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Bhattarai S, Bajracharya S, Shrestha A, Skovlund E, Åsvold BO, Mjolstad BP, Sen A. Facilitators and barriers to hypertension management in urban Nepal: findings from a qualitative study. Open Heart 2023; 10:e002394. [PMID: 37899127 PMCID: PMC10618998 DOI: 10.1136/openhrt-2023-002394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 10/02/2023] [Indexed: 10/31/2023] Open
Abstract
INTRODUCTION In Nepal, one-fourth of the adult population has hypertension. Despite provision of comprehensive hypertension services through the primary healthcare system, huge gaps in treatment and control of hypertension exist. Our study explored the individual, interpersonal, health system and community-level barriers and facilitators affecting hypertension management in urban Nepal. METHODS We used a qualitative methodology informed by Kaufman's socioecological model, conducting focus group discussions with hypertension patients and their family members. In-depth interviews with hypertension patients, healthcare providers and municipal officials were also conducted. RESULTS We found that inadequate knowledge about hypertension and harmful cultural beliefs hindered effective treatment of hypertension. Interrupted medical supply and distrust in primary healthcare providers affected the poor's access to hypertension services. Poor communication between family members and gender norms affected adaptation of treatment measures. This study emphasised the role of family members in supporting patients in adhering to treatment measures and rebuilding community trust in primary healthcare providers for better access to hypertension services. The findings guided the development of a manual to be used by community health workers during home visits to support patients to control high blood pressure. CONCLUSION The study highlights the importance of integrating various aspects of care to overcome the multiple barriers to hypertension management in urban settings in low-resource countries. Participatory home visits have the potential to empower individuals and families to develop and implement feasible and acceptable actions for home management of hypertension through improved adherence to antihypertensive medication, and behaviour change.
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Affiliation(s)
- Sanju Bhattarai
- Institute for Implementation Science and Health, Kathmandu, Nepal
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | | | - Archana Shrestha
- Institute for Implementation Science and Health, Kathmandu, Nepal
- Department of Public Health, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal
- Department of Chronic Disease Epidemiology, Center of Methods for Implementation and Prevention Science, Yale School of Public Health, New Haven, Connecticut, USA
| | - Eva Skovlund
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Bjørn Olav Åsvold
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Endocrinology, Clinic of Medicine, St Olavs Hospital Trondheim University Hospital, Trondheim, Norway
| | - Bente Prytz Mjolstad
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- General Practice Research Unit, Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Abhijit Sen
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Center for Oral Health Services and Research (TkMidt), Trondheim, Norway
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Thapa R, Zengin A, Neupane D, Mishra SR, Koirala S, Kallestrup P, Thrift AG. Sustainability of a 12-month lifestyle intervention delivered by community health workers in reducing blood pressure in Nepal: 5-year follow-up of the COBIN open-label, cluster randomised trial. Lancet Glob Health 2023; 11:e1086-e1095. [PMID: 37349035 DOI: 10.1016/s2214-109x(23)00214-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 04/24/2023] [Accepted: 04/24/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND The sustainability and scalability of limited-duration interventions in low-income and middle-income countries remain unclear. We aimed to investigate the sustainability in reduction of blood pressure through a 12-month lifestyle intervention led by community health workers to reduce blood pressure in Nepal, 4 years after the intervention ceased. METHODS The Community-Based Intervention for Control of Hypertension in Nepal (COBIN) trial was a non-blinded, cluster-randomised trial done in Kaski, Nepal. Adults aged 25-65 years were eligible. People were excluded if they declined consent, were severely ill, unlikely to be in the community throughout the intervention, or pregnant. During the 12-month intervention, female community health volunteers (FCHVs) visited participants in the intervention groups and provided lifestyle counselling and blood pressure measurement every 4 months. At the end of the 12-month intervention, systolic blood pressure was significantly lower in the intervention group than in the usual care group in all cohorts, ranging from -2·3 mm Hg (95% CI -3·8 to -0·8) lower in those with normal blood pressure to -4·9 mm Hg (-7·8 to -2·0) in the hypertensive cohort. The primary outcome for this follow-up study was a mean change in systolic blood pressure from baseline to follow-up at 60 months. We did an intention-to-treat analysis. FINDINGS Between April 1, 2015, and Dec 31, 2015, 1638 participants were recruited in COBIN (939 [57·3%] assigned to intervention and 699 [42·7%] assigned to usual care). Of the 1468 (89·6%) who completed the 12-month assessments, we followed up 1352 (92·1%) participants at 60 months, between Oct 11, 2020, and May 5, 2022. 