Spatial Heterogeneity of Enteric Fever in 2 Diverse Communities in Nepal.

BACKGROUND: Typhoid fever is endemic in the urban Kathmandu Valley of Nepal; however, there have been no population-based studies of typhoid outside of this community in the past 3 decades. Whether typhoid immunization should be prioritized in periurban and rural communities has been unclear. METHODS: We performed population-based surveillance for enteric fever in 1 urban catchment (Kathmandu) and 1 periurban and rural catchment (Kavrepalanchok) as part of the Surveillance for Enteric Fever in Asia Project (SEAP). We recruited individuals presenting to outpatient and emergency departments at 2 study hospitals with suspected enteric fever and performed blood cultures. Additionally, we conducted a household survey in each catchment area to characterize care seeking for febrile illness. We evaluated spatial heterogeneity in febrile illness, care seeking, and enteric fever incidence. RESULTS: Between September 2016 and September 2019, we enrolled 5736 participants with suspected enteric fever at 2 study hospitals. Among these, 304 (5.3%) were culture positive for Salmonella Typhi (249 [81.9%]) or Paratyphi A (55 [18.1%]). Adjusted typhoid incidence in Kathmandu was 484 per 100 000 person-years and in Kavrepalanchok was 615 per 100 000 person-years. While all geographic areas for which estimates could be made had incidence >200 per 100 000 person-years, we observed spatial heterogeneity with up to 10-fold variation in incidence between communities. CONCLUSIONS: In urban, periurban, and rural communities in and around Kathmandu, we measured a high but heterogenous incidence of typhoid. These findings provide some support for the introduction of conjugate vaccines in Nepal, including outside urban areas, alongside other measures to prevent enteric fever.

Worksite intervention study to prevent diabetes in Nepal: a randomised trial protocol.

INTRODUCTION: In Nepal, approximately 31% of adult industrial employees have diabetes. While the prevention of type 2 diabetes through behavioural intervention has been disseminated, worksite could be an effective platform for the translation of this knowledge into action as employed adults spend most of their workday waking hours at workplaces. METHODS AND ANALYSIS: We will conduct a randomised controlled trial to assess the effectiveness of a behavioural and a canteen intervention on diabetes risk reduction among those who are prediabetic at two worksites in eastern Nepal. We will recruit 162 adult full-time factory workers with haemoglobin A1c (HbA1c) of 5.7%-6.4% at baseline or fasting blood sugar of 100-125 mg/dL. The 8-14 months' control period will be followed by the behavioural intervention where half of the participants will be randomised to receive the behavioural intervention and half will act as a control and will not receive any intervention. Then, all participants will receive the canteen intervention. The analysis will be intent-to-treat, comparing the difference in the change in HbA1c% between the behavioural intervention group and the control group using a two-sample t-test. The within-participant changes in HbA1c after 6 or more months on the canteen intervention among those not randomised to the behavioural intervention in the previous period will be assessed using the paired t-test. ETHICS AND DISSEMINATION: Ethical approval was obtained from the Institutional Review Board at Yale School of Public Health, New Havens, USA and the Nepal Health Research Council. TRIAL REGISTRATION NUMBER: NCT04161937.

Pilot Educational Intervention to Promote Safe Pesticide Use Practices Among Farmworkers in Nepal.

OBJECTIVES: The misuse of pesticides among farmworkers in Nepal is commonplace. To address this, we implemented a pilot educational intervention (three modules delivered over 3 days and lasting approximately 3 h each) in Kavre District of Nepal. Modules included: (i) health and environmental effects of pesticides, (ii) use of personal protective equipment, and (iii) label literacy and behavioral factors that influence pesticide exposure. In addition, 10 posters with key messages from each of the modules were hung throughout communities. METHODS: Surveys were administered to cross-sectional convenience samples of farmworkers at baseline (n = 106) and 1 year later (n = 98). Practices relating to pesticides at baseline and endline were compared using multivariable logistic regression to adjust for differences in demographic and socioeconomic characteristics between the samples. RESULTS: Compared with the baseline sample, farmworkers in the endline sample were significantly more likely to report: getting information regarding the amount of pesticides to use from experts or pesticide labels (versus personal judgment); wearing gloves while mixing pesticides; wearing boots while working in the field; using personal hygiene practices after handling pesticides such as bathing or washing hands and feet; changing clothes after handling pesticides; checking the wind direction before spraying; and delaying entry for a longer period of time after spraying. CONCLUSIONS: These results suggest that a simple educational intervention can improve pesticide handling practices among farmworkers in Nepal. Future research should explore the impact of such interventions on pesticide exposure levels and health outcomes, and the potential to scale up these programs nationally.

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

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

Prevalence of hypertension and prehypertension in Nepal: a systematic review and meta-analysis.

