Effect of nutrition education intervention on nutrition knowledge, attitude, and diet quality among school-going adolescents: a quasi-experimental study.

BACKGROUND: Nutrition education is being used to encourage school adolescents to adopt healthy eating habits. To the best of our knowledge, very little study has been undertaken in Nepal to examine the effectiveness of nutrition education programs. This study aimed to assess the effect of nutrition education on nutritional knowledge, attitude, and diet quality among school-going adolescents in selected private schools in Nepal. METHODS: A quasi-experimental study was conducted among 226 students aged 12 - 19 years of two selected private schools in Banepa municipality of Nepal. Students (n = 113) from the first school were assigned to intervention and the same number of students from the second school were enrolled in the study as the control. Over 12 weeks, students in the intervention group received one hour of nutrition education in the form of mini-lectures and interactive discussions, whilst students in the control group received no education. The student's two-sample t-test was used to compare two groups and to assess the effectiveness of the nutrition education program. RESULTS: Between the intervention and control group, the magnitude of difference in knowledge score was 1.80 (95% CI: 1.11 - 2.49), emotional eating was 0.98 (95% CI: 0.42 - 1.54), uncontrolled eating was 3.60 (95% CI: 2.10 - 5.09), and cognitive restraint of eating was 2.26 (95% CI: 1.51 - 3.01). CONCLUSIONS: A tailored health education intervention was found to be effective in increase nutritional knowledge and attitude among school-going adolescents. Adopting nutrition education interventions as part of public health school intervention builds positive knowledge, attitudes, and healthy eating habits in school-going adolescents.

Effectiveness of a dietician-led intervention in reducing glycated haemoglobin among people with type 2 diabetes in Nepal: a single centre, open-label, randomised controlled trial.

Background: Nutrition education and counselling are considered a cornerstone for the management of type 2 diabetes (T2D). However, there is limited research related to the management of T2D through dietary approach, particularly in low-income and middle-income countries (LMICs) like Nepal. This study assessed the effectiveness of a dietician-led dietary intervention in reducing glycated haemoglobin (HbA1c) levels among people with T2D. Methods: An open-label, two-armed, hospital-based, randomised controlled trial was conducted at Tribhuvan University Teaching Hospital, Kathmandu, Nepal. Participants were randomly assigned to either dietician-led dietary intervention group (n = 78) or usual care control group (n = 78). People with type 2 diabetes with HbA1c >6.5% and aged 24-64 years were included in the study. The primary outcome was a change in HbA1c level over six months, and secondary outcomes included changes in biochemical and clinical parameters, Problem Areas in Diabetes (PAID) score, diabetic knowledge, dietary adherence, and macronutrient intake level. Data were analysed using an intention-to-treat approach. This trial is registered with ClinicalTrials.gov, NCT04267367. Findings: Between August 15, 2021 and February 25, 2022, 156 people with type 2 diabetes were recruited for the study, of which 136 participants completed the trial. At six months of follow-up, compared to baseline values, the mean HbA1c (%) level decreased in the intervention group by 0.48 (95% CI: -0.80 to -0.16), while it increased in the control group by 0.22 (95% CI: -0.21 to 0.66). In an adjusted model, the reduction in HbA1c (%) levels for the intervention was 0.61 (95% CI: -1.04 to -0.17; p = 0.006). In addition, fasting blood glucose was decreased by 18.96 mg/dL (95% CI: -36.12 to -1.81; p = 0.031) after the intervention. The intervention resulted in the reduction of BMI, waist and hip circumference, PAID score, dietary adherence, and macronutrient intake in the intervention group compared to the control group. Interpretation: The dietician-led intervention improved glycaemic control, improved macronutrient intake, and clinical outcomes among people with type 2 diabetes. The dietician-led intervention may be considered for diabetes management in LMICs. Funding: The research was funded by the University Grants Commission (UGC), Nepal.

The burden of mental disorders in Nepal between 1990 and 2019: Findings from the Global Burden of Disease Study 2019.