964 (71·3%) participants were women and 388 (28·7%) were men. From baseline to 60 months, the mean systolic blood pressure increased by 10·4 mm Hg (95% CI 9·1-11·6) in the intervention group and 6·0 mm Hg (4·6-7·5) in the usual care group (adjusted mean difference 4·1 mm Hg [2·2 to 5·8]). INTERPRETATION Lifestyle counselling and blood pressure monitoring by community health workers is effective in substantially reducing blood pressure while adults are being monitored in a trial but, following cessation of the intervention, this benefit is not maintained in the long term, with potential for harm. This finding could have important implications for funders and research communities to regularly target participants for education and follow-up at an optimal timepoint to reduce any likelihood of harm. FUNDING Monash University (Melbourne, VIC, Australia) and the Jayanti Memorial Trust (Kathmandu, Nepal). TRANSLATION For the Nepali translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Rajshree Thapa
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia; Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia; Nepal Development Society, Chitwan, Bagmati Province, Nepal
| | - Ayse Zengin
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
| | - Dinesh Neupane
- Nepal Development Society, Chitwan, Bagmati Province, Nepal; Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
| | - Shiva Raj Mishra
- Nepal Development Society, Chitwan, Bagmati Province, Nepal; Epidemiology and Simulation Modelling, School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Sweta Koirala
- Nepal Development Society, Chitwan, Bagmati Province, Nepal
| | - Per Kallestrup
- Center for Global Health, Department of Public Health, Aarhus University, Aarhus, Midtjylland, Denmark
| | - Amanda G Thrift
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia.
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Ghimire K, McLachlan CS, Mishra SR, Kallestrup P, Neupane D. Estimating mean population salt intake using spot urine samples in Nepal: a cross-sectional study. J Hypertens 2023; 41:711-722. [PMID: 36723497 DOI: 10.1097/hjh.0000000000003380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Little is known about the usefulness of spot urine testing compared with 24-h urine samples to estimate salt intake in low-income settings. This is given 24-h urinary collection can be costly, burdensome, and impractical in population surveys. The primary objective of the study was to compare urinary sodium levels (as an estimate of salt intake) of Nepalese population between 24-h urine and spot urine using previously established spot urine-based equations. Additionally, this study explored the 24-h prediction of creatinine and potassium excretion from spot urine samples using available prediction equations. METHODS The sample population was derived from the community-based survey conducted in Nepal in 2018. Mean salt intake was estimated from spot urine samples comparing previously published equations, and this was then contrasted with mean salt intake estimations from 24-h urine samples, using paired t test, Pearson correlation coefficient, intraclass correlation coefficient, and Bland-Altman plots. RESULTS A total of 451 participants provided both complete 24-h and morning spot urine samples. Unweighted mean (±SD) salt intake based on 24-h urine collection was 13.28 ± 4.72 g/day. The corresponding estimates were 15.44 ± 5.92 g/day for the Kawasaki, 11.06 ± 3.17 g/day for the Tanaka, 15.22 ± 16.72 g/day for the Mage, 10.66 ± 3.35 g/day for the Toft, 8.57 ± 1.72 g/day for the INTERSALT with potassium, 8.51 ± 1.73 g/day for the INTERSALT without potassium, 7.88 ± 1.94 g/day for the Whitton, 18.13 ± 19.92 g/day for the Uechi simple-mean and 12.07 ± 1.77 g/day using the Uechi regression. As compared with 24-h urine estimates, all equations showed significant mean differences (biases); the Uechi regression had the least difference with 9% underestimation (-1.21 g/day, P < 0.001).Proportional biases were evident for all equations depending on the level of salt intake in the Bland-Altman plots. CONCLUSION None of the included spot urine-based equations accurately corresponded to 24-h salt intake in the present study. These equations may be useful for longitudinal monitoring of population salt intake in Nepal, our study highlights that there are limitations on using existing equations for estimating mean salt intake in Nepali population. Further studies are warranted for accuracy and validation.
