Effects of a dietary intervention on cardiometabolic risk and food consumption in a workplace.

BACKGROUND: Worksite-based health programs have shown positive impacts on employee health and have led to significant improvements in cardiovascular risk factor profiles. We aimed to determine the effect of cafeteria intervention on cardio-metabolic risk factors diet in a worksite setting (Dhulikhel Hospital) in Nepal. METHODS: In this one-arm pre-post intervention study, we recruited 277 non-pregnant hospital employees aged 18-60 with prediabetes or pre-hypertension. The study was registered in clinicaltrials.gov (NCT03447340; 2018/02/27). All four cafeterias in the hospital premises received cafeteria intervention encouraging healthy foods and discouraging unhealthy foods for six months. We measured blood pressure, fasting glucose level, glycated hemoglobin, cholesterol in the laboratory, and diet intake (in servings per week) using 24-hour recall before and six months after the intervention. The before and after measures were compared using paired-t tests. RESULTS: After six months of cafeteria intervention, the median consumption of whole grains, mono/polyunsaturated fat, fruits, vegetable and nuts servings per week increased by 2.24(p<0.001), 2.88(p<0.001), 0.84(p<0.001) 2.25(p<0.001) and nuts 0.55 (p<0.001) servings per week respectively. The median consumption of refined grains decreased by 5.07 servings per week (p<0.001). Mean systolic and diastolic blood pressure decreased by 2 mmHg (SE = 0.6; p = 0.003) and 0.1 mmHg (SE = 0.6; p = 0.008), respectively. The low-density lipoprotein (LDL) was significantly reduced by 6 mg/dL (SE = 1.4; p<0.001). CONCLUSION: Overall, we found a decrease in consumption of refined grains and an increase in consumption of whole grains, unsaturated fats, fruits, and nuts observed a modest reduction in blood pressure and LDL cholesterol following a 6-month cafeteria-based worksite intervention incorporating access to healthy foods.

Challenges in Effective Referral of Cardiovascular Diseases in Nepal: A Qualitative Study from Health Workers' and Patients' Perspective.

Background: Nepal, currently facing a high burden of noncommunicable diseases (NCDs), including cardiovascular diseases (CVDs), which poses the highest mortality rate in the country, does not seem to have a proper referral strategy. This study explored the wide range of factors and challenges that affect the referral system of CVD cases in Nepal. Methods: In this qualitative study, we conducted face-to-face and telephone interviews with purposely selected 57 key participants which included 35 healthcare professionals from tertiary, secondary, and primary levels from Bagmati Province and 22 CVD patients (myocardial infarction and stroke) from Bagmati and Madhesh Provinces. We interviewed them using an interview guide with open-ended questions for in-depth information in a local language and in a private space. The interviews were audio-recorded, transcribed verbatim, coded, and analyzed using the thematic approach. Results: The findings indicated that the referral system for CVD cases from primary- to secondary- to tertiary-level care is inadequate and malfunctioning. The major factors affecting referral of CVD cases are centralization of CVD-specific services in few urban areas, inadequate systematic communication between the centers, self-referential, lack of human resources for CVD care, and obstacles to patient transfer due to geographical and financial reasons. Conclusion: A referral system for CVD patients is absent in the context of Nepal. Understanding and addressing key factors that affect the referral system of CVD patients may help to improve cardiac outcomes and ultimately save lives.

Cyberbullying and cyber-victimisation among higher secondary school adolescents in an urban city of Nepal: a cross-sectional study.