Mental disorders are the leading cause of disease burden, affecting 13% of all people globally in 2019. However, there is scarce evidence on the burden of mental disorders in Nepal. This study used the Global Burden of Disease Study 2019 data to assess the prevalence and disability-adjusted life-years (DALYs) of mental disorders in Nepal between 1990 and 2019. In 2019, there were 3.9 million (95% UI: 3.6-4.3) people with mental disorders in Nepal. Major depressive disorders (1.1 million; 95% UI: 0.9-1.2 million) and anxiety disorders (0.9 million; 95% UI: 0.8-1.2 million) were the most prevalent mental disorders in 2019. Attention deficit hyperactive disorder, conduct disorder, and autism spectrum disorders were present twice as high in males than in females. The proportional contribution of mental disorders to the total disease burden has tripled between 1990 (1.79% of all DALYs) and 2019 (5.5% of all DALYs). In conclusion, the proportional contribution of mental disorders to total disease burden has increased significantly in the last three decades in Nepal, with apparent sex and age differentials in prevalence and DALY rates. Effective program and policy responses are required to prepare the health system for reducing the growing burden of mental health disorders in Nepal.

Medication adherence and health-related quality of life among people with diabetes in Bangladesh: A cross-sectional study.

INTRODUCTION: Good adherence to anti-diabetic medications is an important protective factor for decreasing diabetes-related complications and disabilities but its association with health-related quality of life (HRQoL) is understudied. The current study aimed to assess an association between medication adherence to anti-diabetic drugs and HRQoL among people with diabetes in Dhaka city, Bangladesh. METHODS: We conducted a cross-sectional study among 480 people with diabetes aged between 50 and 70 years, who attended a tertiary-level hospital in Dhaka city. We used the EuroQol-5 Dimensions Questionnaire (EQ-5D-5L) to measure HRQoL and Morisky Medication Adherence Scale to assess the level of medication adherence to anti-diabetic drugs. Multivariable logistic regression was performed to assess the significance of relevant factors. RESULTS: The mean age of the participants was 59.0 (standard deviation [SD], 7.0) years. The majority of the participants (74%) had a lower level of medication adherence. The mean value of (EQ-5D-5L) was 2.0 (SD, 1.0). The percentage of severe disability in different domains were 6.7% for mobility, 3.5% for self-care, 11.9% for usual daily activities, 11.9% for pain/discomfort and 11.3% for anxiety. After adjusting for age, sex, years of education, household expenditure, hypertension, duration of diabetes, glycemic status and multi-morbidities; low adherence to anti-diabetic medication was inversely associated with pain (OR, 0.26; 95% CI, 0.08-0.80; p = .036), and positively associated with anxiety (OR, 7.18; 95% CI, 1.03-9.59; p = .043). CONCLUSIONS: Low medication adherence to anti-diabetic drugs was associated with anxiety and pain among the EQ-5D-5L indexes measured in people with diabetes in Dhaka, Bangladesh.

Burden of Cardiovascular Diseases in Nepal from 1990 to 2019: The Global Burden of Disease Study, 2019.

Cardiovascular diseases (CVDs) have emerged as the leading cause of deaths worldwide in 2019. Globally, more than three-quarters of the total deaths due to CVDs occur in low- and middle-income countries like Nepal. Although increasing number of studies is available on the prevalence of CVDs, there is limited evidence presenting a complete picture on the burden of CVDs in Nepal. In this context, this study aims to provide comprehensive picture on the burden of CVDs in the country. This study is based on the Global Burden of Disease (GBD) study 2019, which is a multinational collaborative research covering 204 countries and territories across the world. The estimations made from the study are publicly available in the GBD Compare webpage operated by the Institute for Health Metrics and Evaluation (IHME), University of Washington. This article makes use of those data available on the GBD Compare page of IHME website to present the comprehensive picture of the burden of CVDs in Nepal. Overall, in 2019, there were an estimated 1,214,607 cases, 46,501 deaths, and 1,104,474 disability-adjusted life years (DALYs) due to CVDs in Nepal. The age-standardized mortality rates for CVDs witnessed a marginal reduction from 267.60 per 100,000 population in 1990 to 245.38 per 100,000 population in 2019. The proportion of deaths and DALYs attributable to CVDs increased from 9.77% to 24.04% and from 4.82% to 11.89%, respectively, between 1990 and 2019. Even though there are relatively stable rates of age-standardized prevalence, and mortality, the proportion of deaths and DALYs attributed to CVDs have risen sharply between 1990 and 2019. Besides implementing the preventive measures, the health system also needs to prepare itself for the delivery of long-term care of patients with CVDs which could have significant implications on resources and operations.

Electrocardiogram abnormalities and renal impairment in patients with type 2 diabetes mellitus: A healthcare facilities-based cross-sectional study in Dang district of Nepal.