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Affiliation(s)
- Kamal Ghimire
- School of Health, Torrens University, Sydney, New South Wales, Australia
| | - Craig S McLachlan
- School of Health, Torrens University, Sydney, New South Wales, Australia
| | - Shiva R Mishra
- World Heart Federation, Salim Yusuf Emerging Leaders Programme, Geneva, Switzerland
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Australia
| | - Per Kallestrup
- Department of Public Health, Centre for Global Health, Aarhus University, Aarhus, Denmark
| | - Dinesh Neupane
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Nepal Development Society, Bharatpur, Chitwan, Nepal
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Adhikari TB, Gyawali B, Rijal A, Sapkota A, Högman M, Karki A, Sigsgaard T, Neupane D, Kallestrup P. Community-based management of chronic obstructive pulmonary disease in Nepal-Designing and implementing a training program for Female Community Health Volunteers. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000253. [PMID: 36962198 PMCID: PMC10021247 DOI: 10.1371/journal.pgph.0000253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 02/13/2022] [Indexed: 11/19/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality in Nepal. Female community health volunteers (FCHVs) have proven effective in the delivery of reproductive, maternal, and child health services in Nepal and recently in the prevention and management of hypertension and type 2 diabetes. Evidence on their roles in COPD management is not yet available. The aim of this study was to develop, implement, and evaluate a training program for FCHVs regarding COPD prevention and management. The training program was part of a cluster-randomized trial of a 12-month intervention to improve COPD outcomes in a semi-urban area of Western Nepal. A six-day workshop consisting of thirty hours of training was developed for FCHVs. Training materials incorporated introduction to COPD, risk factors and symptoms, COPD status assessment guide for FCHVs, guidance on breathing techniques, and exercises for people living with COPD. Pre- and post-test questionnaires were administered to assess the change in knowledge of FCHVs, post training skills assessment followed by semi-structured interviews assessed FCHVs' satisfaction with the training program. The findings of the pre- and post- test assessments showed a significant improvement in FCHVs' COPD-related knowledge from a median (interquartile range) score of 12 (3-16) before to 21 (21-22) (p<0.001) after the training program. The qualitative assessment revealed the feasibility of FCHVs' training on COPD and their acceptability to deliver the intervention package within the community. It also indicated that implementing future training with an extended period and a few days break in-between could enhance the effectiveness. Training of FCHVs in COPD management is feasible and leads to improvement in knowledge. The motivation shown by FCHVs to deliver the intervention could inform and guide community programs and policies for COPD prevention and management in Nepal and similar settings.
