Report card grades on physical activity for children and adolescents from 18 Asian countries: Patterns, trends, gaps, and future recommendations.

Background: Physical inactivity is a persistent and worsening population health concern in Asia. Led by the Active Healthy Kids Global Alliance, Global Matrix (GM) initiative provides an opportunity to explore how regional and cultural differences across 18 Asian countries relate to physical activity (PA) participation among children and adolescents. Objectives: To synthesize evidence from the GM2.0 to GM4.0 (2016-2022) in Asian countries. Methods: Report Card grades on behavioral/individual and sources of influence indicators were reported from 18 Asian countries. Letter grades were converted into numerical values for quantitative analyses. Based on this, cross-sectional and longitudinal analyses were conducted to investigate patterns and trends. Qualitative evidence synthesis was performed based on Report Card grades and published papers to identify gaps and suggest future recommendations. Results: In total, 18 countries provided grades for at least one round of GM, 12 countries provided grades for at least two rounds, and seven countries provided grades for all three GMs. Of possible grades, 72.8%, 69.2%, and 76.9% of the grades were assigned from GM 2.0 to GM 4.0, respectively. In terms of the Report Card grades, there was a slight decrease in behavioral/individual indicators from "D+" in GM 2.0 to "D-" in GM 3.0 but this reverted to "D" in GM 4.0. For the sources of influence, a "C" grade was given in all three rounds of GM. Longitudinal observation of seven Asian countries that provided grades in all three rounds of GM revealed that grades are generally stable for all indicators with some country-specific fluctuations. In future GM initiatives and research, considerations should be made to provide more accurate and rich data and to better understand contextual challenges in evaluating certain indicators such as Active Transportation, Active Play, and Physical Fitness in particular. Further, macro level factors such as socioeconomic/cultural disparities and gender-specific barriers, ideology, or climate change should also be proactively considered in future research as these factors are becoming increasingly relevant to indicators of GM and United Nation's Sustainable Development Goals. Conclusions: Participation from Asian countries in GM has increased over the years, which demonstrates the region's enthusiasm, capacity, and support for global PA promotion efforts. The efforts to promote a physically active lifestyle among children and adolescents should be a collective interest and priority of the Asia region based on the gaps identified in this paper.

Results from Nepal's 2018 Report Card on Physical Activity for Children and Youth.

BACKGROUND/OBJECTIVE: Nepal's Report Card on Physical Activity for Children and Youth summarises the available evidence on ten physical activity-related indicators among Nepalese children and youth. METHODS: Published scientific papers on physical activity of Nepalese children and youth (5-17 years) were searched systematically in four databases (Medline, Embase, PsycINFO, and PubMed Central) while some survey reports were manually searched. Letter grades were assigned to ten indicators (Overall Physical Activity, Organized Sport Participation, Active Play, Active Transportation, Sedentary Behaviours, Physical Fitness, Family and Peers, School, Community and Environment, and Government) by the country's report card team based on available data. RESULTS: Among the ten indicators, five indicators were successfully graded based on available data. Overall Physical Activity was graded as D+. Active Transportation and Family and Peers were assigned as A- and A, respectively. Community and Environment was graded as C-. The other five indicators could not be graded due to insufficient data. CONCLUSIONS: Though a majority of Nepalese children and youth use active modes of transport and have adequate support for physical activity from family and peers, overall participation in physical activity appears to be low. Lack of data identified with five incomplete indicators reflects the need for further research. Studies with larger sample, more rigorous study design and objective assessment of physical activity is recommended for future physical activity surveillance in Nepal.

Prevalence and associated factors of childhood overweight/obesity among primary school children in urban Nepal.