AIMS/INTRODUCTION: The global burden of diabetes mellitus is rising substantially, with a further increase in cardiovascular and kidney disease burden. These public health problems are highly prevalent in low- and middle-income countries, including Nepal. However, there is limited evidence on cardiac and renal conditions among patients with type 2 diabetes mellitus. We determined the status of electrocardiogram (ECG) abnormalities and renal impairment among patients with type 2 diabetes mellitus in Nepal. METHODS: We carried out a cross-sectional study in Tulsipur Sub-Metropolitan City of Nepal using a multistage stratified sampling technique to recruit patients with type 2 diabetes mellitus. We used World Health Organization stepwise approach to surveillance (WHO STEPS) questionnaires and carried out resting ECG to collect data of 345 patients with type 2 diabetes mellitus. Logistic regression analysis assessed the factors associated with ECG abnormalities and renal impairment. RESULTS: The study showed that 6.1% of participants had major ECG abnormalities (95% confidence interval [CI] 3.8-8.6%), which were associated with hypertension (P = 0.01%) and low socioeconomic status (P = 0.01). The proportion of major and/or minor ECG abnormalities was 47.8% (95% CI 40.5-51%), and were significantly associated with age (odds ratio [OR] 1.04, 95% CI 1.01-1.07), higher education (OR 3.50, 95% CI 1.31-9.33), unemployment (OR 3.02, 95% CI 1.08-8.48), body mass index (OR 1.09, 95% CI 1.02-1.17) and duration of type 2 diabetes mellitus >5 years (OR 2.42, 95% CI 1.19-4.93). The proportion of renal impairment was 3.5% (95% CI 1.5-4.5%) which was associated with older age (OR 1.08, 95% CI 1.00-1.17) and hypertension (OR 12.12, 95% CI 1.07-138.22). CONCLUSION: A significant proportion of patients with type 2 diabetes mellitus had ECG abnormalities and renal impairment, which were significantly associated with hypertension. Therefore, hypertension management and early screening are essential to prevent future cardiorenal complications among patients with type 2 diabetes mellitus.

Risk Factors of Coronary Artery Disease: A Hospital-Based Study.

BACKGROUND: Coronary artery disease is among the leading cause of morbidity and mortality worldwide. There are limited scientific evidence on the risk factors for coronary artery disease specific to the Nepalese context. This study aimed to determine the association of various modifiable cardiovascular risk factors with coronary artery disease in Nepal. METHODS: It is a hospital-based case-control study conducted among 300 participants. Case group comprised of 150 newly diagnosed coronary artery disease patients attending Manmohan Cardiothoracic Vascular and Transplant Centre while the Age and sex matched non-cardiac patients (n=150) from the outpatient department of the Department of General Practice and Emergency Medicine of Tribhuvan University Teaching Hospital were recruited as controls. Adjusted odds ratios (AOR) were calculated using multivariable logistic regression. RESULTS: Of the 300 participants, 208 (69.3%) were males and 92 (30.7%) were females. The mean age was 59.8 years ± 11 years (standard deviation). In multivariable analysis, current smoking (AOR=3.05, 95% CI: 1.61-5.78), hypertension (AOR=1.82, 95% CI: 1.08-3.09), diabetes (AOR=3.78, 95% CI: 1.91-7.47), family history of coronary artery disease (AOR=2.92, 95% CI: 1.27-6.71), and low high density lipoprotein (AOR= 2.0, 95% CI: 1.17-3.42) were significantly associated with coronary artery disease. Current alcohol use (AOR=0.51, 95% CI: 0.29-0.89) was identified as a protective factor for coronary artery disease. CONCLUSIONS: Among the modifiable cardiovascular risk factors, smoking, hypertension, diabetes, and low level of high density lipoprotein were significantly associated with coronary artery disease, which should be considered while developing public health interventions for cardiovascular disease prevention in Nepal in future.

Implementation of non-pharmacological interventions for the treatment of hypertension in primary care: a narrative review of effectiveness, cost-effectiveness, barriers, and facilitators.