OBJECTIVE: To assess the prevalence and factors associated with cyberbullying and cyber-victimisation among high school adolescents of Pokhara Metropolitan City, Nepal. DESIGN: A cross-sectional study. SETTING: Pokhara Metropolitan City, Nepal. PARTICIPANTS: We used convenient sampling to enrol 450 adolescents aged 16-19 years from four distinct higher secondary schools in Pokhara Metropolitan City. OUTCOME MEASURES: We administered the Cyberbullying and an Online Aggression Survey to determine the prevalence of cyberbullying and cyber-victimisation. Univariate and multivariate logistic regression analyses were performed to estimate the ORs and 95% CIs. Data were analysed using STATA V.13. RESULTS: The 30-day prevalence of cyberbullying and cyber-victimisation was 14.4% and 19.8%, and the over-the-lifetime prevalence was 24.2% and 42.2%, respectively. Posting mean or hurtful comments online was the most common form of both cyberbullying and cyber-victimisation. Compared with females, males were more likely to be involved in cyberbullying (adjusted OR (AOR)=13.52; 95% CI: 6.04 to 30.25; p value <0.001) and cyber-victimised (AOR=2.22; 95% CI: 1.33 to 3.73; p value <0.05). Using the internet almost every day was associated with cyberbullying (AOR=9.44; 95% CI: 1.17 to 75.79; p value <0.05) and cyber-victimisation (AOR=4.96; 95% CI: 1.06 to 23.18; p value <0.05). Students from urban place of residence were associated with both cyberbullying (AOR=2.45; 95% CI: 1.23 to 4.88; p value <0.05) and cyber-victimisation (AOR=1.77; 95% CI: 1.02 to 3.05; p value <0.05). CONCLUSION: The study recommends the implementation of cyber-safety educational programmes, and counselling services including the rational use of internet and periodic screening for cyberbullying in educational institutions. The enforcement of strong anti-bullying policies and regulations could be helpful to combat the health-related consequences of cyberbullying.

Physiotherapy and its service in Nepal: implementation and status reported from facility surveys and official registers.

BACKGROUND: Physiotherapy is a growing profession in Nepal. Despite efforts to promote strengthening and development, there are still challenges in providing equitable access and availability to services, particularly in underserved areas. Updated information is needed to address challenges to provide proper planning for resource allocation. OBJECTIVE: To assess implementation of physiotherapy services and to explore plans, policies and the general status of physiotherapy in Nepal. METHOD: Implementation was assessed with a cross-sectional survey conducted in Province III containing closed-ended questions addressing physiotherapy services, human resources, charging and record-keeping systems, and accessibility. Stratified purposive sampling was used to select eligible facilities from the list of Department of Health Services. Official records were explored through visits to governing institutions and by reviews of registers and reports to obtain data and information on status, plans and policy. RESULTS: The survey included 25 urban and 4 rural facilities, covering hospitals and rehabilitation centres; both public (37.9%) and non-public (62.1%). Most facilities (79.3%) employed physiotherapists with bachelor's degrees. Average number of visits were 29.55 physiotherapy outpatients and 14.17 inpatients per day. Patient records were mainly paper based. Most (69%) used the hospital main card, while others (31%) had their own physiotherapy assessment card. Most referrals came from doctors. The most offered services were musculoskeletal, neurological, and paediatric physiotherapy. Daily basis charging was common. A single visit averaged 311 Nepalese rupees ≈ 2.33 US$. Convenience for persons with disabilities was reported as partial by 79% of outpatient departments. Official register data showed 313 master's and 2003 bachelor's graduates. Six colleges offered physiotherapy bachelor's degree, whereof one also offered a master's program. Government records revealed significant progress in physiotherapy in Nepal. CONCLUSION: The study highlights variations in physiotherapy services within a province owing to type, size and location, but also unwarranted variations. Despite the progress, implementation of physiotherapy services in the perspective of official records imply a need of systems for proper planning and monitoring. Physiotherapy provision in underserved areas warrants further attention.

Exploring knowledge, perceptions, and practices of antimicrobials, and their resistance among medicine dispensers and community members in Kavrepalanchok District of Nepal.