BACKGROUND: Childhood overweight/obesity has become a major public health concern globally because of its adverse health consequences and escalating prevalence. The factors underlying the disease conditions manifested during adulthood commonly originate in childhood. Nepal is going through a transition where under-nutrition co-exists with obesity; however, there is a lack of well-documented information on childhood overweight or obesity in Nepal. This study was carried out to determine the prevalence and associated factors of childhood overweight/obesity among urban primary school children. METHODS: A cross-sectional survey was conducted from May to October of 2017. Behavioral data were collected using a structured self-administered questionnaire with parents of children aged 6-13 years old in grades 1-5 studying in private schools of Lalitpur district in Nepal. Study participants were selected using two-stage cluster random sampling from 10 private schools. Height and weight measurements of 575 children were taken and BMI-for-age-sex was calculated using WHO AnthroPlus. Data were analyzed using SPSS version 21. Associated factors were examined using Chi-square tests followed by multivariate logistic regression analyses. RESULTS: The study found that out of 575 students, 107 (18.6%) were overweight and 41 (7.1%) were obese. Among 328 male children, 62 (19.0%) were overweight and 35 (10.6%) were obese. Likewise, among 247 female children, 45 (18.2%) were overweight and 6 (2.4%) were obese. Male children (aOR = 2.21, 95% CI: 1.38-3.53), children of mothers with a high school (aOR = 3.13, 95% CI: 1.39-7.12) or university level of education (aOR = 3.09, 95% CI: 1.23-7.70) and children of mothers in a professional field (aOR = 1.34, 95% CI: 1.02-4.05) had a greater likelihood of being overweight/obese. Likewise, students consuming energy-dense less nutrient food (aOR = 2.92, 95% CI: 1.66-5.12), lacking active travel to and from school (aOR = 2.38, 95% CI: 1.12-4.79) and those having sedentary behaviors (aOR = 3.01, 95% CI: 1.20-7.29) were likely to be overweight/obese. CONCLUSIONS: More than one-quarter of the children in urban Lalitpur were found to be overweight/obese. High junk food consumption and sedentary activity were found to be significantly associated with childhood overweight/obesity. School health and awareness programs aiming to reduce the intake of energy-dense foods and promote an active lifestyle including active transportation to school among children are imperative. Future studies to objectively measure the type and amount of food intake and physical activity of students are recommended.

A cluster randomized implementation trial to measure the effectiveness of an intervention package aiming to increase the utilization of skilled birth attendants by women for childbirth: study protocol.

BACKGROUND: Nepal is on track to achieve MDG 5 but there is a huge sub-national disparity with existing high maternal mortality in western and hilly regions. The national priority is to reduce this disparity to achieve the goal at sub-national level. Evidences from developing countries show that increasing utilization of skilled attendant at birth is an important indicator for reducing maternal death. Further, there is a very low utilization during childbirth in western and hilly regions of Nepal which clearly depicts the barriers in utilization of skilled birth attendants. So, there is a need to overcome the identified barriers to increase the utilization thereby decreasing the maternal mortality. The hypothesis of this study is that through a package of interventions the utilization of skilled birth attendants will be increased and hence improve maternal health in Nepal. METHOD/DESIGN: This study involves a cluster randomized controlled trial involving approximately 5000 pregnant women in 36 clusters. The 18 intervention clusters will receive the following interventions: i) mobilization of family support for pregnant women to reach the health facility, ii) availability of emergency funds for institutional childbirth, iii) availability of transport options to reach a health facility for childbirth, iv) training to health workers on communication skills, v) security provisions for SBAs to reach services 24/24 through community mobilization; 18 control clusters will not receive the intervention package. The final evaluation of the intervention is planned to be completed by October 2014. Primary study output of this study is utilization of SBA services. Secondary study outputs measure the uptake of antenatal care, post natal checkup for mother and baby, availability of transportation for childbirth, operation of emergency fund, improved reception of women at health services, and improved physical security of SBAs. DISCUSSION: The intervention package is designed to increase the utilization of skilled birth attendants by overcoming the barriers related to awareness, finance, transport, security etc. If proven effective, the Ministry of Health has committed to scale up the intervention package throughout the country. TRIAL REGISTRATION NUMBER: ISRCTN78892490.

Estimation of leisure time physical activity and sedentary behaviour among school adolescents in Nepal.

BACKGROUND: Leisure-time physical activity is essential for healthy and physically active life; however, this domain of physical activity is less common in developing countries. Information on leisure time physical activity and sedentary behaviour among Nepalese population is not available. The study was carried out to assess leisure time physical activity and sedentary behaviour among high school adolescents and identify the associated factors in Nepal. METHODS: A cross-sectional descriptive study was carried out in Banke district, Nepal in 2013 among higher secondary school students using self-administered questionnaire based on International Physical Activity Questionnaire. A sample of 405 students, 178 females and 227 males, of the age-group 15 to 20 years from seven schools were included in the study. Multivariate logistic regression analysis was carried out to identify factors associated with participation in leisure time physical activity and sedentary behaviour. RESULTS: Engagement of female in leisure time physical activity was lower but mean time spent on sitting per day was higher. Students who walked to school and have playground/parks near home, younger females (OR = 3.09, 95% CI: 1.18-8.08), females living in nuclear families (OR: 2.16, 95% CI: 1.01-4.62) and males who cycled to school (OR: 8.09, 95% CI: 2.35-27.80) and have provision of extra-curricular activities (OR: 2.49, 95% CI: 1.04-5.97) were more likely to be engaged in leisure time physical activity. On the other hand, students who did not have playground in school and lived in rural areas were more likely to sit for more than 6 hours a day. Likewise, male students of private school (OR: 6.41, 95% CI: 2.89-14.21), who used vehicle to reach school (OR: 5.90, 95% CI: 1.26-27.75) and have no provision of extra-curricular activities (OR: 2.98, 95% CI: 1.09-8.07) had longer sitting time. CONCLUSION: Difference in leisure time physical activity and sedentary behaviour was found among male and female school adolescents. Interventions are needed not only to promote leisure time physical activity but also to reduce sedentary behaviour among this group.