BACKGROUND: Studies regarding blood pressure of Nepal have demonstrated a contrasting prevalence. We aimed at providing a generalized estimate of the prevalence of hypertension and prehypertension in urban, suburban, and rural areas of Nepal. METHODS: This systematic review followed PRISMA guidelines. A thorough search of PubMed, EMBASE, and Web of Science was performed, and studies satisfying the eligibility criteria were reviewed. Pooled prevalence was calculated by random-effects model, and the sources of heterogeneity were explored with meta-regression and subgroup analysis. RESULTS: Twenty-three studies with 99,792 subjects were identified, and the estimated rate of hypertension and prehypertension were found to be 27.3% (95% CI: 23.8-30.9) and 35.4% (30.3-40.8). The prevalence of hypertension was 28.4% (22.4-34.7), 25.5% (21.4-29.8), and 24.4% (17.9-31.6) among urban, suburban, and rural populations, respectively. Moreover, rates of hypertension were found to be substantially higher in male (31.6%, 27.3-36.1) compared to female (20.0%, 14.2-26.6), and significantly higher among the middle-aged (≥40 years; 36.8%, 29.4-44.5) than among younger adults (< 40 years; 13.2%, 9.2-17.7). Further, prehypertension prevalence was found to be highest in rural areas (40.4%, 25.4-56.4) followed by urban areas (29.3%, 20.8-38.5) and lowest in suburban areas (25.5%, 18.9-32.7). CONCLUSIONS: Our study identified an alarming situation of hypertension among Nepalese males and middle-aged, and a situation of concern with prehypertension in rural areas affecting almost 40 % of the population.

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

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

Community Health Workers and Disasters: Lessons Learned from the 2015 Earthquake in Nepal.

Introduction The Nepal earthquake of 2015 was a major disaster that exacted an enormous toll on human lives and caused extensive damage to the infrastructure of the region. Similar to other developing countries, Nepal has a network of community health workers (CHWs; known as female community health volunteers [FCHVs]) that was in place prior to the earthquake and continues to function to improve maternal and child health. These FCHVs and other community members were responsible, by default, for providing the first wave of assistance after the earthquake. Hypothesis/Problem Community health workers such as FCHVs could be used to provide formal relief services in the event of an emergency, but there is a paucity of evidence-based literature on how to best utilize them in disaster risk reduction, preparedness, and response. Data are needed to further characterize the roles that this cadre has played in past disasters and what strategies can be implemented to better incorporate them into future emergency management. METHODS: In March 2016, key-informant interviews, FCHV interviews, and focus group discussions (FGDs) were conducted in Nepali health facilities using semi-structured guides. The audio-recorded data were obtained with the assistance of a translator (Nepali-English), transcribed verbatim in English, and coded by two independent researchers (manually and with NVivo 11 Pro software [QSR International; Melbourne, Australia]). RESULTS: Across seven different regions, 14 interviews with FCHVs, two FGDs with community women, and three key-informant interviews were conducted. Four major themes emerged around the topic of FCHVs and the 2015 earthquake: (1) community care and rapport between FCHVs and local residents; (2) emergency response of FCHVs in the immediate aftermath of the earthquake; (3) training requested to improve the FCHVs' ability to manage disasters; and (4) interaction with relief organizations and how to create collaborations that provide aid relief more effectively. CONCLUSIONS: The FCHVs in Nepal provided multiple services to their communities in the aftermath of the earthquake, largely without any specific training or instruction. Proper preparation, in addition to improved collaboration with aid agencies, could increase the capacity of FCHVs to respond in the event of a future disaster. The information gained from this study of the FCHV experience in the Nepal earthquake could be used to inform risk reduction and emergency management policies for CHWs in various settings worldwide. Fredricks K , Dinh H , Kusi M , Yogal C , Karmacharya BM , Burke TF , Nelson BD . Community health workers and disasters: lessons learned from the 2015 earthquake in Nepal. Prehosp Disaster Med. 2017;32(6):604-609.

Awareness, treatment and control of hypertension in Nepal: findings from the Dhulikhel Heart Study.

OBJECTIVES: Although previous studies have suggested alarming rise in the prevalence of hypertension in Nepal, there is dearth of information on its awareness, treatment and control. In this cross-sectional study, we assessed awareness, treatment and control of hypertension among 298 hypertensive adults from the suburban town of Dhulikhel, Nepal. METHODS: This cross-sectional study is based on Dhulikhel Heart Study, which included 1073 adults, aged ≥18 years, recruited from randomly selected households. Comprehensive health interviews and blood pressure measurements were completed during home interviews. Hypertensives (systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg or receiving antihypertensive medication) were further evaluated for awareness, treatment and control of hypertension. Multivariate regression model quantified the association of the sociodemographic characteristics and the cardiovascular disease (CVD) risk factors with hypertension awareness. Differences between sociodemographic characteristics and CVD risk factors with treatment and control of hypertension were tested using χ2 tests. RESULTS: A total of 43.6% of all hypertensives (n=298) were aware of their hypertension status. In multivariate analyses, hypertension awareness was associated with increasing age (p<0.001). More than three-fourth (76.1%) of those who were aware of their hypertension status (n=130) were currently on treatment. There were significant differences in treatment status by sex, occupation, age, income quartiles and body mass index. Only 35.3% of those on treatment (n=99) had blood pressure control. CONCLUSIONS: The levels of awareness, treatment and control of hypertension in this sample of Nepalese adults were low.

