Health Services Utilization among Older Adults in Pokhara Metropolitan City.

The Government of Nepal provides a range of welfare schemes to senior citizens, but little is known about the use of public benefits by older adults. This community-based cross-sectional survey thus aims to assess the utilization and correlates of health services (through both private and public health facilities), free essential health services (provided by the government through public health facilities), and other welfare schemes - discounts in health treatment for certain diseases, monthly senior citizen allowance, reservation and concession in transportation, and the government-run health insurance program - among 201 Nepali older adults. Notably, a sizable proportion of the participants (22.4%) did not visit a health facility despite having a health problem. Females and those with higher co-morbidity had higher odds of health facility visits. Only 8% utilized the free essential health services, and 47% one or more of the other welfare schemes. Lack of awareness of free health services and welfare schemes were associated with lower odds of their utilization, respectively.

Prevalence and associated factors of hypertension among veterans of the Indian Gorkha regiments living in Pokhara Metropolitan City, Nepal.

BACKGROUND: Hypertension is a major preventable risk factor for cardiovascular disease. Occupational factors such as having served or serving in armed forces may be associated with hypertension. This study aimed to assess the prevalence and factors associated with hypertension among veterans of the Indian Gorkha army living in western Nepal. METHODS: A community-based cross-sectional study was conducted among the veterans living in the Pokhara metropolitan city. Data on blood pressure (BP), anthropometric measurements, and behavioral factors were collected by face-to-face interviews using the World Health Organization's non-communicable disease risk factor surveillance (STEPS) tool. Hypertension was defined as systolic blood pressure (BP) ≥ 140 mm Hg and/or diastolic BP of ≥ 90 mm Hg or currently on antihypertensive medication. RESULTS: The age-adjusted prevalence of hypertension was 66.2 % among the study participants (317). Mean systolic and diastolic blood pressure was 144.5 mmHg (± 18.3) and 89.3mmHg (± 16.0), respectively. Among the hypertensive participants, 67 % were aware of their disease, 90 % of them were under treatment, and 14 % of the individuals who received treatment had their hypertension under control. The proportion of smokers was 12.9 % and alcohol drinker was 86.1 %. One-fourth (25.9 %) of the participants had a family history of hypertension. Veterans aged 55-64 years had higher odds (AOR: 5.3; 95 % CI: 1.8-15.9; p = 0.003) of being associated with hypertension as compared to 35-44 years. Being a current alcohol drinker (AOR: 2.5; 95 % CI: 1.4-4.5; p = 0.003), overweight (AOR: 1.9; 95 % CI: 1.0-3.5; p = 0.04), obese (AOR: 3.1; 95 % CI: 1.1-8.3; p = 0.03) and family history of hypertension (AOR: 2.9; 95 % CI: 1.5-5.8; p = 0.002) were independently associated with hypertension. CONCLUSIONS: Hypertension was prevalent in retired Nepal veterans. Hypertension was associated with a number of modifiable lifestyle and behavioral factors. Our findings suggest the need for screening, education and management of Nepal veterans for hypertension.

Knowledge and Perception Towards Universal Safety Precautions During Early Phase of the COVID-19 Outbreak in Nepal.

The objective of the study was to assess the knowledge and perception of COVID-19 and relevant universal safety measures among the Nepalese population. A web-based cross-sectional study was conducted among Nepalese adults from March 29 to April 07, 2020. A 13- and 15- items structured questionnaire assessed the COVID-19 related knowledge and perception of the universal safety measure. Kruskal-Wallis test and Mann-Whitney U test evaluated the differences in knowledge between the groups. Data analysis was performed using IBM SPSS Statistics for Windows Version 21.0 (IBM Corp. Armonk, NY, USA). Of the 884 surveys accessed, a total of 871 consented (electronically) and completed the online survey (response rate 98.52%). The median knowledge score of the participants was 10.0 (± 3.0 IQR). Although participants' overall knowledge score was high, only about half of the participants knew about the concept of quarantine and the ideal distance to be maintained between individuals to prevent the transmission. Though the majority of the participants had positive perception towards universal safety measure of COVID-19, about 18% perceived that coronavirus infected only older people, 11% opined that the infection was highly fatal with no chances of survival and 70% considered that limiting consumptions of poultry and meat would prevent the spread of COVID-19. A statistically significant difference in knowledge was noted by participants' age, educational status, occupational type, and household monthly income. This study found optimal knowledge and perception of universal safety measures of COVID-19 among the Nepalese population, but misinformation and misunderstanding prevailed.

Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study.

BACKGROUND: We report the main findings of the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS), which aimed to assess the burden of complications related to pregnancy, the coverage of key maternal health interventions, and use of the maternal severity index (MSI) in a global network of health facilities. METHODS: In our cross-sectional study, we included women attending health facilities in Africa, Asia, Latin America, and the Middle East that dealt with at least 1000 childbirths per year and had the capacity to provide caesarean section. We obtained data from analysis of hospital records for all women giving birth and all women who had a severe maternal outcome (SMO; ie, maternal death or maternal near miss). We regarded coverage of key maternal health interventions as the proportion of the target population who received an indicated intervention (eg, the proportion of women with eclampsia who received magnesium sulphate). We used areas under the receiver operator characteristic curves (AUROC) with 95% CI to externally validate a previously reported MSI as an indicator of severity. We assessed the overall performance of care (ie, the ability to produce a positive effect on health outcomes) through standardised mortality ratios. RESULTS: From May 1, 2010, to Dec 31, 2011, we included 314,623 women attending 357 health facilities in 29 countries (2538 had a maternal near miss and 486 maternal deaths occurred). The mean period of data collection in each health facility was 89 days (SD 21). 23,015 (7.3%) women had potentially life-threatening disorders and 3024 (1.0%) developed an SMO. 808 (26.7%) women with an SMO had post-partum haemorrhage and 784 (25.9%) had pre-eclampsia or eclampsia. Cardiovascular, respiratory, and coagulation dysfunctions were the most frequent organ dysfunctions in women who had an SMO. Reported mortality in countries with a high or very high maternal mortality ratio was two-to-three-times higher than that expected for the assessed severity despite a high coverage of essential interventions. The MSI had good accuracy for maternal death prediction in women with markers of organ dysfunction (AUROC 0.826 [95% CI 0.802-0.851]). INTERPRETATION: High coverage of essential interventions did not imply reduced maternal mortality in the health-care facilities we studied. If substantial reductions in maternal mortality are to be achieved, universal coverage of life-saving interventions need to be matched with comprehensive emergency care and overall improvements in the quality of maternal health care. The MSI could be used to assess the performance of health facilities providing care to women with complications related to pregnancy. FUNDING: UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP); WHO; USAID; Ministry of Health, Labour and Welfare of Japan; Gynuity Health Projects.

Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007-08.

BACKGROUND: There has been concern about rising rates of caesarean section worldwide. This Article reports the third phase of the WHO global survey, which aimed to estimate the rate of different methods of delivery and to examine the relation between method of delivery and maternal and perinatal outcomes in selected facilities in Africa and Latin America in 2004-05, and in Asia in 2007-08. METHODS: Nine countries participated in the Asia global survey: Cambodia, China, India, Japan, Nepal, Philippines, Sri Lanka, Thailand, and Vietnam. In each country, the capital city and two other regions or provinces were randomly selected. We studied all women admitted for delivery during 3 months in institutions with 6000 or fewer expected deliveries per year and during 2 months in those with more than 6000 deliveries. We gathered data for institutions to obtain a detailed description of the health facility and its resources for obstetric care. We obtained data from women's medical records to summarise obstetric and perinatal events. FINDINGS: We obtained data for 109 101 of 112 152 deliveries reported in 122 recruited facilities (97% coverage), and analysed 107 950 deliveries. The overall rate of caesarean section was 27.3% (n=29 428) and of operative vaginal delivery was 3.2% (n=3465). Risk of maternal mortality and morbidity index (at least one of: maternal mortality, admission to intensive care unit [ICU], blood transfusion, hysterectomy, or internal iliac artery ligation) was increased for operative vaginal delivery (adjusted odds ratio 2.1, 95% CI 1.7-2.6) and all types of caesarean section (antepartum without indication 2.7, 1.4-5.5; antepartum with indication 10.6, 9.3-12.0; intrapartum without indication 14.2, 9.8-20.7; intrapartum with indication 14.5, 13.2-16.0). For breech presentation, caesarean section, either antepartum (0.2, 0.1-0.3) or intrapartum (0.3, 0.2-0.4), was associated with improved perinatal outcomes, but also with increased risk of stay in neonatal ICU (2.0, 1.1-3.6; and 2.1, 1.2-3.7, respectively). INTERPRETATION: To improve maternal and perinatal outcomes, caesarean section should be done only when there is a medical indication. FUNDING: US Agency for International Development (USAID); UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), WHO, Switzerland; Ministry of Health, Labour and Welfare of Japan; Ministry of Public Health, China; and Indian Council of Medical Research.