Stakeholder perceptions of factors contributing to effective implementation of exercise cardiac telerehabilitation in clinical practice.

AIMS: Cardiac exercise telerehabilitation is effective and can be cost-effective for managing ischaemic heart disease, but implementation of evidence-based interventions in clinical practice remains a challenge. We aimed to identify factors that cardiac rehabilitation stakeholders perceived could influence the effectiveness of implementing an evidence-based, real-time remotely monitored cardiac exercise telerehabilitation intervention (REMOTE-CR). METHODS AND RESULTS: Online interviews and focus groups were conducted with cardiac rehabilitation consumers (n = 16, 5 female, 61.1 ± 10.0 years), practitioners (n = 20, 14 female; 36.6 ± 11.8 years), and health service managers (n = 11, 7 female; 46.2 ± 9.2 years) recruited from one metropolitan and three inner-regional healthcare services in Western Victoria, Australia. Discussions were guided by two theoretical frameworks (Non-adoption, Abandonment, Scale-up, Spread, and Sustainability; Consolidated Framework for Implementation Research), and analysed thematically. Factors perceived to influence effective implementation of REMOTE-CR spanned all domains of the theoretical frameworks, related to six major themes (resources, change management, stakeholder targeting, knowledge, intervention design, security) and were largely consistent across study sites; however, the relative importance of each factor may vary between sites. CONCLUSION: Effective implementation of exercise telerehabilitation interventions like REMOTE-CR will require a coordinated context-specific approach that considers factors across all levels of the healthcare system and implementation science frameworks. Key requirements include prioritizing resources, managing change, selecting target stakeholders, developing digital health capabilities, and selecting fit-for-purpose technologies that enable programme delivery objectives.

Epidemiology of multimorbidity in Nepal: A systematic review and meta-analysis.

Background: Multimorbidity is rising in low-and middle-income countries such as Nepal, yet the research has not gained pace in this field. We aimed to systematically review the existing multimorbidity literature in Nepal and estimate the prevalence and map its risk factors and consequences. Methods: We reviewed data collated from PubMed, Embase and CINAHL by including original studies that reported prevalence of multimorbidity in Nepal. The quality of included studies was assessed using the Appraisal Tool for Cross-sectional Studies. The summary of the review is presented both qualitatively as well as through meta-analysis to give pooled prevalence. We prospectively registered in PROSPERO (CRD42024499598). Results: We identified 423 studies out of which seven were included in this review. All studies were conducted in a community setting except one which was hospital based. The prevalence reported across various studies ranged from 13.96% to 70.1%. The pooled prevalence of multimorbidity was observed to be 25.05% (95% CI: 16.99 to 34.09). The number of conditions used to assess multimorbidity ranged from four to nine. The major risk factors identified were increasing age, urban residence, and lower literacy rates. Conclusion: A wide variance in the prevalence of multimorbidity was observed. Moreover, multimorbidity assessment tool/conditions considered for assessing multimorbidity were heterogeneous.

Development and validation of the Global Adolescent and Child Physical Activity Questionnaire (GAC-PAQ) in 14 countries: study protocol.