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Affiliation(s)
- Tara Ballav Adhikari
- COBIN Project, Nepal Development Society, Bharatpur, Chitwan, Nepal
- Department of Public Health, Section for Global Health, Aarhus University, Aarhus, Denmark
| | - Bishal Gyawali
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Anupa Rijal
- Department of Internal Medicine, Holbæk Hospital, Holbæk, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Abhishek Sapkota
- COBIN Project, Nepal Development Society, Bharatpur, Chitwan, Nepal
| | - Marieann Högman
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Arjun Karki
- Department of Pulmonary, Critical Care and Sleep Medicine, HAMS Hospital, Kathmandu, Nepal
| | - Torben Sigsgaard
- Department of Public Health, Section for Environment, Occupation & Health, Aarhus University, Aarhus, Denmark
| | - Dinesh Neupane
- COBIN Project, Nepal Development Society, Bharatpur, Chitwan, Nepal
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Per Kallestrup
- Department of Public Health, Section for Global Health, Aarhus University, Aarhus, Denmark
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Paudel S, Subedi N, McLachlan CS, Smith BJ, Kallestrup P, Neupane D. Active commuting and leisure-time physical activity among adults in western Nepal: a cross-sectional study. BMJ Open 2021; 11:e051846. [PMID: 34385256 PMCID: PMC8362701 DOI: 10.1136/bmjopen-2021-051846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/28/2021] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To determine the prevalence and sociodemographic factors associated with active commuting and leisure-time physical activity (LTPA) among adults in western Nepal. DESIGN Cross-sectional study. SETTING Adults from semiurban areas in western Nepal. PARTICIPANTS 2815 adults aged 25-65 years who participated in the 'Community-Based Management of Hypertension in Nepal (COBIN)' Study. Multiple logistic regression analysis was used to identify the sociodemographic factors associated with active commuting and LTPA. OUTCOME Self-reported participation in active commuting and LTPA. RESULTS Most study participants (96%) commuted actively (walked or cycled) from one place to another. Our results showed that only a small proportion (3.7%) of participants engaged in moderate or vigorous LTPA. Compared with those in paid employment, the odds of commuting actively were higher among people working in agriculture or as labourers (OR: 4.57, 95% CI: 2.46 to 8.48), those retired/unemployed (OR: 2.98, 95% CI: 1.42 to 6.25) and those in unpaid employment (OR: 1.85, 95% CI: 1.06 to 3.22). Adults who were overweight or had obesity were less likely to commute actively. Compared with adults aged 25-34 years, older adults were less likely (OR: 0.35, 95% CI: 0.17 to 0.72) to engage in LTPA. Women were 0.46 times less likely to engage in LTPA compared with men. CONCLUSION Most adults engaged in active commuting for work or travel. Less than 5% participated in any form of moderate or vigorous LTPA. Longitudinal studies incorporating objective assessment of physical activity and a range of individual, interpersonal, and environmental factors will help understand how to promote active commuting and LTPA among Nepalese adults.Trial registration number: ClinicalTrials.gov NCT02428075.
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Affiliation(s)
- Susan Paudel
- Nepal Development Society, Bharatpur, Bagmati, Nepal
| | - Narayan Subedi
- Nepal Development Society, Bharatpur, Bagmati, Nepal
- School of Exercise and Nutrition Sciences, Deakin University Faculty of Health, Burwood, Victoria, Australia
| | - Craig S McLachlan
- Torrens University Australia-Sydney Campus Pyrmont, Pyrmont, New South Wales, Australia
| | - Ben J Smith
- The University of Sydney, Sydney, New South Wales, Australia
| | - Per Kallestrup
- Center for Global Health, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Dinesh Neupane
- Nepal Development Society, Bharatpur, Bagmati, Nepal
- Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland, USA
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Adhikari TB, Neupane D, Karki A, Drews A, Cooper B, Högman M, Sigsgaard T, Kallestrup P. Community-based intervention for prevention and management of chronic obstructive pulmonary disease in Nepal (COBIN-P trial): study protocol for a cluster-randomized controlled trial. Trials 2021; 22:474. [PMID: 34289879 PMCID: PMC8293490 DOI: 10.1186/s13063-021-05447-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 07/11/2021] [Indexed: 11/25/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) is one of the leading causes of death worldwide and the commonest of non-communicable diseases (NCDs) in Nepal. Risk factors like indoor and outdoor air pollution, a high prevalence of smoking, and the lack of awareness of COPD make it a serious public health concern. However, no attempt has been made in Nepal to estimate its burden and address the disease at the community level. Method This study aims to evaluate the effect of a community-based health educational intervention administered by Female Community Health Volunteers (FCHVs) on the prevention and management of COPD. An open-label, two-group, community-based, cluster-randomized controlled trial will be implemented in the semi-urban area of Pokhara Metropolitan city (former Lekhnath Municipality) located in the Kaski district of Nepal. The estimated sample size of the intervention will be 1143. The unit of randomization is the ward (administrative unit) of the study area. The follow-up survey will be conducted immediately after 12 months of FCHVs-led interventions. The difference in the rate of decline of forced expiratory volume in 1 s (FEV1) and FEV1/FVC (forced vital capacity) ratio are the primary outcomes and the change in the proportion of modifiable risk factors of COPD, health-related quality of life scores, and change in knowledge of COPD will be secondary outcomes. Discussion This study will estimate the burden of COPD, the magnitude of risk factors and generate evidence to mobilize community health workers for COPD prevention and management at the community level in Nepal. Trial registration ClinicalTrials.gov NCT03797768. Registered on January 9, 2019.
