Cardiovascular disease mortality based on verbal autopsy in low- and middle-income countries: a systematic review.

Objective: To conduct a systematic review of verbal autopsy studies in low- and middle-income countries to estimate the fraction of deaths due to cardiovascular disease. Method: We searched MEDLINE®, Embase® and Scopus databases for verbal autopsy studies in low- and middle-income countries that reported deaths from cardiovascular disease. Two reviewers screened the studies, extracted data and assessed study quality. We calculated cause-specific mortality fractions for cardiovascular disease for each study, both overall and according to age, sex, geographical location and type of cardiovascular disease. Findings: We identified 42 studies for inclusion in the review. Overall, the cardiovascular disease cause-specific mortality fractions for people aged 15 years and above was 22.9%. This fraction was generally higher for males (24.7%) than females (20.9%), but the pattern varied across World Health Organization regions. The highest cardiovascular disease mortality fraction was reported in the Western Pacific Region (26.3%), followed by the South-East Asia Region (24.1%) and the African Region (12.7%). The cardiovascular disease mortality fraction was higher in urban than rural populations in all regions, except the South-East Asia Region. The mortality fraction for ischaemic heart disease (12.3%) was higher than that for stroke (8.7%). Overall, 69.4% of cardiovascular disease deaths were reported in people aged 65 years and above. Conclusion: The burden of cardiovascular disease deaths outside health-care settings in low- and middle-income countries is substantial. Increasing coverage of verbal autopsies in these countries could help fill gaps in cardiovascular disease mortality data and improve monitoring of national, regional and global health goals.

Meeting report: Advancing accelerated regulatory review with Real-Time Oncology Review (RTOR), Project Orbis, and the Product Quality Assessment Aid.

The American Association of Pharmaceutical Scientists (AAPS) Chemistry, Manufacturing, and Controls (CMC) Community hosted two virtual panel discussions focusing on several novel regulatory review pathways for innovative oncology products: Real-Time Oncology Review (RTOR), Project Orbis, and the Product Quality Assessment Aid (PQAAid). The panel sessions were held on August 27, 2021, for the discussion of RTOR, and January 21, 2022, for the discussion of Project Orbis and the PQAAid. Both panel sessions included representatives from the US Food and Drug Administration (FDA) and subject matter experts from the pharmaceutical and biotechnology industries, with the aim of facilitating knowledge sharing on CMC-specific advantages, challenges, eligibility criteria for participation, and operational modifications instituted through the utilization of these acceleration initiatives. Key topics included managing cross-regional regulatory CMC requirements, adapting to expedited development timelines, coordinating interactions between health authorities and industry, and potential opportunities for future improvement and expansion of these programs. As RTOR, Project Orbis, and PQAAid are relatively new initiatives, the experiences shared by the panel experts are valuable for providing deeper insight into these new regulatory pathways and processes.

Validation studies of verbal autopsy methods: a systematic review.

BACKGROUND: Verbal autopsy (VA) has emerged as an increasingly popular technique to assign cause of death in parts of the world where the majority of deaths occur without proper medical certification. The purpose of this study was to examine the key characteristics of studies that have attempted to validate VA cause of death against an established cause of death. METHODS: A systematic review was conducted by searching the MEDLINE, EMBASE, Cochrane-library, and Scopus electronic databases. Included studies contained 1) a VA component, 2) a validation component, and 3) original analysis or re-analysis. Characteristics of VA studies were extracted. A total of 527 studies were assessed, and 481 studies screened to give 66 studies selected for data extraction. RESULTS: Sixty-six studies were included from multiple countries. Ten studies used an existing database. Sixteen studies used the World Health Organization VA questionnaire and 5 studies used the Population Health Metrics Research Consortium VA questionnaire. Physician certification was used in 36 studies and computer coded methods were used in 14 studies. Thirty-seven studies used high level comparator data with detailed laboratory investigations. CONCLUSION: Most studies found VA to be an effective cause of death assignment method and compared VA cause of death to a high-quality established cause of death. Nonetheless, there were inconsistencies in the methodologies of the validation studies, and many used poor quality comparison cause of death data. Future VA validation studies should adhere to consistent methodological criteria so that policymakers can easily interpret the findings to select the most appropriate VA method. PROSPERO REGISTRATION: CRD42020186886.

Facilitators and barriers to participation in health mothers' groups in improving maternal and child health and nutrition in Nepal : A mixed-methods study.