INTRODUCTION: Global surveillance of physical activity (PA) of children and adolescents with questionnaires is limited by the use of instruments developed in high-income countries (HICs) lacking sociocultural adaptation, especially in low- and middle-income countries (LMICs); under-representation of some PA domains; and omission of active play, an important source of PA. Addressing these limitations would help improve international comparisons, and facilitate the cross-fertilisation of ideas to promote PA. We aim to develop and assess the reliability and validity of the app-based Global Adolescent and Child Physical Activity Questionnaire (GAC-PAQ) among 8-17 years old in 14 LMICs and HICs representing all continents; and generate the 'first available data' on active play in most participating countries. METHODS AND ANALYSIS: Our study involves eight stages: (1) systematic review of psychometric properties of existing PA questionnaires for children and adolescents; (2) development of the GAC-PAQ (first version); (3) content validity assessment with global experts; (4) cognitive interviews with children/adolescents and parents in all 14 countries; (5) development of a revised GAC-PAQ; (6) development and adaptation of the questionnaire app (application); (7) pilot-test of the app-based GAC-PAQ; and, (8) main study with a stratified, sex-balanced and urban/rural-balanced sample of 500 children/adolescents and one of their parents/guardians per country. Participants will complete the GAC-PAQ twice to assess 1-week test-retest reliability and wear an ActiGraph wGT3X-BT accelerometer for 9 days to test concurrent validity. To assess convergent validity, subsamples (50 adolescents/country) will simultaneously complete the PA module from existing international surveys. ETHICS AND DISSEMINATION: Approvals from research ethics boards and relevant organisations will be obtained in all participating countries. We anticipate that the GAC-PAQ will facilitate global surveillance of PA in children/adolescents. Our project includes a robust knowledge translation strategy sensitive to social determinants of health to inform inclusive surveillance and PA interventions globally.

Improving National and International Surveillance of Movement Behaviours in Childhood and Adolescence: An International Modified Delphi Study.

BACKGROUND: The actions required to achieve higher-quality and harmonised global surveillance of child and adolescent movement behaviours (physical activity, sedentary behaviour including screen time, sleep) are unclear. OBJECTIVE: To identify how to improve surveillance of movement behaviours, from the perspective of experts. METHODS: This Delphi Study involved 62 experts from the SUNRISE International Study of Movement Behaviours in the Early Years and Active Healthy Kids Global Alliance (AHKGA). Two survey rounds were used, with items categorised under: (1) funding, (2) capacity building, (3) methods, and (4) other issues (e.g., policymaker awareness of relevant WHO Guidelines and Strategies). Expert participants ranked 40 items on a five-point Likert scale from 'extremely' to 'not at all' important. Consensus was defined as > 70% rating of 'extremely' or 'very' important. RESULTS: We received 62 responses to round 1 of the survey and 59 to round 2. There was consensus for most items. The two highest rated round 2 items in each category were the following; for funding (1) it was greater funding for surveillance and public funding of surveillance; for capacity building (2) it was increased human capacity for surveillance (e.g. knowledge, skills) and regional or global partnerships to support national surveillance; for methods (3) it was standard protocols for surveillance measures and improved measurement method for screen time; and for other issues (4) it was greater awareness of physical activity guidelines and strategies from WHO and greater awareness of the importance of surveillance for NCD prevention. We generally found no significant differences in priorities between low-middle-income (n = 29) and high-income countries (n = 30) or between SUNRISE (n = 20), AHKGA (n = 26) or both (n = 13) initiatives. There was a lack of agreement on using private funding for surveillance or surveillance research. CONCLUSIONS: This study provides a prioritised and international consensus list of actions required to improve surveillance of movement behaviours in children and adolescents globally.

Barriers to using skilled birth attendants' services in mid- and far-western Nepal: a cross-sectional study.

BACKGROUND: Skilled birth attendants (SBAs) provide important interventions that improve maternal and neonatal health and reduce maternal and neonatal mortality. However, utilization and coverage of services by SBAs remain poor, especially in rural and remote areas of Nepal. This study examined the characteristics associated with utilization of SBA services in mid- and far-western Nepal. METHODS: This cross-sectional study examined three rural and remote districts of mid- and far-western Nepal (i.e., Kanchanpur, Dailekh and Bajhang), representing three ecological zones (southern plains [Tarai], hill and mountain, respectively) with low utilization of services by SBAs. Enumerators assisted a total of 2,481 women. All respondents had delivered a baby within the past 12 months. We used bivariate and multivariate analyses to assess the association between antenatal and delivery care visits and the women's background characteristics. RESULTS: Fifty-seven percent of study participants had completed at least four antenatal care visits and 48% delivered their babies with the assistance of SBAs. Knowing the danger signs of pregnancy and delivery (e.g., premature labor, prolonged labor, breech delivery, postpartum hemorrhage, severe headache) associated positively with four or more antenatal care visits (OR = 1.71; 95% CI: 1.41-2.07). Living less than 30 min from a health facility associated positively with increased use of both antenatal care (OR = 1.44; 95% CI: 1.18-1.77) and delivery services (OR = 1.25; CI: 1.03-1.52). Four or more antenatal care visits was a determining factor for the utilization of SBAs. CONCLUSIONS: Less than half of the women in our study delivered babies with the aid of SBAs, indicating a need to increase utilization of such services in rural and remote areas of Nepal. Distance from health facilities and inadequate transportation pose major barriers to the utilization of SBAs. Providing women with transportation funds before they go to a facility for delivery and managing transportation options will increase service utilization. Moreover, SBA utilization associates positively with women's knowledge of pregnancy danger signs, wealth quintile, and completed antenatal care visits. Nepal's health system must develop strategies that generate demand for SBAs and also reduce financial, geographic and cultural barriers to such services.