BACKGROUND: The current guidelines for the prevention, detection, evaluation, and management of hypertension recommend six types of non-pharmacological interventions: alcohol reduction, salt intake reduction, increased potassium intake, physical activity, weight loss, and heart-healthy diets. However, the non-pharmacological interventions are still not widely used in primary care. In this paper, we, therefore, reviewed and summarised the evidence on the effectiveness, cost-effectiveness, barriers, and facilitators of non-pharmacological interventions for the treatment of hypertension in primary care. METHODS: A thorough literature search was conducted in Embase, Google Scholar, and PubMed databases, to identify the most recent reviews or, in their absence, primary studies on alcohol reduction, salt intake reduction, potassium supplementation, physical activity, weight reduction, heart-healthy diets, and other non-pharmacological interventions for the treatment of hypertension in primary care. RESULTS: Alcohol reduction is a non-pharmacological intervention for the treatment of hypertension in primary care with proven effectiveness, feasibility, and acceptability. Interventions for sodium intake reduction, physical activity, and weight reduction are effective but there is insufficient evidence regarding their feasibility and acceptability in primary care settings. Evidence on the effectiveness of potassium intake and heart-healthy diets is limited and inconsistent. There is a lack of evidence on the cost-effectiveness of non-pharmacological interventions in the treatment of hypertension. The most common barriers to deliver such interventions related to healthcare providers include a lack of time, knowledge, self-confidence, resources, clear guidelines, and financial incentives. The most common barriers related to patients include a lack of motivation and educational resources. Less evidence is available on facilitators of implementing non-pharmacological interventions in primary care. Besides, facilitators differed by different types of interventions. CONCLUSIONS: Available evidence suggests that more pragmatic, clinically feasible, and logistically simple interventions are required for sodium intake reduction, physical activity, and weight reduction in primary care settings. Future studies should provide further evidence on the effectiveness of weight control, potassium intake, and heart-healthy diets. More research is also needed on cost-effectiveness and facilitators of all types of effective non-pharmacological interventions for the treatment of hypertension in primary care.

Poor glycemic control, cardiovascular disease risk factors and their clustering among patients with type 2 diabetes mellitus: A cross-sectional study from Nepal.

BACKGROUND: Cardiovascular disease (CVD) is the most common complication of diabetes mellitus (DM). To prevent morbidity and mortality among patients with type 2 diabetes mellitus (T2DM), optimization of glycemic status and minimizing CVD risk factors is essential. As Nepal has limited data on these CVD risk parameters, we assessed the prevalence of poor glycemic control, CVD risk factors, and their clustering among patients with T2DM. METHODS: Using a cross-sectional study design, we collected data of 366 patients with T2DM. We applied a multistage cluster sampling technique and used the WHO STEPS tools. Binary logistic and Poisson regression was applied to calculate odds and prevalence ratio of clustering of risk factors, considering P< 0.05 statistically significant. RESULTS: The mean age of participants was 54.5±10.7 years and 208 (57%) were male. The prevalence of poor glycemic control was 66.4% (95% C.I: 61.5-71.2). The prevalence of smoking, alcohol users, inadequate fruit and vegetables intake and physical inactivity were 18% (95% C.I:14 to 21.9), 14.8% (95% C.I:11.1 to 18.4), 98.1% (95% C.I: 96.7-99.4), and 9.8% (95% C.I:6.7-12.8), respectively. Overall, 47.3% (95% C.I: 42.1-52.4) were overweight and obese, 59% (95% C.I: 52.9-63) were hypertensive, and 68% (95% C.I: 63.2-72.7) had dyslipidemia. Clustering of two, three, four, five and more than five risk factors was 12.6%, 30%, 30%,19%, and 8.7%, respectively. Four or more risk factors clustering was significantly associated with gender, age, level of education, T2DM duration, and use of medication. Risk factors clustering was significantly higher among males and users of anti-diabetic medications with prevalence ratio of 1.14 (95% C.I:1.05-1.23) and 1.09 (95% C.I: 1.09-1.18)], respectively. CONCLUSIONS: The majority of the patients with T2DM had poor glycemic control and CVD risk factors. Policies and programs focused on the prevention and better management of T2DM and CVD risk factors should be implemented to reduce mortality in Nepal.

Hypertension screening, awareness, treatment, and control: a study of their prevalence and associated factors in a nationally representative sample from Nepal.