Maternal and Obstetric Factors Associated with Low Birth Weight.

BACKGROUND: Low birth weight is a factor associated with perinatal, neonatal and post-neonatal morbidity and mortality and is associated with development of chronic diseases in adulthood. This study aimed to identify the maternal and obstetric factors associated with low birth weight in selected hospitals of Nepal. METHODS: Matched case control study was conducted in two tertiary level hospital of Nepal during May 2017 to April 2018. There were 368 mothers with single full term live low birth weight babies (cases) and 736 mothers with single full term live normal birth weight babies (controls) matched on babies' gender and place of delivery included in the study. Multivariable conditional logistic regression analysis was used to eliminate the effects of potential confounders and to identify the independent effect of various risk factors associated with low birth weight. RESULTS: A total of 1104 respondents (1 case : 2 controls) were included in the study. Multivariable conditional logistic regression analysis revealed that maternal height <146 cm [AOR 5.14, (95%CI:2.03-13.01),(p=0.001)], maternal weight ?50 kg [AOR 3.75,(95%CI:2.15-6.56), (p<0.001)], primi-parity [AOR 4.58, (95%CI:1.71-12.25),(p=0.002)], multi-parity [AOR 3.01,(95%CI: 1.11-8.12),(p=0.030)], rest in day time ?2 hours [AOR 3.68, (95%CI: 2.01-6.75),(p<0.001)], rest in night time for <8 hours [AOR 5.76, (95%CI: 2.32-14.33), (p<0.001)], Iron and folic acid consumption for ?60 days [AOR 5.47, (95%CI: 2.73-10.95),(p<0.001)], Iron and folic acid consumption for 61-120 days [AOR 3.04, (95%CI: 1.90-4.87),(p<0.001), no calcium consumption [AOR 3.00, (95%CI: 1.78-5.04),(p<0.001)] were the significant risk factors associated with Low birth weight Conclusions: Height and weight of women, parity, duration of rest in day time and night time, consumption of Iron and folic acid and calcium were the maternal and obstetric determinants for the occurrence of low birth weight.

Health Care Utilization and Health Care Expenditure of Nepali Older Adults.

Introduction: Aging is associated with multiple chronic conditions. In older age, health needs and demand for health services utilization increase. There are limited data in Nepal on the health care utilization as well as health care costs among the elderly population. Therefore, it is imperative to explore the factors hindering access to health care among Nepalese older adults. Our study aims to explore the health care utilization and expenditure among Nepali older adults. Method: A community-based cross-sectional survey was conducted among 401 older adults residing in Pokhara Lekhnath metropolitan of Nepal. The survey tool was adapted from the Study on Global Aging and Adult Health (SAGE)'s questions on "Health Care Utilization." The predictors of health care utilization were assessed in binary logistic regression models. Results: Study participants, mean (±SD) age 70.2 (±8.0) years, had various preexisting conditions such as hypertension (37.7 %), gastritis (28.4 %), asthma (25.4 %), and arthritis (23.4%) reported in the past 12 months but only 70% visited a health facility. A notable proportion (30%) of participants didn't utilize health services despite having a health problem. The utilization of out-patient and in-patient health services were 87.5 and 14.6% respectively. The use of private health facilities (56.4%) was high compared to the use of government health facilities (35.7%). Privileged ethnicity, living with a partner, higher annual income, knowledge of social insurance, and multi-morbidity were associated with higher odds of utilizing health services. Participants of privileged ethnicity, with higher household income, attending private health facility, and having multi-morbidities had significantly higher out of pocket health expenditures. Conclusions: A notable proportion of elderly participants did not utilize health services despite having a health problem. The public health system must develop effective strategies to attract this segment of the society. High dependency on private health facilities, as noted in the study, will only lead toward higher out of pocket health expenditures. The health benefits of regular health screenings must be disseminated among the elderly population. Developing quality and affordable health care services for older adults to ensure equity in accessibility will be a major task for the public health system in Nepal.

Undergraduate pharmacy students' attitudes and perceived barriers toward provision of pharmaceutical care: a multi-institutional study in Nepal.