BACKGROUND: Inappropriate use of antimicrobials is a global public health issue, particularly in developing countries, including Nepal, where over-the-counter sales and self-medication of antimicrobials are common. OBJECTIVES: To explore knowledge, perceptions, and practices of antimicrobials and their resistance among medicine dispensers and community members in Nepal. METHODS: The study was conducted in three rural and five urban municipalities of the Kavrepalanchok district from May 2021 to August 2021. Data were collected using two qualitative approaches: In-Depth Interviews (IDIs) and Focus Group Discussions (FGDs). Data were analyzed using thematic analysis that combined deductive and inductive approaches to identify codes under pre-specified themes. RESULTS: A total of 16 In-depth interviews with medicine dispensers and 3 focus group discussions with community members were conducted. Knowledge regarding antimicrobial resistance varied among dispensers. Those with a prior educational background in pharmacy often had good knowledge about the causes and consequences of antimicrobial resistance. Meanwhile, consumers were less aware of antimicrobial resistance. Community members perceived antimicrobials as effective medicines but not long-term solution for treating diseases. They reported that dispensing without a prescription was common and that both consumers and dispensers were responsible for the inappropriate use of antimicrobials. On the contrary, several dispensers said that self-medication was common among the consumers, especially among more educated groups. The medicine dispensers and consumers expressed concerns about the weak enforcement of policies regarding pharmacy drug use and dispensing practices. CONCLUSION: Promoting and strengthening the appropriate use of antimicrobials among medicine dispensers and community members is crucial. Bold policies and collective implementation of regulations could help combat antimicrobial resistance.

Protocol for an evaluation of the initiation of an integrated longitudinal outpatient care model for severe chronic non-communicable diseases (PEN-Plus) at secondary care facilities (district hospitals) in 10 lower-income countries.

INTRODUCTION: The Package of Essential Noncommunicable Disease Interventions-Plus (PEN-Plus) is a strategy decentralising care for severe non-communicable diseases (NCDs) including type 1 diabetes, rheumatic heart disease and sickle cell disease, to increase access to care. In the PEN-Plus model, mid-level clinicians in intermediary facilities in low and lower middle income countries are trained to provide integrated care for conditions where services traditionally were only available at tertiary referral facilities. For the upcoming phase of activities, 18 first-level hospitals in 9 countries and 1 state in India were selected for PEN-Plus expansion and will treat a variety of severe NCDs. Over 3 years, the countries and state are expected to: (1) establish PEN-Plus clinics in one or two district hospitals, (2) support these clinics to mature into training sites in preparation for national or state-level scale-up, and (3) work with the national or state-level stakeholders to describe, measure and advocate for PEN-Plus to support development of a national operational plan for scale-up. METHODS AND ANALYSIS: Guided by Proctor outcomes for implementation research, we are conducting a mixed-method evaluation consisting of 10 components to understand outcomes in clinical implementation, training and policy development. Data will be collected through a mix of quantitative surveys, routine reporting, routine clinical data and qualitative interviews. ETHICS AND DISSEMINATION: This protocol has been considered exempt or covered by central and local institutional review boards. Findings will be disseminated throughout the project's course, including through quarterly M&E discussions, semiannual formative assessments, dashboard mapping of progress, quarterly newsletters, regular feedback loops with national stakeholders and publication in peer-reviewed journals.

Effectiveness of interventions for emergency care of hypoglycaemia and diabetic ketoacidosis: A systematic review.