BACKGROUND: The growing burden of hypertension is emerging as one of the major healthcare challenges in low- and middle-income countries (LMICs), such as Nepal. Given that they are struggling to deliver adequate health services, some LMICs have significant gaps in the cascade of hypertension care (including screening, awareness, treatment, and control). This results in uncontrolled hypertension, placing a high burden on both patients and healthcare providers. OBJECTIVE: The objective of this study was to quantify the gaps in hypertension screening, awareness, treatment, and control in the Nepalese population. METHODS: We used the data from a pooled sample of 9682 participants collected through two consecutive STEPwise approach to Surveillance (STEPS) surveys conducted in Nepal in 2013 and 2019. A multistage cluster sampling method was applied in the surveys, to select nationally representative samples of 15- to 69-year-old Nepalese individuals. Prevalence ratios were calculated using multivariable Poisson regression. RESULTS: Among the hypertensive participants, the prevalence of hypertension screening was 65.9% (95% CI: 62.2, 69.5), the prevalence of hypertension awareness was 20% (95% CI: 18.1, 22.1), the prevalence of hypertension treatment was 10.3% (95% CI: 8.8, 12.0), and the prevalence of hypertension control was 3.8% (95% CI: 2.9, 4.9). The unmet need of hypertension treatment and control was highest amongst the poorest individuals, the participants from Lumbini and Sudurpaschim provinces, those who received treatment in public hospitals, the uninsured, and those under the age of 30 years. CONCLUSIONS: The gaps in the cascade of hypertension care in Nepal are large. These gaps are particularly pronounced among the poor, persons living in Lumbini and Sudurpaschim provinces, those who sought treatment in public hospitals, those who did not have health insurance, and young people. National- and local-level public health interventions are needed to improve hypertension screening, awareness, treatment, and control in Nepal.

Barriers, Enablers and Strategies for the Treatment and Control of Hypertension in Nepal: A Systematic Review.

Background: Understanding country-specific factors influencing hypertension care is critical to address the gaps in the management of hypertension. However, no systematic investigation of factors influencing hypertension treatment and control in Nepal is available. This study aimed to systematically review the published literature and synthesise the findings on barriers, enablers, and strategies for hypertension treatment and control in Nepal. Methods: Embase, PubMed, Web of Science, CINAHL, ProQuest and WorldCat, and Nepali journals and government websites were searched for qualitative, quantitative, and mixed-methods studies on factors or strategies related to hypertension treatment and control in Nepal. Information from qualitative studies was analysed using template analysis, while results from quantitative studies were narratively synthesised. Summary findings were framed under "health system", "provider", and "patient" domains. The protocol was registered in PROSPERO (registration number: CRD42020145823). Results: We identified 15 studies; ten related to barriers and enablers and five to strategies. The identified barriers associated with the health system were: lack of affordable services and lack of resources. The barriers at the provider's level were: communication gaps, inadequate counselling, long waiting hours for appointments, lack of national guidelines for hypertension treatment, and provider's unsupportive behaviours. Non-adherence to medication, irregular follow-up visits, lack of awareness on blood pressure target, poor help-seeking behaviours, reluctance to change behaviours, perceived side-effects of anti-hypertensive medication, self-medication, lack of family support, financial hardship, lack of awareness on blood pressure complications, and comorbidity were barriers identified at patient level. The following enablers were identified: free essential health care services, family support, positive illness perception, and drug reminders. Strategies implemented at the health system, provider and patient levels were: establishing digital health records at health centres, health worker's capacity development, and health education. Conclusion: There is a range of barriers for hypertension treatment and control in Nepal pertaining to the health system, health providers, and patients. Comprehensive interventions are needed at all three levels to further improve management and control of hypertension in Nepal.

Burden of chronic kidney disease in the general population and high-risk groups in South Asia: A systematic review and meta-analysis.

BACKGROUND: Chronic kidney disease (CKD) is an emerging public health issue globally. The prevalence estimates on CKD in South Asia are however limited. This study aimed to examine the prevalence of CKD among the general and high-risk population in South Asia. METHODS: We conducted a systematic review and meta-analysis of population-level prevalence studies in South Asia (Afghanistan, Bangladesh, Bhutan, Maldives, Nepal, India, Pakistan, and Sri Lanka). Three databases namely PubMed, Scopus and Web of Science were systematically searched for published reports of kidney disease in South Asia up to 28 October 2020. A random-effect model for computing the pooled prevalence was used. RESULTS: Of the 8749 identified studies, a total of 24 studies were included in the review. The pooled prevalence of CKD among the general population was 14% (95% CI 11-18%), and 15% (95% CI 11-20%) among adult males and 13% (95% CI 10-17%) in adult females. The prevalence of CKD was 27% (95% CI 20-35%) in adults with hypertension, 31% (95% CI 22-41%) in adults with diabetes and 14% (95% CI 10-19%) in adults who were overweight/obese. We found substantial heterogeneity across the included studies in the pooled estimates for CKD prevalence in both general and high-risk populations. The prevalence of CKD of unknown origin in the endemic population was 8% (95% CI 3-16%). CONCLUSION: Our study reaffirms the previous reports that CKD represents a serious public health challenge in South Asia, with the disease prevalent among 1 in 7 adults in South Asian countries.

Effectiveness of community-based health education and home support program to reduce blood pressure among patients with uncontrolled hypertension in Nepal: A cluster-randomized trial.