Background: Pharmaceutical care (PC) has a significant impact on optimizing pharmacotherapy and improving patients' quality of life. We aimed to determine the attitudes and perceived barriers of final year pharmacy undergraduates towards provision of PC services in Nepal. Methods: A cross-sectional study was conducted among 232 students using a 13-item-standard PC attitude survey (PCAS) questionnaire and 12-itemed PC barrier questionnaires. Mann-Whitney U test and Kruskal-Wallis tests were used to measure the median difference between groups, at alpha=0.05, and Spearman's rho test was used to measure the strength of the correlation. Results: Majority of students were self-motivated in undertaking the current pharmacy education (178, 76.7%) and had no previous incomplete grades that could delay their graduation (177, 76.3%). Over 80% of students had a positive attitude toward all items of PCAS (agreed and strongly agreed) except for two items. Whereas, 61 (26.3%) disagreed and strongly disagreed that providing PC takes too much time and effort. The major barriers perceived were inadequate PC training (176, 75.9%), inadequate drug information resources in the pharmacy (170, 73.3%), and lack of access to patient medical records in the pharmacy (165, 71.1%). A significant relationship was noticed between positive attitude towards PC and three factors; source of motivation, current employment in pharmacy job, and incomplete grades delaying graduation. Age factor was significant but negatively correlated with the scores of positive attitudes namely "I would like to perform PC as a pharmacist practitioner", "Providing PC is professionally rewarding" and "I feel that the PC is the right direction for the provision to be headed". Conclusion: Nepalese undergraduate pharmacy students had positive attitudes toward PC. Exercising proper pharmacy practice regulations and educational efforts to overcome the perceived barriers may lead to better delivery of PC.

Barriers to Dietary Salt Reduction among Hypertensive Patients.

BACKGROUND: Despite knowing the ill consequences of high salt intake, many hypertensive patients in Nepal continue to consume high levels of salt in their diet. Hence, this study aims to reveal the barriers to dietary salt reduction among hypertensive patients in Nepal. METHODS: A barrier analysis was conducted in the outpatient department of Sahid Gangalal National Heart Center, Nepal among 180 hypertensive patients under physician advice to reduce salt in their diet. A logistic regression modeling was used to calculate odds ratios (ORs) for the barriers. RESULTS: Low self-efficacy (OR=0.04; 95%CI: 0.01-0.24) was a significant barrier to dietary salt reduction among study participants, as well as lack of taste (23.3% Compliant vs. 53.3% Non-Compliant) and lack of family support (5.6% compliant vs. 27.8% noncompliant).Difficulty in remembering to eat low salt (OR=3.89; 95%CI: 1.28-11.87) was a barrier for males. There were differences seen by gender in barriers: among female participants, low perceived social acceptability (OR=0.05; 95%CI: 0.01-0.32), and living in a joint rather than nuclear family (OR=0.21; 95%CI: 0.06-0.77) were significant barriers to dietary salt reduction. Presence of a son (7.8% Compliant vs.30.0% Non-Compliant) and/or husband (1.1% Compliant vs. 11.1% Non-Compliant) had an influence on females' decisions to reduce salt. CONCLUSIONS: Perceived self-efficacy, reminder to action, social acceptability, and family structure were barriers to dietary salt reduction among hypertensive patients in Nepal. Presence of a son and/or husband had an influence on females' decisions to reduce salt. Addressing the modifiable barriers identified in this study is important for successful salt reduction initiatives in Nepal. The inclusion of a son and/or husband in nutritional counseling may be beneficial to achieve salt reduction in this population.

Prevalence of Risk Factors of Major Non-Communicable Diseases among Adolescents of Higher Secondary Schools of Kaski District.

BACKGROUND: The main aim of this study is to determine the prevalence of major non communicable disease risk factors among higher secondary school students. METHODS: A cross-sectional study was conducted among higher secondary students of grade 11 and 12 of Kaski district in Nepal. The study period was from July 2016 to June 2017. Total sample 640 higher secondary students were recruited through two-stage cluster sampling. Self-administrated questionnaire was used for the data collection tool along with other tools which were used such as UNICEF electronic weighing scale, stature meter and mechanical aneroid sphygmomanometer. Ethical approval was obtained from IRC, Pokhara University. Data were entered intoEpiData software and analysis was performed with the help of the Statistical Package for Social Science (SPSS). RESULTS: The prevalence of smoking was 6.1% which was high in male (11.9%) than female (0.6%). Alcohol consumption practice among the adolescents was 18.9%. Family history of hypertension was seen higher than family history of diabetes.The prevalence of hypertension was 11.7%. High prevalence of abnormal values of systolic and diastolic BP was found in male than female students. Overweight was seen in 6.1% students. Prevalence of obesity was almost equal in both groups. CONCLUSIONS: There is high prevalence of smoking, alcoholism among adolescents. Hypertension was more common than overwieght among adolescents.