AIM: This systematic review aims to provide evidence on effectiveness of interventions used in emergency care of hypoglycaemia and diabetic ketoacidosis (DKA). METHODOLOGY: This is a systematic review of randomized controlled trials and analytical studies. We selected studies based on eligibility criteria. The databases Medline, Cochrane library and Embase were searched from their inception till November 2, 2022, using search strategy. We used the term such as "diabetes mellitus", "treatment", "hypoglycaemia", "diabetic ketoacidosis", "low blood sugar", "high blood sugar" and Mesh terms like "disease management", "hypoglycaemia", "diabetic ketoacidosis", and "diabetes mellitus" to form search strategy. RESULTS: Hypoglycemia: Both 10 % dextrose (D10) and 50 % dextrose (D50) are effective options with similar hospital mortality D10 (4.7 %) and D50 (6.2 %). DKA: Low dose insulin is non-inferior to standard dose with time till resolution of DKA 16.5 (7.2) hours and 17.2 (7.7) hours (p value = 0.73) respectively. In children, subcutaneous insulin was associated with reduced ICU admissions and hospital readmissions (67.8 % to 27.9 %). Plasmalyte (PL) is noninferior to sodium chloride (SC), with ICU length of stay 49 h (IQR 23-72) and 55 h (IQR 41-80) respectively, hyperchloremia was associated with longer in-hospital length of stay and longer time to resolution of DKA. And potassium replacement at < 10 mmol/L was associated with higher mortality (n = 72). CONCLUSION: We conclude either of the 10 % or 50 % dextrose is effective for management of hypoglycaemia. For DKA subcutaneous insulin and intravenous insulin, chloride levels ≤ 109 mEq/L, potassium above 10 mmol/l, IV fluids like Plasmalyte and normal saline are effective.

Using the Journey to Health and Immunization (JTHI) Framework to Engage Stakeholders in Identifying Behavioral and Social Drivers of Routine Immunization in Nepal.

Although the Government of Nepal has achieved high and sustained childhood vaccination coverage, reaching under-immunized and zero-dose children requires different approaches. Behavioral science offers promise in better understanding the drivers of vaccination and development of more effective programs; however, the application of behavioral science to immunization programs in Nepal is nascent. Through the Behavioral Science Immunization Network, JSI, UNICEF Nepal, and Dhulikhel Hospital-Kathmandu University School of Medical Sciences established a Behavioral Science Center to engage a diverse group of stakeholders in increasing the capacity of practitioners to use behavioral science in immunization programming. As a result of the engagement during formative research, government stakeholders requested and applied tools from behavioral science to solve different immunization challenges. Of particular value was the use of the Journey to Health and Immunization framework, which helped stakeholders identify behavioral and social drivers of zero-dose communities in Kathmandu. Our experience in Nepal demonstrates that there is strong demand for approaches and tools from behavioral science to use in relation to immunization and that this type of engagement model is effective for generating demand for and strengthening capacity to use behavioral science approaches.

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.

A critical analysis of health system in Nepal; Perspective's based on COVID-19 response.

Background: Nepal moved from a unitary government to a federal system of government in 2015 under its constitution. Nepal is a federal democratic republic governed by three levels of government: a federal, provincial, and local level. The response to COVID-19 in Nepal has been majorly led and controlled by the federal government. All three levels of government are performing their responsibilities; however, they face various challenges in responding to COVID-19. This study aimed to critically analyze Nepal's health system in the context of the COVID-19 response. Methods: We conducted semi-structured in-depth interviews by telephone among the policymakers, health workers, and stakeholders at the federal, provincial, and local levels (n = 41) between January to July 2021. The interviews were audio recorded, transcribed into English, and coded using inductive-deductive approaches. Results: COVID-19 considerably impacted routine health care, mainly maternity services and immunization. Inadequate financial resources, inadequate human resources, and the lack of ventilators, ICUs, and X-ray services were the significant challenges in tackling and managing COVID-19 effectively. Conclusion: The study found that all three levels of government perform their roles and responsibilities and effectively manage the pandemic. The federal and provincial governments focused more on the plans and policy development, while the local government demonstrated greater accountability in implementing those plans and policies. Therefore, all three tiers of government need to coordinate together for preparing and communicating information in times of emergency. Besides, it is imperative to empower local governments to maintain Nepal's federal health system.

How Did People with Prediabetes Who Attended the Diabetes Prevention Education Program (DiPEP) Experience Making Lifestyle Changes? A Qualitative Study in Nepal.