Utilization of adolescent friendly health services and its associated factors among higher secondary students in mid-western Himalayan mountainous district of Nepal.

Adolescent friendly health services (AFHS) are designed to make health services accommodate the unique needs of adolescents. AFHS are characterized by three basic characteristics (programmatic, health facilities and health service providers) that should be applied. However, limited is known about the use of AFHS in the context of Nepal. This study aimed to assess the extent of AFHS utilization and associated factors among higher secondary students in the Jumla district of Nepal. A cross-sectional quantitative study was conducted in October-November 2017. Data were collected from a random sample of 528 aged 16-19 years old using a self-administered survey in their classroom. Adjusted Odds Ratios (AOR) and a 95% confidence level were estimated to measure the strength of association between the outcome variable (utilization of AFHS) and independent variable using multivariable logistic regression. Knowledge related to AFHS, measured by a seven-item scale, was based on information about the availability of AFHS. More than two-thirds (67.05%) of adolescents had utilized AFHS at least once in the last twelve months before the survey. In multivariable logistic regression analysis, knowledge level [AOR = 14.796, 95%CI (5.326-41.099)], cost of services [AOR = 2.971, 95%CI (1.764-5.003)], satisfaction from services [AOR = 1.817, 95%CI (1.037-3.185)] and availability of waiting room [AOR = 1.897, 95%CI (1.096-3.283)] were significantly associated with the utilization of AFHS. The utilization of AFHS was less than the country's target of universal utilization in this study. Adolescents' knowledge level about AFHS was importantly associated with its utilization. Utilization increases with lower service costs, client satisfaction, and availability of waiting rooms in the health facility. The health planners should make efforts to create a conducive environment for the adolescent by training the AFHS providers, particularly those who work in government institutions, and strengthening the awareness creation strategies among adolescents to increase the utilization of the services.

Wearable cuffless blood pressure monitoring devices: a systematic review and meta-analysis.

Aims: High blood pressure (BP) is the commonest modifiable cardiovascular risk factor, yet its monitoring remains problematic. Wearable cuffless BP devices offer potential solutions; however, little is known about their validity and utility. We aimed to systematically review the validity, features and clinical use of wearable cuffless BP devices. Methods and results: We searched MEDLINE, Embase, IEEE Xplore and the Cochrane Database till December 2019 for studies that reported validating cuffless BP devices. We extracted information about study characteristics, device features, validation processes, and clinical applications. Devices were classified according to their functions and features. We defined devices with a mean systolic BP (SBP) and diastolic BP (DBP) biases of <5 mmHg as valid as a consensus. Our definition of validity did not include assessment of device measurement precision, which is assessed by standard deviation of the mean difference-a critical component of ISO protocol validation criteria. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies version 2 tool. A random-effects model meta-analysis was performed to summarise the mean biases for SBP and DBP across studies. Of the 430 studies identified, 16 studies (15 devices, 974 participants) were selected. The majority of devices (81.3%) used photoplethysmography to estimate BP against a reference device; other technologies included tonometry, auscultation and electrocardiogram. In addition to BP and heart rate, some devices also measured night-time BP (n = 5), sleep monitoring (n = 3), oxygen saturation (n = 3), temperature (n = 2) and electrocardiogram (n = 3). Eight devices showed mean biases of <5 mmHg for SBP and DBP compared with a reference device and three devices were commercially available. The meta-analysis showed no statistically significant differences between the wearable and reference devices for SBP (pooled mean difference = 3.42 mmHg, 95% CI: -2.17, 9.01, I2 95.4%) and DBP (pooled mean = 1.16 mmHg, 95% CI: -1.26, 3.58, I2 87.1%). Conclusion: Several cuffless BP devices are currently available using different technologies, offering the potential for continuous BP monitoring. The variation in standards and validation protocols limited the comparability of findings across studies and the identification of the most accurate device. Challenges such as validation using standard protocols and in real-life settings must be overcome before they can be recommended for uptake into clinical practice.