BACKGROUND: Hypertension is a major global public health problem. Elevated blood pressure can cause cardiovascular and kidney diseases. We assessed the effectiveness of health education sessions and home support programs in reducing blood pressure among patients with uncontrolled hypertension in a suburban community of Nepal. METHODS: We conducted a community-based, open-level, parallel-group, cluster randomized controlled trial in Birendranagar municipality of Surkhet, Nepal. We randomly assigned four clusters (wards) into intervention and control arms. We provided four health education sessions, frequent home and usual care for intervention groups over six months. The participants of the control arm received only usual care from health facilities. The primary outcome of this study was the proportion of controlled systolic blood pressure (SBP). The analysis included all participants who completed follow-up at six months. RESULTS: 125 participants were assigned to either the intervention (n = 63) or the control (n = 62) group. Of them, 60 participants in each group completed six months follow-up. The proportion of controlled SBP was significantly higher among the intervention participants compared to the control (58.3% vs. 40%). Odds ratio of this was 2.1 with 95% CI: 1.01-4.35 (p = 0.046) and that of controlled diastolic blood pressure (DBP) was 1.31 (0.63-2.72) (p = 0.600). The mean change (follow-up minus baseline) in SBP was significantly higher in the intervention than in the usual care (-18.7 mmHg vs. -11.2 mmHg, p = 0.041). Such mean change of DBP was also higher in the intervention (-10.95 mmHg vs. -5.53 mmHg, p = 0.065). The knowledge score on hypertension improved by 2.38 (SD 2.4) in the intervention arm, which was significantly different from that of the control group, 0.13 (1.8) (p<0.001). CONCLUSIONS: Multiple health education sessions complemented by frequent household visits by health volunteers can effectively improve knowledge on hypertension and reduce blood pressure among uncontrolled hypertensive patients at the community level in Nepal. TRIAL REGISTRATION: ClinicalTrial.gov: NCT02981251.

Prevalence, pattern and determinants of chronic disease multimorbidity in Nepal: secondary analysis of a national survey.

OBJECTIVES: To assess the prevalence, pattern and determinants of non-communicable diseases (NCDs) multimorbidity in Nepal. DESIGN: Secondary analysis of the data from the NCD survey 2018, which was conducted between 2016 and 2018. SETTING: The data belong to the nationally representative survey, that selected the study samples from throughout Nepal using multistage cluster sampling. PARTICIPANTS: 8931 participants aged 20 years and older were included in the study. PRIMARY OUTCOMES: NCD multimorbidity (occurrence of two or more chronic conditions including hypertension, diabetes, chronic obstructive pulmonary disease, chronic kidney disease, coronary artery disease and cancer). Descriptive statistics, prevalence ratio and odds ratio were computed to assess pattern and determinants of multimorbidity. RESULTS: Mean (SD) age was 46.7 years (14.9 years). The majority of the participants were women (57.8%), without formal education (53.4%) and from urban areas (51.5%). Multimorbidity was present in 13.96% (95% CI: 12.9% to 15.1%). Hypertension and diabetes coexisted in 5.7%. Age, alcohol consumption, body mass index, non-high-density lipoprotein (non-HDL) level and rural-urban setting were significantly associated with multimorbidity. CONCLUSION: Multimorbidity was prevalent in particular groups or geographical areas in Nepal suggesting a need for coordinated and integrated NCD care approach for the management of multiplicative co-comorbid conditions.

Yoga for hypertensive patients: a study on barriers and facilitators of its implementation in primary care.

BACKGROUND: International guidelines for hypertension treatment recommend the use of yoga, particularly among low-risk patients. However, evidence is lacking on the implementation potential of health-worker-led yoga interventions in low-resource, primary care settings. OBJECTIVE: To assess barriers to and facilitators of the implementation of a yoga intervention for hypertensive patients in primary care in Nepal. METHODS: The study was conducted using focus group discussions, in-depth interviews, key informant interviews, and telephone interviews. Data were collected from the 'Yoga and Hypertension' (YoH) trial participants, YoH intervention implementers, and officials from the Ministry of Health and Population in Nepal. RESULTS: Most YoH trial participants stated that: (1) it was easy to learn yoga during a five-day training period and practise it for three months at home; (2) practising yoga improved their health; and (3) group yoga sessions in a community centre would help them practise yoga more regularly. Most YoH intervention implementers stated that: (1) they were highly motivated to implement the intervention; (2) the cost of implementation was acceptable; (3) they did not need additional staff to effectively implement the intervention; (4) providing remuneration to the staff involved in the intervention would increase their motivation; and (5) the yoga programme was 'simple and easy to follow' and 'easily performed by participants of any age'. The government officials stated that: (1) yoga is considered as a key health promotional activity in Nepal; and (2) the integration of the yoga intervention into the existing health care programme would not be too challenging, because the existing personnel and other resources can be utilised. CONCLUSION: While there is a good potential that a yoga intervention can be implemented in primary care, capacity development for health workers and the involvement of community yoga centres in the delivery of the interventions may be required to facilitate this implementation.