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Affiliation(s)
- Tara Ballav Adhikari
- Department of Public Health, Section for Global Health, Aarhus University, Aarhus, Denmark. .,COBIN Project, Nepal Development Society, Bharatpur, Chitwan, Nepal.
| | - Dinesh Neupane
- COBIN Project, Nepal Development Society, Bharatpur, Chitwan, Nepal.,Welch Center for Prevention, Epidemiology, and Clinical Research, Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - Arjun Karki
- Department of Pulmonary, Critical Care and Sleep Medicine, HAMS Hospital, Kathmandu, Nepal
| | | | - Brendan Cooper
- Lung Function and Sleep, University Hospitals Birmingham, Birmingham, UK
| | - Marieann Högman
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Torben Sigsgaard
- Department of Public Health, Section for Environment, Occupation & Health, Aarhus University, Aarhus, Denmark
| | - Per Kallestrup
- Department of Public Health, Section for Global Health, Aarhus University, Aarhus, Denmark
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Gyawali B, Sharma R, Mishra SR, Neupane D, Vaidya A, Sandbæk A, Kallestrup P. Effectiveness of a Female Community Health Volunteer-Delivered Intervention in Reducing Blood Glucose Among Adults With Type 2 Diabetes: An Open-Label, Cluster Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2035799. [PMID: 33523189 PMCID: PMC7851734 DOI: 10.1001/jamanetworkopen.2020.35799] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
IMPORTANCE Female community health volunteers (FCHVs) are frontline community health workers who have been a valuable resource in improving public health outcomes in Nepal, but their value is understudied in diabetes care. OBJECTIVE To assess whether an FCHV-delivered intervention is associated with reduced blood glucose levels among adults with type 2 diabetes. DESIGN, SETTING, AND PARTICIPANTS This community-based, open-label, 2-group, cluster randomized clinical trial with a 12-month delayed control group design was conducted in 14 clusters of a semiurban setting in Western Nepal. A total of 244 adults with type 2 diabetes were recruited between November 2016 and April 2017. The follow-up assessment was conducted at 12 months after enrollment. Data analysis was performed from January to February 2019. INTERVENTIONS Seven clusters were randomized to the FCHV-delivered intervention in which 20 FCHVs provided home visits 3 times a year (once every 4 months) for health promotion counseling and blood glucose monitoring. If participants had blood glucose levels of 126 mg/dL or higher, the FCHVs referred them to the nearest health facility, and if participants were taking antihyperglycemic medication, they were followed up by the FCHVs for adherence to their medication. Seven clusters were randomized to usual care (control group). MAIN OUTCOMES AND MEASURES The primary outcome was the change in mean fasting blood glucose from baseline to 12-month follow-up. Secondary outcomes included changes in mean systolic blood pressure, mean diastolic blood pressure, mean body mass index, percentage change in the proportion of low physical activity, harmful alcohol consumption, current smoking, low fruit and vegetable intake, and antihyperglycemic medication status. RESULTS Of 244 participants, 120 women (56.6%) and 92 men (43.4%) completed the trial. At baseline, the mean (SD) age was 51.71 (8.77) years; 127 participants were in the intervention group, and 117 participants were in the control group (usual care). At baseline, the mean (SD) fasting blood glucose level was 156.06 (44.48) mg/dL (158.48 [45.50] mg/dL in the intervention group and 153.43 [43.39] mg/dL in the control group). At 12-month follow-up, the mean fasting blood glucose decreased by 22.86 mg/dL in the intervention group, whereas it increased by 7.38 mg/dL in the control group. The mean reduction was 27.90 mg/dL greater with the intervention (95% CI, -37.62 to -18.18 mg/dL; P < .001). In secondary outcome analyses, there was a greater decline in mean systolic blood pressure in the intervention group than in the control group (-5.40 mm Hg; 95% CI, -8.88 to -1.92 mm Hg; P = .002). There was detectable difference in the intake of antihyperglycemic medication between the groups (relative risk, 1.35; 95% CI, 1.1 to 1.74; P = .02). CONCLUSIONS AND RELEVANCE These findings suggest that an FCHV-delivered intervention is associated with reduced blood glucose levels among adults with type 2 diabetes in a low-resource setting in Nepal. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03304158.