Active commuting and leisure-time physical activity among adults in western Nepal: a cross-sectional study.

OBJECTIVE: To determine the prevalence and sociodemographic factors associated with active commuting and leisure-time physical activity (LTPA) among adults in western Nepal. DESIGN: Cross-sectional study. SETTING: Adults from semiurban areas in western Nepal. PARTICIPANTS: 2815 adults aged 25-65 years who participated in the 'Community-Based Management of Hypertension in Nepal (COBIN)' Study. Multiple logistic regression analysis was used to identify the sociodemographic factors associated with active commuting and LTPA. OUTCOME: Self-reported participation in active commuting and LTPA. RESULTS: Most study participants (96%) commuted actively (walked or cycled) from one place to another. Our results showed that only a small proportion (3.7%) of participants engaged in moderate or vigorous LTPA. Compared with those in paid employment, the odds of commuting actively were higher among people working in agriculture or as labourers (OR: 4.57, 95% CI: 2.46 to 8.48), those retired/unemployed (OR: 2.98, 95% CI: 1.42 to 6.25) and those in unpaid employment (OR: 1.85, 95% CI: 1.06 to 3.22). Adults who were overweight or had obesity were less likely to commute actively. Compared with adults aged 25-34 years, older adults were less likely (OR: 0.35, 95% CI: 0.17 to 0.72) to engage in LTPA. Women were 0.46 times less likely to engage in LTPA compared with men. CONCLUSION: Most adults engaged in active commuting for work or travel. Less than 5% participated in any form of moderate or vigorous LTPA. Longitudinal studies incorporating objective assessment of physical activity and a range of individual, interpersonal, and environmental factors will help understand how to promote active commuting and LTPA among Nepalese adults.Trial registration number: ClinicalTrials.gov NCT02428075.

Implementation of Telerehabilitation Interventions for the Self-Management of Cardiovascular Disease: Systematic Review.

BACKGROUND: Coronary heart disease (CHD) is a leading cause of disability and deaths worldwide. Secondary prevention, including cardiac rehabilitation (CR), is crucial to improve risk factors and to reduce disease burden and disability. Accessibility barriers contribute to underutilization of traditional center-based CR programs; therefore, alternative delivery models, including cardiac telerehabilitation (ie, delivery via mobile, smartphone, and/or web-based apps), have been tested. Experimental studies have shown cardiac telerehabilitation to be effective and cost-effective, but there is inadequate evidence about how to translate this research into routine clinical practice. OBJECTIVE: This systematic review aimed to synthesize research evaluating the effectiveness of implementing cardiac telerehabilitation interventions at scale in routine clinical practice, including factors underlying successful implementation processes, and experimental research evaluating implementation-related outcomes. METHODS: MEDLINE, Embase, PsycINFO, and Global Health databases were searched from 1990 through November 9, 2018, for studies evaluating the implementation of telerehabilitation for the self-management of CHD. Reference lists of included studies and relevant systematic reviews were hand searched to identify additional studies. Implementation outcomes of interest included acceptability, appropriateness, adoption, feasibility, fidelity, implementation cost, penetration, and sustainability. A narrative synthesis of results was carried out. RESULTS: No included studies evaluated the implementation of cardiac telerehabilitation in routine clinical practice. A total of 10 studies of 2250 participants evaluated implementation outcomes, including acceptability (8/10, 80%), appropriateness (9/10, 90%), adoption (6/10, 60%), feasibility (6/10, 60%), fidelity (7/10, 70%), and implementation cost (4/10, 40%), predominantly from the participant perspective. Cardiac telerehabilitation interventions had high acceptance among the majority of participants, but technical challenges such as reliable broadband internet connectivity can impact acceptability and feasibility. Many participants considered telerehabilitation to be an appropriate alternative CR delivery model, as it was convenient, flexible, and easy to access. Participants valued interactive intervention components, such as real-time exercise monitoring and feedback as well as individualized support. The penetration and sustainability of cardiac telerehabilitation, as well as the perspectives of CR practitioners and health care organizations, have received little attention in existing cardiac telerehabilitation research. CONCLUSIONS: Experimental trials suggest that participants perceive cardiac telerehabilitation to be an acceptable and appropriate approach to improve the reach and utilization of CR, but pragmatic implementation studies are needed to understand how interventions can be sustainably translated from research into clinical practice. Addressing this gap could help realize the potential impact of telerehabilitation on CR accessibility and participation as well as person-centered, health, and economic outcomes. TRIAL REGISTRATION: International Prospective Register of Systematic Reviews (PROSPERO) CRD42019124254; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=124254.