Health-Related Quality of Life of Patients Receiving Cancer Treatment in Nepal: A Hospital-based Cross-Sectional Study.

BACKGROUND: Information on health-related quality of life of the patients enables healthcare providers to understand patients' concerns and guides to introduce appropriate treatment care. This study assessed the health-related quality of life of the cancer patients attending a tertiary hospital in Nepal. METHODS: A cross-sectional study was conducted among 294 cancer patients receiving treatment service from Bhaktapur Cancer Hospital between November 2016 and February 2017. We used the European Organization for Research and Treatment of Cancer, Quality of Life Questionnaire-Core 30 to record the scores in different domains of health-related quality of life. The scores were compared across different socio-economic characteristics using non-parametric tests. RESULTS: Majority of the participants were female (57.5%), of age 50 years and above (64.7%) and had either lung or breast or cervical cancer (49.32%). Participants' median scores of the global health status (overall health) and quality of life, functionality, and symptoms were 83.3, 52.7 and 31.9 respectively. Among functionality, lower mean scores were of role (45.40) and social (53.17) functioning. Among symptoms and single items, higher mean scores were of appetite loss (49.88), fatigue (46.67), insomnia (43.99), and financial difficulty (68.02). The overall health and quality of life varied significantly with different characteristics of the participants. CONCLUSIONS: Participants reported a higher score of overall health and quality of life that reflects subjective satisfactory condition. Improving respective functionality and relieving symptoms and difficulty could enhance health-related quality of life in respective domains.

Trends in the Prevalence, Awareness, Treatment, and Control of Hypertension in Nepal between 2000 and 2025: A Systematic Review and Meta-Analysis.

BACKGROUND: Understanding the burden and trend of hypertension and the associated care cascade can provide direction to the development of interventions preventing and controlling hypertension. This study aimed to assess prevalence and trends of hypertension and its awareness, treatment, and control in Nepal. METHODS: We systematically searched CINAHL, Embase, ProQuest, PubMed, Web of Science, WorldCat, and government and health agency-owned websites to identify studies reporting prevalence of hypertension, awareness, treatment, and control in Nepal between 2000 and 2020. We applied the random-effects model to compute the pooled prevalence in the overall population and among subgroups in each 5-year interval period between 2000 and 2020. We used linear meta-regression analysis to predict hypertension from 2000 to 2025. RESULTS: We identified 23 studies having a total of 84,006 participants. The pooled prevalence of hypertension, awareness, treatment, and control for 2016-2020 was 32% (95% CI: 23-40%), 50% (95% CI: 30-69%), 27% (95% CI: 19-34%), and 38% (95% CI: 28-48%), respectively. The prevalence of hypertension varied by age, gender, education, and geographical area. Hypertension increased by 6 percentage points (pp), awareness increased by 12 pp, treatment increased by 11 pp, and control increased by 3 pp over the 20 years studied. Since 2000, the rate of increment of hypertension has been 3.5 pp per decade, where 44.7% of men are expected to suffer from hypertension by 2025. CONCLUSION: The markedly increased prevalence of hypertension and relatively poor progress in hypertension awareness, treatment, and control in Nepal suggest that there is a need for hypertension preventive approaches as well as strategies to optimize hypertension care cascade.

Factors associated with physical and sexual violence among school-going adolescents in Nepal: Findings from Global School-based Student Health Survey.