Determining the Prevalence of and Risk Factors for Depressive Symptoms among Adults in Nepal.

CONTEXT: Nepal is currently experiencing a rapid growth in non-communicable diseases (NCDs). Depression has previously been associated with NCDs in South Asia; however, data regarding its prevalence and risk factors is lacking in Nepal. AIMS: This study aims to describe the prevalence of and risk factors for depressive symptoms in a suburban population of adults within Nepal. SETTING AND DESIGN: We conducted a cross-sectional analysis of baseline data collected from participants enrolled in the Dhulikhel Heart Study (DHS), a population-based, longitudinal cohort study investigating cardiovascular risk factors in Dhulikhel, a suburban town outside Kathmandu. SUBJECTS AND METHODS: Baseline questionnaire data from 1,073 adults age 18 years and older included the Center for Epidemiologic Studies Depression Scale (CESD). A score of 16 or greater on the CESD has been shown to indicate major depressive symptomatology. STATISTICAL ANALYSIS: Using STATA 13 we conducted Pearson's chi-squared tests and multiple logistic regressions to examine associations between the binary CESD score and gender, age, education, marital status, body mass index (BMI), physical activity, and hypertensive status. RESULTS: The mean CESD score in the sample was 11.7 (SD: 5.3), with 21.3% scoring 16 or greater. Age over 60 and lack of formal education were associated with increased risk of depressive symptoms. Being physically active was associated with decreased risk of depressive symptoms. CONCLUSIONS: The estimated prevalence of depression among adults in Dhulikhel was 21.3%. Significant risk factors for increased depressive symptoms included lack of formal education, age over 60, and physical inactivity.

Prevalence of human papillomavirus infection among women in rural Nepal.

INTRODUCTION: In this study we aimed to determine the overall and type-specific prevalence of cervical human papillomavirus (HPV) infection and risk factors for such infection among women in rural Nepal, and to investigate the distribution of HPV infection by cervical cytology. MATERIAL AND METHODS: The study was conducted among women aged ≥15 years in five rural villages within Kavre District in Nepal. Sociodemographic data and information on risk factors for cervical cancer were obtained through an interview, and a cervical specimen was collected for HPV DNA detection and typing using the Anyplex™ ll HPV28 Detection system, and for Papanicolaou test. RESULTS: Among the 1289 women in whom a valid HPV result was obtained the median age was 40 years (range 17-86 years). Overall, the HPV prevalence was 14.4%, 7.9% for high-risk and 6.5% for low-risk HPV types, and was similar between age groups. The five most common HR types were HPV-18 (2.3%), HPV-51 (1.2%), HPV-59 (1.1%), HPV-31 (0.9%), and HPV-16 (0.8%). The prevalence of high-risk types in women with and without abnormal cytology was 8.3 and 7.7%, respectively. HPV infection was associated with current smoking, formal education, and being married to a husband with at least one previous marriage. CONCLUSIONS: This is the first population-based study to report the prevalence of a broad range of HPV types among women from rural Nepal. These data are crucial for development of preventive strategies to reduce cervical cancer burden in the country.

Medical students' preferences for problem-based learning in relation to culture and personality: a multicultural study.

OBJECTIVE: The aim of this study was to explore positive and negative preferences towards problem-based learning in relation to personality traits and socio-cultural context. METHODS: The study was an anonymous and voluntary cross-sectional survey of medical students (N=449) in hybrid problem-based curricula in Nepal, Norway and North Dakota. Data was collected on gender, age, year of study, cohabitation and medical school. The PBL Preference Inventory identified students' positive and negative preferences in relation to problem-based learning; the personality traits were detected by the NEO Five-Factor Inventory. The determinants of the two kinds of preferences were analyzed by hierarchical multiple linear regressions. RESULTS: Positive preferences were mostly determined by personality; associations were found with the traits Extra-version, Openness to experience, Conscientiousness and Neuroticism; the first three are related to sociability, curiosity and orderliness, the last, to mental health. The learn-ing environments of such curricula may be supportive for some and unnerving for others who score high on Neuroticism. Negative preferences were rather determined by culture, but also, they correlated with Neuroticism and Conscientiousness. Negative preferences were lower among females and students living in symmetrical relationships. Some high on Conscientiousness disliked group work, and the negative correlation with Agreeableness indicated that less sociable students were not predisposed to this kind of learning activity. CONCLUSIONS: Preferences related to problem-based learning were significantly and independently determined both by personality traits and culture. More insights into the nature of students' preferences may guide aspects of curriculum modifications and the daily facilitation of groups.