Dietary Risk Factors Associated with Development of Gastric Cancer in Nepal: A Hospital-Based Case-Control Study.

OBJECTIVES: Gastric cancer (GC) is one of the most prevalent neoplasms and a leading cause of mortality globally. To our knowledge, its relationship with dietary factors is not adequately studied and understood in the Nepalese context. This study is aimed at exploring the relationship between the possible dietary risk factors responsible for gastric cancer in Nepal. METHODS: A hospital-based matched case-control study was conducted in two specialized cancer hospitals in Nepal. A total of 237 participants (79 cases and 158 controls) were included in the study. Patients diagnosed within one year (incidence case) with histologically confirmed gastric cancer were taken as cases, and healthy visitors of gastric and nongastric cancer patients without past and present history or not a suspected information of gastric cancer were included as controls. A face-to-face interview was conducted using a semi-structured food frequency questionnaire. Backward stepwise conditional logistic regression was used to estimate the magnitude of the association between the independent variables and gastric cancer. Results were presented as the crude odds ratio (COR) and adjusted odds ratio (AOR) with 95% confidence intervals (CI). A P value < 0.05 was considered statistically significant. RESULTS: In the adjusted multivariable conditional logistic regression model, an increased risk of gastric cancer was more likely to have higher odds among those respondents who had a high consumption of processed meat (AOR = 3.99, 95% CI: 0.90-17.66), preferences of a high amount of fats/oil (AOR = 4.64, 95% CI: 1.56-13.72), and preferences of high amounts of salts (AOR = 4.18, 95% CI: 1.30-13.44). Conversely, those respondents who consumed higher amounts of fruits (AOR = 0.21, 95% CI: 0.07-0.65) were seen to have lower odds of gastric cancer. CONCLUSIONS: Our study found an increased risk of gastric cancer with frequent consumption of red meat, processed meat, high preferences of salt, fats/oil, and condiments. Regular consumption of fruits had a protective effect against gastric cancer. Providing nutrition education, public awareness, and lifestyle modification are primary steps to promote the avoidance of risk factors and change unhealthy dietary habits to prevent gastric cancer in Nepal.

Indicators of Physical Activity Among Children and Youth in 9 Countries With Low to Medium Human Development Indices: A Global Matrix 3.0 Paper.

BACKGROUND: This study compares results of physical activity report cards from 9 countries with low to medium human development indices, participating in the Global Matrix 3.0 initiative. METHODS: Country-specific report cards were informed by relevant data and government policy documents, reporting on 10 core indicators of physical activity for children and youth. Data were synthesized by report card working groups following a harmonized process. Grade assignments for each indicator utilized a standard grading rubric. Indicators were grouped into one of 2 categories: daily behaviors and settings and sources of influence. Descriptive statistics (average grades) were computed after letter grades were converted into interval variables. Spearman's rank correlation coefficients were calculated for all correlation analyses. RESULTS: Mean grades for daily behaviors were higher (C) than those for settings and sources of influence (D+). Twenty-nine out of the possible 90 grades were assigned an incomplete. There were moderate to strong positive and negative relationships between different global indices and overall physical activity, organized sport and physical activity, active play, family, community and environment, and government. CONCLUSIONS: Findings demonstrate an urgent need for high-quality data at the country level in order to better characterize the physical activity levels of children and youth in countries with low to medium human development indices.

Correlates of mobile screen media use among children aged 0-8: a systematic review.

OBJECTIVE: This study is a systematic review of the peer-reviewed literature to identify the correlates of mobile screen media use among children aged 8 years and less. SETTING: Home or community-based studies were included in this review while child care or school-based studies were excluded. PARTICIPANTS: Children aged 8 years or less were the study population. Studies that included larger age groups without subgroup analysis specific to the 0-8 years category were excluded. Eight electronic databases were searched for peer-reviewed English language primary research articles published or in press between January 2009 and March 2017 that have studied correlates of mobile screen media use in this age group. OUTCOME MEASURE: Mobile screen media use was the primary outcome measure. Mobile screen media use refers to children's use of mobile screens, such as mobile phones, electronic tablets, handheld computers or personal digital assistants. RESULTS: Thirteen studies meeting the inclusion criteria were identified of which a total of 36 correlates were examined. Older children, children better skilled in using mobile screen media devices, those having greater access to such devices at home and whose parents had high mobile screen media use were more likely to have higher use of mobile screen media devices. No association existed with parent's age, sex and education. CONCLUSION: Limited research has been undertaken into young children's mobile screen media use and most of the variables have been studied too infrequently for robust conclusions to be reached. Future studies with objective assessment of mobile screen media use and frequent examination of the potential correlates across multiple studies and settings are recommended. TRIAL REGISTRATION NUMBER: This review is registered with PROSPERO International Prospective Register of Ongoing Systematic Reviews (registration number: CRD42015028028).