BACKGROUND: Globally violence is a matter of public health concern with severe physical and mental health implications and social consequences. Evidence suggest that adolescents have an elevated risk of exposure to physical and sexual violence. However, there is a lack of nationally representative research on violence and its associated factors in Nepal to inform interventions. This paper attempts to find the factors associated with various forms of physical and sexual violence among school-going adolescents in Nepal. METHODS: We analysed the cross-sectional data from the Global School-based Student Health Survey (GSHS) 2015. The GSHS survey applied a two-stage cluster sampling process to select a representative sample of 7 to 11 grade students from 74 schools across the country. We applied logistic regression analysis to identify the factors associated with physical and sexual violence. RESULTS: Out of the total 6,529 participants, 45.24% of them faced a physical attack, 39.25% were involved in a physical fight, and 11.65% were victims of sexual violence in the survey administered between 7 August 2015 to 14 March 2016. In a multiple regression analysis, the age of participants, parental supervision, feeling unsafe at school, and the number of close friends were found to be associated with a physical attack. Participants who were bullied, had multiple sex partners, and had received corporal punishment in school had a higher engagement in a physical fight. Likewise, school grade, having parents who understand the problems, having multiple sex partners, and corporal punishment at school were associated with instances of sexual violence. CONCLUSION: The study identified multiple factors associated with experiences of physical attacks, involvement in a physical fight, and sexual violence among school-going adolescents. This study results can have important implications for school administration, parents, and policymakers alike to plan appropriate anti-violence strategies and interventions. Since various forms of violence share some common risk factors, a comprehensive strategy could be worth considering to prevent such acts of violence.

Effects of a health worker-led 3-month yoga intervention on blood pressure of hypertensive patients: a randomised controlled multicentre trial in the primary care setting.

BACKGROUND: Hypertension control remains a major challenge globally. A recent systematic review suggested that yoga has beneficial effects on reducing blood pressure. However, the role of yoga in hypertension management in primary health care has received little attention, and no studies have evaluated the impact of a yoga program fully delivered by health care staff on hypertension. This study, therefore, assessed the effects of a health worker-led yoga intervention on blood pressure reduction among hypertensives patients in the primary care setting. METHODS: This was a multicentric, two-arm, randomised trial conducted among hypertensive patients in seven Ayurveda Health Centres in Nepal between March 2017 and June 2018. One hundred and twenty-one participants who were on or without medications were randomised to intervention (n = 61) and wait-list control (n = 60) groups using stratified block randomisation. Participants in the intervention arm received an intervention consisting of an initial five-day structured yoga training at the centres and then a further home-based practice of yoga for five days a week for the following 90 days. Both intervention and control groups also participated in a 2-h health education session. The primary outcome of this trial was systolic blood pressure at 90-day follow-up. Data were analysed on an intention-to-treat basis using linear mixed-effects regression models. RESULTS: We included all 121 study participants (intervention/control = 61/60) in the primary analysis (52.1% males; mean ± SD age = 47.8 ± 10.8 years). The difference in systolic blood pressure between the intervention group and the control group was - 7.66 mmHg (95% CI: - 10.4, - 4.93). For diastolic blood pressure, the difference was - 3.86 mmHg (95% CI: - 6.65, - 1.06). No adverse events were reported by the participants. CONCLUSIONS: A yoga program for hypertensive patients consisting of a five-day training in health centres and 90 days of practice at home is effective for reducing blood pressure. Significant benefits for hypertensive patients could be expected if such programmes would become a part of the standard treatment practice. TRIAL REGISTRATION: This trial was prospectively registered with the Clinical Trial Registry of India [ CTRI/2017/02/007822 ] on 10/02/2017.

Accessing health services in India: experiences of seasonal migrants returning to Nepal.

BACKGROUND: Migration to India is a common livelihood strategy for poor people in remote Western Nepal. To date, little research has explored the degree and nature of healthcare access among Nepali migrant workers in India. This study explores the experiences of returnee Nepali migrants with regard to accessing healthcare and the perspectives of stakeholders in the government, support organizations, and health providers working with migrant workers in India. METHODS: Six focus group discussions (FGDs) and 12 in-depth interviews with returnee migrants were conducted by trained moderators in six districts in Western Nepal in late 2017. A further 12 stakeholders working in the health and education sector were also interviewed. With the consent of the participants, FGDs and interviews were audio-recorded. They were then transcribed and translated into English and the data were analysed thematically. RESULTS: The interviewed returnee migrants worked in 15 of India's 29 states, most as daily-wage labourers. Most were from among the lowest castes so called-Dalits. Most migrants had had difficulty accessing healthcare services in India. The major barriers to access were the lack of insurance, low wages, not having an Indian identification card tied to individual biometrics so called: Aadhaar card. Other barriers were unsupportive employers, discrimination at healthcare facilities and limited information about the locations of healthcare services. CONCLUSIONS: Nepali migrants experience difficulties in accessing healthcare in India. Partnerships between the Nepali and Indian governments, migrant support organizations and relevant stakeholders such as healthcare providers, government agencies and employers should be strengthened so that this vulnerable population can access the healthcare they are entitled to.