/folate supplementation in Kathmandu, Nepal. MATERIAL AND METHOD: The present study was conducted in Paropakar Maternity and Womens' Hospital in Kathmandu. Systematic random sampling was used to select 406 persons who were either given a self-administered questionnaire or interviewed. RESULTS: 73.2% of the respondents showed good adherence. Bivariate analysis revealed significant associations between adherence and both knowledge and perception (p<0.05), but through multiple linear regression analysis only perception was found to be statistically associated with adherence (p<0.05). Further multivariate analysis demonstrated that the most important predictors of adherence were: perception of side effects, availability, forgetfulness and reminders from family. CONCLUSION: Adherence to iron/folate supplementation among women during pregnancy needs continuous improvement by minimizing the perception of constraints (viz., side-effects and forgetfulness) and, enhancing availability andfamily support.

Exploring ways to support patients with noncommunicable diseases: A pilot study in Nepal during the COVID-19 pandemic.

Global healthcare systems have faced unprecedented strain due to the COVID-19 pandemic, with a profound impact on individuals with non-communicable diseases (NCDs), a scenario particularly pronounced in low-income countries like Nepal. This study aimed to understand the experiences of and challenges faced by patients with NCDs in Nepal during the pandemic, focusing on healthcare service availability and identifying factors affecting healthcare use, with the goal of being prepared for future emergencies. This study utilized a telephonic survey of 102 patients with NCDs and 10 qualitative interviews with healthcare providers in the Kavrepalanchok and Nuwakot districts of Nepal. We used mixed methods, with both qualitative and quantitative approaches. Specifically, multiple correspondence analysis, hierarchical cluster analysis, and classification tree analysis were used as exploratory methods. The study revealed that while 69.6% of the participants reported no difficulty in obtaining medication, other questions revealed that 58.8% experienced challenges in accessing routine medical care. Major barriers, such as fear of infection, unavailability of medicine in rural areas, and lack of transportation, were found through the qualitative interviews. Meanwhile, participants identified innovative strategies, such as telemedicine and community-based awareness programs, as potential facilitators for addressing barriers that arise during pandemic situations such as COVID-19. The COVID-19 pandemic exacerbated challenges in accessing healthcare services for patients with NCDs in Nepal. Our findings suggest the need to design and implement telemedicine services for patients with NCDs, as well as community-based programs that aim to improve health literacy, encourage healthy behavior, prevent development of NCDs, and ensure continuity of care during such crises, especially in countries with limited resources.

Community-based lifestyle intervention for diabetes (Co-LID study) management rural Nepal: study protocol for a clustered randomized controlled trial.

BACKGROUND: Type 2 diabetes mellitus (T2DM) has increased globally; with a disproportionate burden in South and Southeast Asian countries, including Nepal. There is an urgent need for clinically and cost-effective culturally adapted T2DM management programs. In this study, we aim to assess the effectiveness of community based culturally appropriate lifestyle intervention in improving the management and care of people with T2DM. METHODS: We will conduct a cluster randomized control trial to evaluate the effectiveness of community based culturally appropriate lifestyle intervention in improving T2DM outcomes. The trial will be conducted in 30 randomly selected healthcare facilities from two purposively selected districts (Kavrepalanchowk and Nuwakot districts) of Bagmati province, Nepal. The selected healthcare facilities are being randomized into 15 interventions (n = 15) and usual care (n = 15) groups. Those in the intervention will receive group-based 12 an hour-long fortnightly session delivered over 6 months period. The intervention package includes 12 planned modules related to diabetes care, ongoing support, supervision and monitoring, follow-up from the trained community health workers, and educational materials on diabetes self-management. The participants in the usual care groups will receive pictorial brochure on diabetes management and they will continue receiving the usual care available from the local health facilities. The primary outcome is HbA1c level, and the secondary outcomes include quality of life, health care utilization, and practice of self-care behaviour, depression, oral health quality of life, and economic assessment of the intervention. Two points measurements will be collected by the trained research assistants at baseline and at the end of the intervention. DISCUSSION: This study will provide tested approaches for culturally adapting T2DM interventions in the Nepalese context. The findings will also have practice and policy implications for T2DM prevention and management in Nepal. TRIAL REGISTRATION: Australia and New Zealand Clinical Trial Registry (ACTRN12621000531819). Registered on May 6, 2021.