Factors Associated With Health-Related Quality of Life among Hypertensive Patients in Kathmandu, Nepal.

INTRODUCTION: Nepal has a high prevalence of hypertension. While improving the overall health-related quality of life (HRQOL) is a central tenet to public health plans in developed nations, this focus has yet to be articulated in Nepal. Therefore, this study aims to identify the factors associated with HRQOL among hypertensive patients in Nepal. METHOD: The EuroQol-5Dimension HRQOL survey was administered to 180 hypertensive patients, attending the outpatient clinic at Shahid Gangalal National Heart Center in Kathmandu, Nepal. Multiple linear regression models, adjusted for age and sex, were used to identify factors associated with HRQOL. RESULTS: The mean age and EuroQol visual analytic scale of the participants were 53.2 years and 63.7, respectively. Age [ß = -0.56; 95% confidence interval (CI): -0.75 to -0.37], income (ß = 0.02; 95% CI: 0.01, 0.03), family size (ß = -0.98; 95% CI: -1.89, -0.07), number of antihypertensive drugs use (ß = 4.62; 95% CI: 1.33, 7.90), and compliance to dietary salt advise (ß = 4.86; 95% CI: 0.29, 9.43) were significant factors associated with HRQOL among participants. In addition, levels of education and self-perceived health were associated in a positive gradient to HRQOL. In mediation analysis, both, dietary low salt compliance and use of antihypertensive drugs, had a significant direct effect on HRQOL, and the use of antihypertensive drugs did not significantly mediate the relationship between dietary salt compliance and HRQOL. CONCLUSION: Various factors were found to be associated with HRQOL among hypertensive patients in Kathmandu. Assessing HRQOL is a valuable technique to identify populations in need of services and interventions. This assessment can serve as a baseline, and in conjunction with multiple stakeholders, can guide public health policy, planning, and practices, especially those aimed toward improving the HRQOL of Nepalese with hypertension.

Practical approach to lung health in Nepal: better prescribing and reduction of cost.

OBJECTIVES: To assess the impact of Practical Approach to Lung Health (PAL) guidelines on prescription behaviour and the total cost of prescription for patients with asthma, chronic obstructive pulmonary disease and pneumonia. METHODS: Pre- and post-intervention comparison in a cluster randomized trial of primary care facilities. Seven health posts and 33 subhealth posts in Nepal were stratified by type and randomized into intervention and control groups. Health workers from the intervention facilities received 5 days training on the adapted PAL guidelines and their use. To collect prescription details, we used carbon-copy prescription pads in both groups. To measure the impact of PAL guidelines we used the World Health Organization's rational use of drug indicators and drug cost indicators, in a multivariate regression analysis. RESULTS: The PAL guidelines led to fewer prescriptions of multiple drugs and to more prescriptions of generic and essential drugs. The guidelines also lowered average prescription cost and wastage by disease except for chronic obstructive pulmonary disease although not to a statistically significant degree. Similarly, the prescription of antibiotics and adherence to guidelines improved, albeit not statistically significant. CONCLUSION: There is evidence that the implementation of PAL guidelines promotes rational use of drugs for some respiratory diseases. The expected health effects of PAL guidelines should be compared with their implementation costs before continuing training on lung health, and strategies put in place to sustain the effects.

Intervention studies on rational use of drugs in public and private sector in Nepal.

In developing countries, inappropriate, inefficient and ineffective use of pharmaceuticals have resulted into the poor health and medical cares for the community people. For improving the situation, various interventions have been tested and proved effective in different settings. In Nepal also, various strategies have been tested and found effective to improve the prescribing and dispensing practices. This paper has examined the process and results of different studies. The educational intervention, the training has not been effective in improving the prescribing practices but has limited effect on dispensing practices in the public sector. However, it becomes effective in improving prescribing practices if combined with a managerial intervention e.g. peer-group discussion. In private sector, training alone is effective in changing the drug recommendation practices of retailers. But none of interventions have been found to be effective in improving dispensing practices. After examining the effectiveness of different interventions, training combined with peer-group discussion is recommended for piloting in all Primary Health Care (PHC) outlets of a district to improve the prescribing practices. For improving the dispensing practices in both public and private sector, additional studies have to be carried out using different strategies.