BACKGROUND: In Nepal, Health Mother's Groups (HMG) are women's group-based programmes for improving maternal and child health. However, they remain underutilised with only 27% of reproductive-aged women participating in an HMG meeting in 2016. This study aimed to understand the facilitators and barriers to HMG meeting participation. METHODS: We conducted a convergent mixed-methods study using cross-sectional quantitative data from the 2016 Nepal Demographic and Health Survey and primary data collected via 35 in-depth interviews and eight focus group discussions with 1000-day women and their family members, female community health volunteers (FCHVs) and health facility staff in two geographies of Nepal, Kaligandaki and Chapakot. Quantitative data were analysed using logistic regression and qualitative data using deductive coding. The results were triangulated and thematically organised according to the socio-ecological model (SEM). RESULTS: Facilitators and barriers emerged across individual, interpersonal and community levels of the SEM. In the survey, women with more children under five years of age, living in a male-headed household, or in rural areas had increased odds of HMG participation (p < 0.05) while belonging to the Janajati caste was associated with lower odds of participation (p < 0.05). Qualitative data helped to explain the findings. For instance, the quantitative analysis found women's education level associated with HMG participation (p < 0.05) while the qualitative analysis showed different ways women's education level could facilitate or hinder participation. Qualitative interviews further revealed that participation was facilitated by women's interest in acquiring new knowledge, having advanced awareness of the meeting schedule and venue, and engagement with health workers or non-government organisation staff. Participation was hindered by the lack of meeting structure and work obligations during the agricultural season. CONCLUSIONS: To improve women's participation in HMGs in Nepal, it is necessary to address factors at the SEM's individual, interpersonal, and community levels, such as enhancing FCHV literacy, providing advance notice of the meeting schedule, upgrading the meeting venues and reducing women's workload through family support, particularly during agricultural season. These improvements are essential for strengthening effective implementation of HMG meetings and similar women's group-based platforms, and for ultimately improving maternal and child health in Nepal.

Health Mothers' Groups in Nepal: Barriers, Facilitators, and Recommendations.

Background: Nepal's female community health volunteers (FCHVs) each lead a monthly health mothers' group (HMG) to share health-related information and engage communities in the health system. Suaahara II (SII), a US Agency for International Development-funded multisectoral nutrition program, uses social and behavior change interventions to promote HMG participation and uses its health systems interventions to strengthen HMG quality. Objectives: This study aimed to explore HMG functionality and variation across Nepal, including barriers and facilitators to attending HMG meetings. Methods: SII's cross-sectional annual survey data from 16 districts (n = 192 FCHVs and 1850 mothers with children <2 y) were used. Descriptive and logistic regression analyses were conducted where the outcome variable was whether mothers were active HMG members or not, with FCHV and maternal characteristics as explanatory variables. Qualitative data were obtained from 3 of 16 survey districts (n = 30 observations, n = 30 in-depth interviews with mothers, and n = 16 focus group discussions with mothers, family members, FCHVs, health workers, and SII staff). Results: Among FCHVs, 90% reported facilitating HMG meetings, whereas 64% of mothers reported HMG availability, and only 25% reported participating actively in meetings. Household head sex, maternal age, maternal education, maternal self-efficacy, and engagement with an FCHV and SII were associated with whether mothers were active participants in HMG meetings. Qualitative findings highlighted systems-level barriers, including lack of FCHV skills, demotivation, and heavy workload. Mothers noted time as the major constraint and family support, the HMG's savings component, and active FCHVs as facilitators to participation. Conclusions: Findings suggest that both supply- and demand-side solutions are needed to improve HMG performance and uptake in Nepal. These solutions need to include improving FCHV skills and motivating them to provide high-quality HMG services, as well as encouraging family members to support women so that they have time to participate in the HMGs.

Exploring the Use of Mobile Health to Improve Community-Based Health and Nutrition Service Utilization in the Hills of Nepal: Qualitative Study.

BACKGROUND: With mobile phone coverage and ownership expanding globally, mobile health (mHealth) interventions are increasingly being used to improve coverage and quality of health and nutrition services. However, evidence on mHealth intervention feasibility and factors to consider during program design is limited in low- and middle-income countries like Nepal. OBJECTIVE: This study aimed to examine the potential of using text messages to improve health and nutrition services by exploring mobile phone ownership and sharing; mobile phone use and skills; and interest, preferences, and limitations regarding mHealth interventions. METHODS: We conducted 35 in-depth interviews with 1000-day women (the period from conception to a child's second birthday), health facility staff, and female community health volunteers (FCHVs), as well as eight focus group discussions with health facility staff, FCHVs, and 1000-day household decision-makers (ie, husbands, mothers-in-law, and fathers-in-law). We also conducted a mobile phone skills test. We employed thematic analysis using framework matrices and analytical memos. RESULTS: The study included 70 study participants, of whom 68 (97%) had a mobile phone, and phone sharing was uncommon. Use of text messages was most commonly reported by 1000-day women and health facility staff than household decision-makers and FCHVs. More than 8 in 10 participants (54/64, 84%) could dial numbers, and the majority (28/34, 82%) of 1000-day women, health facility staff, and male decision-makers could also read and write text messages. We found that 1000-day women preferred educational and reminder messages, whereas health facility staff and FCHVs desired educational and motivational messages. Participants suggested different types of texts for 1000-day women, families, FCHVs, and health facility staff, and reported less value for texts received from unknown phone numbers. CONCLUSIONS: A text message-based mHealth intervention is acceptable in the hills of Nepal and has the potential to improve community health and nutrition service utilization, particularly by sending meeting reminders and by providing information. Our findings contribute to text message-based mHealth intervention design in under-resourced settings.

Intimate partner violence and nutritional status among nepalese women: an investigation of associations.