Analyzing the Implementation of Policies and Guidelines for the Prevention and Management of Type 2 Diabetes at Primary Health Care Level in Nepal.

BACKGROUND: Nepal, in recent years, is witnessing an increasing problem of type 2 diabetes that has resulted significant premature deaths and disability. Prevention and management of non-communicable diseases (NCDs) including diabetes have been prioritized in the national policies and guidelines of the Nepal Government. However, research looking at the overview of the implementation of the existing policies and guidelines for diabetes prevention and control is scarce. Hence, this study reviewed diabetes related existing policies and its implementation process at the primary health care level in Nepal. METHODS: This study involved two phases: Phase I: situation analyses through review of documents and Phase II: qualitative exploratory study. In phase I, four databases (Medline, Web of Science, Embase and PubMed) were systematically searched using key search terms related to diabetes care and policies between January 2000 and June 2021. Also, relevant gray literature was reviewed to understand the trajectory of policy development and its translation with regards to diabetes prevention and management at primary health care level in Nepal. Following the phase I, we conducted in-depth interviews (IDI) and key informant interviews (KII) with health care providers, policy makers, and managers (IDI = 13, and KII = 7) at peripheral and central levels in Kavrepalanchowk and Nuwakot districts of Nepal. The in-depth interviews were audio recorded, transcribed, and coded. The triangulation of data from document review and interviews was done and presented in themes. RESULTS: Four key themes were identified through triangulating findings from the document review and interviews including (i) limited implementation of policies into practices; (ii) lack of coordination among the different levels of service providers; (iii) lack of trained human resources for health and inadequate quality services at the primary health care level, and (iv) inadequate access and utilization of diabetes care services at primary health care level. Specifically, this study identified some key pertinent challenges to the implementation of policies and programs including inadequate resources, limited engagement of stakeholders in service design and delivery, lack of trained health care providers, lack of financial resources to strengthen peripheral health services, fragmented health governance, and weak reporting and monitoring systems. CONCLUSION: This study revealed that the policies, plans, and strategies for prevention and management of NCDs in Nepal recognized the importance of diabetes prevention and control. However, a major gap remains with adequate and lack of clarity in terms of implementation of available policies, plans, strategies, and programs to address the problem of diabetes. We suggest the need for multisectoral approach (engaging both health and non-health sectors) at central as well as peripheral levels to strengthen the policies implementation process, building capacity of health care providers, ensuring adequate financial and non-financial resources, and improving quality of services at primary health care levels.

Diabetes Prevalence and Associated Risk Factors among Women in a Rural District of Nepal Using HbA1c as a Diagnostic Tool: A Population-Based Study.

Given the scarcity of data on diabetes prevalence and associated risk factors among women in rural Nepal, we aimed to examine this, using glycated hemoglobin (HbA1c) as a diagnostic tool. A cross-sectional survey addressing reproductive health and non-communicable diseases was conducted in 2012-2013 among non-pregnant, married women in Bolde, a rural district of Nepal. HbA1c ≥ 6.5% (48 mmol/mol) was used as diagnostic criterion for diabetes, a cut-off of 7.0% (53 mmol/mol) was used to increase the specificity. HbA1c was measured in 757 women (17-86 years). The prevalence of diabetes and prediabetes was 13.5% and 38.5%, respectively. When using 7.0% as a cut-off, the prevalence of diabetes was 5.8%. Aging, intake of instant noodles and milk and vegetarian food (ns) were associated with increased risk for diabetes. Waist circumference was higher among women with diabetes, although not significant. The women were uneducated (87.6%), and only 12% had heard about diabetes. In conclusion, we observed a higher prevalence of diabetes and prediabetes than anticipated among rural, Nepalese women. The increased risk was mainly attributed to dietary factors. In contrast to most previous studies in Nepal, we used HbA1c as diagnostic criterion.