Diabetes can be prevented through lifestyle modification in the prediabetic phase. A group-based lifestyle intervention called 'Diabetes Prevention Education Program' (DiPEP) was tested recently in Nepal. The present study aimed to explore experiences of making lifestyle changes among people with prediabetes participating in the DiPEP. This qualitative study, with semi-structured interviews of 20 participants, was conducted 4-7 months following DiPEP intervention. Data analysis was performed by thematic analysis. The results included four themes, understanding that diabetes could be prevented, lifestyle changes made, hurdles to overcome, and experiencing benefits leading to sustained change. Some participants said they felt relieved to know that they had a chance to prevent diabetes. The participants talked mostly about making changes in diet (reducing carbohydrate intake) and physical activity (starting exercises). Obstacles mentioned included a lack of motivation and a lack of family support to implement changes. Experiencing benefits such as weight loss and reduced blood sugar levels were reported to lead them to maintain the changes they had made. Understanding that diabetes could be prevented was a key motivator for implementing changes. The benefits and hurdles experienced by the participants of the present study can be taken into consideration while designing lifestyle intervention programs in similar settings.

Factors Associated with Medication Adherence among Patients with Type 2 Diabetes Mellitus: A Hospital-Based Cross-Sectional Study in Nepal.

As diabetes increases globally, high mortality increases due to complications of uncontrolled sugar. Medication adherence is important to control blood sugar and prevent its complications. Objective of the study was to identify factors associated with medication adherence among type 2 diabetes patients. A cross-sectional study was conducted among 343 patients visiting Dhulikhel Hospital, Nepal, for their fasting blood sugar test from September to December 2016. Inclusion criteria: patients with type 2 diabetes, under diabetes medication for past three months (minimum), age ≥ 18 years. The outcome of the study was medication adherence measured using the eight-item Morisky medication adherence scale (MMAS-8) (© 2006 Donald E. Morisky). Multivariate logistic regression was used for the analysis. Results showed that 61% of respondents had high medication adherence; adherence was positively associated with formal education [AOR: 2.43 (95% CI: 1.34, 4.39)] and attendance at diabetes counseling [AOR: 1.76 (95% CI: 1.02, 3.04)] after adjusting for age, occupation, medicine intake duration and diabetes medicine types. The study concluded that formal education and attendance at diabetes counseling positively affected patients' adherence to medicine. We encourage healthcare institutions to provide counseling services to all the patients with type 2 diabetes and focus more on those who are less educated.

Prevalence and factors associated with depression, anxiety, and stress symptoms among home isolated COVID-19 patients in Western Nepal.

Introduction: Globally, COVID-19 pandemic has a significant impact on mental health. In Nepal, COVID-19 positive cases have to self-isolate at home in multi-generational and multi-family households. This could be strongly associated with depression, anxiety, and stress-related health outcomes. Additionally, COVID-19 related stigma and fear of transmission may intensify depression, anxiety, and stress symptoms. This study determined the prevalence of depression, anxiety, and stress symptoms and their association with presence of COVID-19 symptoms and comorbid conditions among home isolated COVID-19 positives in the Karnali province, Nepal. Methods: We conducted a cross-sectional study to assess depression, anxiety, and stress symptoms among 402 home isolated COVID-19 patients of Karnali province from January to May 2021 using "Depression, Anxiety and Stress Scale-21 (DASS-21)". We interviewed patients to collect socio-demographic, DASS-21, COVID-19 symptoms, comorbid conditions, and self-treatment. We conducted a telephonic interview using a standardized questionnaire using Kobotoolbox. We calculated the prevalence of depression, anxiety, and stress symptoms. We utilized univariate and multivariate logistic regression to determine their association with the presence of COVID-19 symptoms and comorbid conditions. In multivariate logistic regression, we adjusted sociodemographic factors (age, gender, ethnicity, marital status, monthly family income, education level), smoking status and history of self-treatment. We reported adjusted odds ratios (aOR) with 95% confidence intervals. All analyses were conducted in R (version: 4.0.3). Results: The prevalence of depression, anxiety and stress symptoms among home isolated COVID-19 patients were 8.0% (95% CI: 5.5 to 11.1), 11.2% (95% CI: 8.3 to 14.7), and 4.0% (95% CI: 2.3 to 6.4) respectively. Higher odds of depression symptoms (aOR: 2.86; 95% CI: 1.10-7.44, p = 0.03), anxiety symptoms (aOR: 3.81; 95% CI: 1.62 to 8.93; p = <0.01) and stress symptoms (aOR: 7.78; 95% CI: 1.43 to 42.28; p = 0.02) were associated significantly with presence of COVID-19 symptoms in past week. Higher odds of anxiety symptoms were associated with the presence of comorbid conditions (aOR = 2.92; 95% CI: 1.09 to 7.80; p = 0.03). Conclusion: Depression, anxiety, and stress symptoms were present in a significant proportion of home isolated COVID-19 patients in western Nepal and positively associated with the presence of COVID-19 symptoms. In this global COVID-19 pandemic, it is important to provide timely counseling to high-risk groups like those with comorbidities and COVID-19 symptoms to maintain a high level of mental health among home isolated COVID-19 patients.