BACKGROUND: Malnutrition among women in Nepal persists as a major public health burden. Global literature suggests that domestic violence may have a negative impact on women's nutritional status. The contribution of intimate partner violence (IPV) to increased stress levels, poor self-care including the consumption of less food and, in turn, malnutrition has been documented. However, there is little empirical evidence on IPV and its relationship with women's nutritional status in Nepal and thus, this paper assesses these associations. METHODS: We used data on non-pregnant married women (n = 3293) from the 2016 Nepal Demographic and Health Survey (NDHS). The primary exposure variable was whether the women had ever experienced physical, sexual, or emotional violence or controlling behaviours by a current or former partner, based on her responses to the NDHS domestic violence questions. The primary outcome variables were three indicators of malnutrition: under-weight (BMI < 18.5), over-weight (BMI > 25), and anemia (Hb < 11.0 g dL). We used logistic and multinomial regression models, adjusted for potential socio-demographic and economic confounders, as well as clustering, to examine associations between IPV exposure and malnutrition. RESULTS: Approximately 44% of women had experienced at least one of the four types of IPV. Among them, around 16, 25%. and 44% were underweight, overweight, or anemic, respectively, compared to 13, 29, and 35% of women never exposed to IPV. We did not find any associations between underweight and any of the four types of IPV. Overweight was associated with physical violence (adjusted RRR = 0.67, P < 0.01, CI = 0.50-0.88) and severe physical violence (adjusted RRR = 0.53, P < 0.05, CI = 0.32-0.88) Controlling behaviors were associated with anemia (adjusted RRR = 1.31, P < 0.01, CI = 1.11-1.54). CONCLUSIONS: Among married Nepalese women, physical violence appears to be a risk factor for one's weight and controlling behaviors for one's anemia status. Additional, rigorous, mixed-methods research is needed to understand the reporting of IPV and what relationships do or do not exist between IPV experience and nutrition both in Nepal and in other settings.

Intimate partner violence and contraceptive use among married women in Nepal.

OBJECTIVE: To examine relationships between lifetime experience of intimate partner violence (IPV), and current contraceptive use and method among married women of reproductive age in Nepal. METHODS: A cross-sectional analysis of 2016 Nepal Demographic Health Survey data on contraceptive use and IPV experience among ever-married women of reproductive age. Weighted percentages were reported and multinomial logistic regression was used to assess associations between IPV (physical, sexual, emotional, or any form) and contraception use (modern reversible, sterilization, or traditional). RESULTS: Among 3562 women who responded to the violence module, 26% reported experiencing any form (physical, sexual or emotional) of IPV in their lifetime. Lifetime exposure to any form of IPV was associated with sterilization (adjusted odds ratio [aOR], 1.50; 95% confidence interval [CI], 1.12-2.00) and lifetime exposure to physical violence only was significantly associated with having been sterilized (aOR, 1.59; 95% CI, 1.17-2.16). CONCLUSION: Experience of violence, particularly physical violence, was found to be associated with sterilization in Nepal. Research is needed to understand the causes of this association, and the decision-making power dynamics related to contraceptive use, husbands' attitudes toward sterilization, and the reasons why sterilization-relative to other contraceptive options-was the contraceptive method of choice.

Determinants of stunting among children aged 0-59 months in Nepal: findings from Nepal Demographic and health Survey, 2006, 2011, and 2016.

BACKGROUND: Stunting is one of the most commonly used indicators of child nutrition and health status. Despite significant efforts by the government and external development partners to improve maternal and child health and nutrition, stunting is consistently high in Nepal. This paper assesses the potential determinants of stunting among children aged 0-59 months using the last three successive Nepal Demographic and Health Surveys (NDHS). METHODS: We used three nationally representative cross-sectional household surveys, known as the NDHS- 2006, 2011 and 2016. Logistic regression was used to identify the potential determinants of stunting. The sub sample for this study includes n = 5083 in 2006, n = 2485 in 2011, and n = 2421 in 2016. RESULTS: Rates of stunting decreased from nearly 50% in 2006 to about 36% in 2016. The prevalence of stunting was higher among children from larger families (51.0% in 2006, 41.1% in 2011, 38.7% in 2016), poor wealth quintile households (61.2% in 2006, 56.0% in 2011, 49.2% in 2016), and severely food insecure households (49.0% in 2011, 46.5% in 2016). For child stunting, the common determinants in all three surveys included: being from the highest equity quintile (OR: 0.58 in 2006, 0.26 in 2011, 0.28 in 2016), being older (OR: 2.24 in 2006, 2.58 in 2011, 1.58 in 2016), being below average size at time of birth (OR: 1.64 in 2006, 1.55 in 2011, 1.60 in 2016), and being affected by anemia (OR: 1.32 in 2006, 1.59 in 2011, 1.40 in 2016). CONCLUSIONS: This study found that household wealth status, age of child, size of child at time of birth, and child anemia comprised the common determinants of stunting in all three surveys in Nepal. Study findings underscore the need for effective implementation of evidence-based nutrition interventions in health and non-health sectors to reduce the high rates of child stunting in Nepal.