Vitamin D Status among Women in a Rural District of Nepal: Determinants and Association with Metabolic Profile-A Population-Based Study.

Hypovitaminosis D is prevalent worldwide, and especially in South-Asia. According to the Institute of Medicine (IOM), 25(OH)D levels below 30 nmol/L are defined as vitamin D deficiency (VDD) and levels between 30−50 nmol/L as insufficiency (VDI). Besides its role in calcium homeostasis, it has been postulated that vitamin D is involved in metabolic syndrome. Given the scarcity of data on vitamin D status in Nepal, we aimed to examine the prevalence of VDD and VDI, as well as the determinants and association with metabolic parameters (lipids, HbA1c), in a cohort of women in rural Nepal. Altogether, 733 women 48.5 ± 11.7 years of age were included. VDD and VDI were observed in 6.3 and 42.4% of the participants, respectively, and the prevalence increased by age. Women reporting intake of milk and eggs > 2 times weekly had higher 25(OH)D levels than those reporting intake < 2 times weekly. Women with vitamin D levels < 50 nmol/L displayed higher levels of cholesterol, LDL-cholesterol, triglycerides, and HbA1c. Additionally, a regression analysis showed a significant association between hypovitaminosis D, dyslipidemia, and HbA1c elevation. In conclusion, VDI was prevalent and increased with age. Milk and egg intake > 2 times weekly seemed to decrease the risk of VDI. Moreover, hypovitaminosis D was associated with an adverse metabolic profile.

Perception of obesity and overweight among adults living in suburban Nepal: a qualitative study.

OBJECTIVE: To explore the perception of obesity and overweight among Nepalese adults living in a suburban community. DESIGN: A qualitative study composed of focus group discussion (FGD) and in-depth interview (IDI). SETTING: Community and healthcare facilities in Dhulikhel, Nepal. PARTICIPANTS: Four FGDs were conducted with community members (n=22) and four IDIs were conducted with healthcare providers (HCPs). RESULTS: Obesity is a rising problem in this suburban community. Participants had inadequate knowledge regarding the consequences of obesity, and they perceived overweight as normal, healthy and attractive. The participants above 40 years of age did not perceive themselves to be overweight or obese. Despite participants' awareness of the importance of diet control and exercise to prevent obesity, these were not translated into practice. CONCLUSIONS: This study provided insight into perceptions of obesity in a suburban Dhulikhel community through both community members' and HCPs' perspective. Misconceptions and inadequate knowledge of obesity among people in this community indicate the need for health education and intervention programme to increase health awareness and preventive practices.

Cardiovascular disease trends in Nepal - An analysis of global burden of disease data 2017.

Cardiovascular diseases (CVDs) are the leading cause of disease burden globally, disproportionately affecting low and middle-income countries. The continued scarcity of literature on CVDs burden in Nepal has thwarted efforts to develop population-specific prevention and management strategies. This article reports the burden of CVDs in Nepal including, prevalence, incidence, and disability basis as well as trends over the past two decades by age and gender. We used the Institute of Health Metrics and Evaluation's Global Burden of Diseases database on cardiovascular disease from Nepal to describe the most recent data available (2017) and trends by age, gender and year from 1990 to 2017. Data are presented as percentages or as rates per 100,000 population. In 2017, CVDs contributed to 26·9% of total deaths and 12·8% of total DALYs in Nepal. Ischemic heart disease was the predominant CVDs, contributing 16·4% to total deaths and 7·5% to total DALYs. Cardiovascular disease incidence and mortality rates have increased from 1990 to 2017, with the burden greater among males and among older age groups. The leading risk factors for CVDs were determined to be high systolic blood pressure, high low density lipoprotein cholesterol, smoking, air pollution, a diet low in whole grains, and a diet low in fruit. CVDs are a major public health problem in Nepal contributing to the high DALYs with unacceptable numbers of premature deaths. There is an urgent need to address the increasing burden of CVDs and their associated risk factors, particularly high blood pressure, body mass index and unhealthy diet.