A cluster randomized controlled trial of an electronic decision-support system to enhance antenatal care services in pregnancy at primary healthcare level in Telangana, India: trial protocol.

BACKGROUND: India contributes 15% of the total global maternal mortality burden. An increasing proportion of these deaths are due to Pregnancy Induced Hypertension (PIH), Gestational Diabetes Mellitus (GDM), and anaemia. This study aims to evaluate the effectiveness of a tablet-based electronic decision-support system (EDSS) to enhance routine antenatal care (ANC) and improve the screening and management of PIH, GDM, and anaemia in pregnancy in primary healthcare facilities of Telangana, India. The EDSS will work at two levels of primary health facilities and is customized for three cadres of healthcare providers - Auxiliary Nurse Midwifes (ANMs), staff nurses, and physicians (Medical Officers). METHODS: This will be a cluster randomized controlled trial involving 66 clusters with a total of 1320 women in both the intervention and control arms. Each cluster will include three health facilities-one Primary Health Centre (PHC) and two linked sub-centers (SC). In the facilities under the intervention arm, ANMs, staff nurses, and Medical Officers will use the EDSS while providing ANC for all pregnant women. Facilities in the control arm will continue to provide ANC services using the existing standard of care in Telangana. The primary outcome is ANC quality, measured as provision of a composite of four selected ANC components (measurement of blood pressure, blood glucose, hemoglobin levels, and conducting a urinary dipstick test) by the healthcare providers per visit, observed over two visits. Trained field research staff will collect outcome data via an observation checklist. DISCUSSION: To our knowledge, this is the first trial in India to evaluate an EDSS, targeted to enhance the quality of ANC and improve the screening and management of PIH, GDM, and anaemia, for multiple levels of health facilities and several cadres of healthcare providers. If effective, insights from the trial on the feasibility and cost of implementing the EDSS can inform potential national scale-up. Lessons learned from this trial will also inform recommendations for designing and upscaling similar mHealth interventions in other low and middle-income countries. CLINICALTRIALS: gov, NCT03700034, registered 9 Oct 2018, https://www. CLINICALTRIALS: gov/ct2/show/NCT03700034 CTRI, CTRI/2019/01/016857, registered on 3 Mar 2019, http://www.ctri.nic.in/Clinicaltrials/pdf_generate.php?trialid=28627&EncHid=&modid=&compid=%27,%2728627det%27.

Health system capacity to manage diabetic ketoacidosis in nine low-income and lower-middle income countries: A cross-sectional analysis of nationally representative survey data.