A cluster-randomized evaluation of an intervention to increase skilled birth attendant utilization in mid- and far-western Nepal.

Skilled birth attendant (SBA) utilization is low in remote and rural areas of Nepal. We designed and implemented an evaluation to assess the effectiveness of a five-component intervention that addressed previously identified barriers to SBA services in mid- and far-western Nepal. We randomly and equally allocated 36 village development committees with low SBA utilization among 1-year intervention and control groups. The eligible participants for the survey were women that had delivered a baby within the past 12 months preceding the survey. Implementation was administered by trained health volunteers, youth groups, mothers' groups and health facility management committee members. Post-intervention, we used difference-in-differences and mixed-effects regression models to assess and analyse any increase in the utilization of skilled birth care and antenatal care (ANC) services. All analyses were done by intention to treat. Our trial registration number was ISRCTN78892490 (http://www.isrctn.com/ISRCTN78892490). Interviewees included 1746 and 2098 eligible women in the intervention and control groups, respectively. The 1-year intervention was effective in increasing the use of skilled birth care services (OR = 1.57; CI 1.19-2.08); however, the intervention had no effect on the utilization of ANC services. Expanding the intervention with modifications, e.g. mobilizing more active and stable community groups, ensuring adequate human resources and improving quality of services as well as longer or repeated interventions will help achieve greater effect in increasing the utilization of SBA.

Physical Activity Level and Associated Factors Among Higher Secondary School Students in Banke, Nepal: A Cross-Sectional Study.

BACKGROUND: This study was carried out to assess physical activity level and identify associated factors among higher secondary school students in Banke district, Nepal. METHODS: A school-based, cross-sectional descriptive study was conducted among 405 students studying in grades 11 and 12 in 7 higher secondary schools selected randomly. A self-administered questionnaire based on the International Physical Activity Questionnaire was used to measure physical activity level. RESULTS: Only 5% of students were found to be inactive, and domestic and transport-related activities were major contributors to total physical activity score. No significant difference existed for total physical activity and domain-specific and activity-specific scores across different age groups when males and females were tested separately. Being male (P = .046), lower economic status (P = .026), living at a distance of less than 30 minutes (P = .007), walking/cycling to school (P < .001), and studying in government school (P < .001) were associated with increased physical activity scores on multivariate logistic regression analysis. CONCLUSION: Routine activities such as transport and household chores contributed greatly to total physical activity among students. This study highlights the need for physical activity promotion interventions at school addressing the associated factors and a need for greater focus on leisure-time physical activities.

Variation in Prices of Cardiovascular Drugs in Public and Private Pharmacies in Nepal.

INTRODUCTION: Higher price of cardiovascular drugs is one of the reasons for high out-of-pocket expenditure in cardiovascular care. The objective of the study was to determine the price variation in commonly available cardiovascular drugs between public and private hospital pharmacies in Nepal. METHODS: A cross-sectional survey was conducted in 3 public and 3 private pharmacies in tertiary-level hospitals in Nepal. The price was recorded for the list of drugs commonly available in those pharmacies. A total of 23 drugs were selected for data collection. The price was recorded based on the payment receipt and price reported by surrogate customers. We defined the price variation as the difference between price of cardiovascular drugs between public hospital and private pharmacy. The price variation was expressed as percentage. RESULTS: Price of Amlodipine 5 mg was higher by 667% in private pharmacy nearby Tribhuvan University Teaching Hospital (TUTH) compared to that of TUTH pharmacy. Price of Enalapril 5 mg was higher by 14.47% in Manmohan Cardio Thoracic and Vascular Transplant Centre (MCVTC) compared to nearby private pharmacy. We observed that the price of cardiovascular drugs varied significantly between hospital and private retail pharmacies in TUTH (P < .001) and MCVTC (P < .001). CONCLUSION: For most of the cardiovascular drugs, the price in private retail pharmacies were significantly higher than in hospital pharmacies. Future steps should be taken to establish and run own pharmacies in hospitals which would reduce the cost of medicine and thereby, increase access to medicine.