The international medical elective in Nepal: perspectives from local patients, host physicians and visiting students.

OBJECTIVES: To understand the impact of the international medical elective (IME) on Nepali patients and physicians alongside visiting European and American medical students. METHODS: At a hospital in Nepal, semi-structured interviews were conducted with 15 patients and 15 physicians about positive and negative experiences with visiting medical students. Likert scale surveys about knowledge of Nepal, clinical competencies, and post-elective feedback were administered to 56 visiting medical students before and after their elective. Interviews were coded using conventional content analysis and surveys were analyzed using descriptive statistics and paired t-tests. RESULTS: Emergent positive themes from interviews were that visiting students enhanced the reputation of the hospital, afforded financial benefits, improved international collaboration, and increased knowledge, culture and language exchange. However, negative themes were the language barrier and time expended to orient students. Before vs. after the elective, visiting students had increased knowledge of Nepal's healthcare system (M=1.9, SD=0.6 vs. M=3.2, SD=0.6, t(55)=-10.22, p<.001), ability to communicate with health professionals from different backgrounds (M=3.3, SD=0.7 vs. M=3.6, SD=0.7, t(55)=-3.11, p=0.003) and practice in resource constrained environments (M=2.4, SD=0.9 vs. M=2.8, SD=0.9, t(55)=-2.42, p=0.02). However, students had no change in history (M=4.0, SD=0.7 vs. M=3.9, SD=0.7, t(55)=0.84, p=0.40), physical exam (M=3.9, SD=0.6 vs. M=3.9, SD= 0.7, t(55)=0.22, p=0.82) or diagnostic (M=3.5, SD=0.7 vs. M=3.4, SD=0.8, t(55)=1.52, p=0.14) abilities. CONCLUSIONS: This study demonstrated a variety of benefits and harms of the IME. To improve the IME experience, medical educators should emphasize pre-departure orientation and fostering equitable partnerships between sending and receiving institutions.

Presenting complaints and mortality in a cohort of 22 000 adult emergency patients at a local hospital in Nepal.

BACKGROUND: There is a need to develop sustainable emergency health care systems in low-resource settings, but data that analyses emergency health care needs in these settings are scarce. We aimed at assessing presenting complaints (PCs) and post-discharge mortality in a large emergency department population in Nepal. METHODS: Characteristics of adult patients who entered the emergency department (ED) in a hospital in Nepal were prospectively recorded in the local emergency registry from September 2013 until December 2016. To assess post-ED mortality, patient households were followed-up by telephone interviews at 90 days. RESULTS: In 21892 included adults, the major PC categories were injuries (29%), abdominal complaints (23%), and infections (16%). Median age was 40 years and sex distribution was balanced. Among 3793 patients followed at 90 days, 8% had died. For respiratory and cardiovascular PCs, 90-day mortality were 25% and 23%. The highest mortality was in individuals with known chronic lung disease, in this group 32% had died by 90 days of ED discharge, regardless of PC. In women, illiteracy compared to literacy (adjusted odds ratio (aOR) = 7.0, 95% confidence interval (CI) = 2.1-23.6) and being both exposed to tobacco-smoking and traditional cooking stove compared to no smoke (aOR = 2.8, 95% CI = 1.6-4.9) were associated with mortality. The mortality was much higher among family-initiated discharged patients (17%, aOR = 5.4, 95% CI = 3.3-8.9) compared to doctor-initiated discharged (3%). CONCLUSIONS: Our report suggests that nearly one in ten patients seeking emergency health care died within 90 days. This finding is alarming and novel. Post-discharge studies need to be replicated and appropriate follow-up programs in low-resource settings where primary health care is underdeveloped are urgently needed.