Background: There has been increasing awareness about the importance of type 1 diabetes (T1D) globally. Diabetic ketoacidosis (DKA) is a life-threatening complication of T1D in low-income settings. Little is known about health system capacity to manage DKA in low- and lower-middle income countries (LLMICs). As such, we describe health system capacity to diagnose and manage DKA across nine LLMICs using data from Service Provision Assessments. Methods: In this cross-sectional study, we used data from Service Provision Assessment (SPA) surveys, which are part of the Demographic and Health Survey (DHS) Program. We defined an item set to diagnose and manage DKA in higher-level (tertiary or secondary) facilities, and a set to assess and refer patients presenting to lower-level (primary) facilities. We quantified each item's availability by service level in Bangladesh (Survey 1: May 22 2014-Jul 20 2014; Survey 2: Jul 2017-Oct 2017), the Democratic Republic of the Congo (DRC) (Oct 16 2017-Nov 24 2017 in Kinshasha; Aug 08 2018-Apr 20 2018 in rest of country), Haiti (Survey 1: Mar 05 2013-Jul 2013; Survey 2: Dec 16 2017-May 09 2018), Ethiopia (Feb 06 2014-Mar 09 2014), Malawi (Phase 1: Jun 11 2013-Aug 20 2013; Phase 2: Nov 13 2013-Feb 7 2014), Nepal (Phase 1: Apr 20 2015-Apr 25 2015; Phase 2: Jun 04 2015-Nov 05 2015), Senegal (Survey 1: Jan 2014-Oct 2014; Survey 2: Feb 09 2015-Nov 10 2015; Survey 3: Feb 2016-Nov 2016; Survey 4: Mar 13 2017-Dec 15 2017; Survey 5: Apr 15 2018-Dec 31 2018; Survey 6: Apr 15 2019-Feb 28 2020), Tanzania (Oct 20 2014-Feb 21 2015), and Afghanistan (Nov 1 2018-Jan 20 2019). Variation in secondary facilities' capacity and trends over time were also explored. Findings: We examined data from 2028 higher-level and 7534 lower-level facilities. Of these, 1874 higher-level and 6636 lower-level facilities' data were eligible for analysis. Availability of all item sets were low at higher-level facilities, where less than 50% had the minimal set of supplies, less than 20% had the full minimal set, and less than 15% had the ideal set needed to diagnose and manage DKA. Across countries in lower-level facilities, less than 14% had the minimal set of supplies and less than 9% the full set of supplies for diagnosis and transfer of DKA patients. No country had more than 20% of facilities with the minimal set of items needed to assess or manage DKA. Where data were available for more than one survey (Bangladesh, Senegal, and Haiti), changes in availability of the minimal set and ideal set of items did not exceed 15%. Tertiary facilities performed best in Haiti, Ethiopia, Malawi, Nepal, Senegal, Tanzania, and Afghanistan. Secondary facilities that were rural, public, and had fewer staff had lower capacity. Interpretation: Health system capacity to manage DKA was low across these nine LLMICs. Although efforts are underway to strengthen health systems, a specific focus on DKA management is still needed. Funding: Leona M. and Harry B. Helmsley Charitable Trust, and Juvenile Diabetes Research Foundation Ltd.

Effectiveness of a group-based Diabetes Prevention Education Program (DiPEP) in a population with pre-diabetes: a cluster randomised controlled trial in Nepal.

Background: Although several lifestyle intervention studies have been conducted in low/middle-income countries, there were no such studies in Nepal. Therefore, a group-based culturally tailored Diabetes Prevention Education Program (DiPEP) was conducted recently. The study aimed to evaluate the effect of DiPEP in glycated haemoglobin (HbA1c), weight, waist circumference, physical activity and diet among population with pre-diabetes. Method: A two-arm cluster randomised controlled trial was conducted in 12 clusters of two urban areas in Nepal. The DiPEP was a 6 month intervention (four 1-hour weekly educational sessions and 5 months of follow-up by community health workers/volunteers (CHW/Vs)). A postintervention assessment was done after 6 months. Linear mixed model was used to estimate the mean difference in primary outcome (HbA1c) and secondary outcomes (weight, waist circumference, physical activity and diet) between intervention and control arms, adjusted for baseline measure. Results: In intention-to-treat analysis with a total of 291 participants, the estimated mean difference in HbA1c was found to be 0.015 percentage point (95% CI -0.074 to 0.104) between the intervention arm and the control arm, while it was -0.077 (95% CI -0.152 to -0.002) among those who attended at least 3 out of 4 educational sessions. The estimated mean difference in weight (in participants who attended ≥1 educational session) was -1.6 kg (95% CI -3.1 to -0.1). A significantly lower grain consumption was found in intervention arm (-39 g/day, 95% CI -65 to -14) compared with the control arm at postintervention assessment. Conclusion: Although compliance was affected by COVID-19, individuals who participated in ≥3 educational sessions had significant reduction in HbA1c and those who attended ≥1 educational session had significant weight reduction. Grain intake was significantly reduced among the intervention arm than the control arm. Hence, group-based lifestyle intervention programmes involving CHW/vs is recommended for diabetes prevention. Trial registration number: NCT04074148.

Prevalence of prediabetes and associated factors of prediabetic stages: a cross-sectional study among adults in Nepal.

OBJECTIVES: To estimate the prevalence of prediabetes and to assess the association of prediabetic stages with sociodemographic, lifestyle and clinical factors DESIGN: Cross-sectional study at the screening and inclusion stage of a Diabetes Prevention Education Program (DiPEP) trial SETTING: The study was conducted in two urban communities in Nepal (October 2019-March 2020). PARTICIPANTS: A total of 6222 residents of two study sites, aged 18-64 years and without a history of diabetes, were eligible for prediabetes screening. Exclusion criteria were pregnancy, history of diabetes and critical illness. A total of 291 participants with prediabetes were included in this study. PRIMARY AND SECONDARY OUTCOME MEASURES: Prevalence of prediabetes based on glycated haemoglobin (HbA1c) criteria (5.7%-6.4%) was the primary outcome of the study. Odds Ratio and 95% CI were estimated to assess the associations between the outcome prediabetic stages (5.7%-5.9% vs 6.0%-6.4%) and sociodemographic, lifestyle and clinical factors in both unadjusted and adjusted models. RESULTS: Out of 6222 screened participants, 308 (5%, 95% CI: 4.4% to 5.5%) individuals were detected with prediabetes based on HbA1c. The mean age of 291 responded participants was 50.3±7.6 years and 67% were females. Among them, 78% aged 45-64 years, 97% had central obesity, 90% had high waist-hip ratio, 63% were hypertensive and 66% had no family history of diabetes. Approximately, 54% and 46% of individuals with prediabetes had HbA1c of 5.7%-5.9% and 6.0%-6.4%, respectively. Female gender was associated with prediabetes with HbA1c 6.0%-6.4% (OR, 1.98, 95% CI: 1.07 to 3.67) in the adjusted model. CONCLUSION: The estimated prevalence of prediabetes was 5% among screened participants, and female gender was associated with the prediabetic stage. As a large proportion of the population with prediabetes were not aware of their status, this study demonstrates a need for regular community screening programmes to detect individuals with prediabetes and provide them a comprehensive lifestyle intervention for diabetes prevention. TRIAL REGISTRATION NUMBER: NCT04074148, 2019/783.

A robust host-response-based signature distinguishes bacterial and viral infections across diverse global populations.

Limited sensitivity and specificity of current diagnostics lead to the erroneous prescription of antibiotics. Host-response-based diagnostics could address these challenges. However, using 4,200 samples across 69 blood transcriptome datasets from 20 countries from patients with bacterial or viral infections representing a broad spectrum of biological, clinical, and technical heterogeneity, we show current host-response-based gene signatures have lower accuracy to distinguish intracellular bacterial infections from viral infections than extracellular bacterial infections. Using these 69 datasets, we identify an 8-gene signature to distinguish intracellular or extracellular bacterial infections from viral infections with an area under the receiver operating characteristic curve (AUROC) > 0.91 (85.9% specificity and 90.2% sensitivity). In prospective cohorts from Nepal and Laos, the 8-gene classifier distinguished bacterial infections from viral infections with an AUROC of 0.94 (87.9% specificity and 91% sensitivity). The 8-gene signature meets the target product profile proposed by the World Health Organization and others for distinguishing bacterial and viral infections.