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Affiliation(s)
- Bishal Gyawali
- Section of Global Health, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Community Health Development Nepal, Kathmandu, Nepal
| | - Rajan Sharma
- Macquarie University Centre for the Health Economy, Macquarie Park, Sydney, Australia
| | | | - Dinesh Neupane
- Nepal Development Society, Chitwan, Nepal
- Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Abhinav Vaidya
- Department of Community Medicine, Kathmandu Medical College and Teaching Hospital, Kathmandu, Nepal
| | - Annelli Sandbæk
- Department of Public Health, Aarhus University, Aarhus, Denmark
- Steno Diabetes Centre Aarhus, Aarhus, Denmark
| | - Per Kallestrup
- Department of Public Health, Aarhus University, Aarhus, Denmark
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Shrestha AD, Neupane D, Ghimire S, Campbell C, Kallestrup P. Community-based intervention for cervical cancer screening uptake in a semi-urban area of Pokhara Metropolitan, Nepal (COBIN-C): study protocol for a cluster-randomized controlled trial. Trials 2021; 22:94. [PMID: 33499911 PMCID: PMC7836185 DOI: 10.1186/s13063-021-05049-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 01/16/2021] [Indexed: 12/04/2022] Open
Abstract
Background Previous studies suggest that health intervention designed to increase cervical cancer screening has been effective to reduce cervical cancer incidence and mortality. The aim of this study is to determine the effect of a home-based health education intervention for increasing cervical cancer screening uptake delivered by trained female community health volunteers (FCHVs), a category of community health worker in Nepal. Methods A community-based, open-label, two-armed, cluster-randomized trial [seven clusters (geographical wards) randomized for the intervention, and seven for the control arm]. The participants are recruited from a population-based survey with a sample size of 884. Based on population proportion size, 277 women will be recruited for the intervention group and 413 women recruited for the control group. A 12-month community-based health education intervention will be administered mobilizing the FCHVs, based on the Health Belief Model. The primary outcome measure of the study will be the difference in percentage of cervical cancer screening uptake between the two study arms. The primary outcomes will be modeled by using mixed-effect logistic regression analysis. Discussion COBIN-C is the first study investigating the effect of a community-based health education intervention by FCHVs on increasing cervical cancer screening uptake among women in Nepal. The purpose of this study is to develop and implement a home-based, culturally sensitive program to increase cervical cancer screening coverage at the community level. Trial registration ClinicalTrials.gov NCT03808064. Registered on January 14, 2019. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05049-3.
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Affiliation(s)
- Aamod Dhoj Shrestha
- Center for Global Health, Department of Public Health, Aarhus University, Aarhus, Denmark. .,COBIN, Nepal Development Society, Bharatpur, Nepal.
| | - Dinesh Neupane
- COBIN, Nepal Development Society, Bharatpur, Nepal.,Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | - Per Kallestrup
- Center for Global Health, Department of Public Health, Aarhus University, Aarhus, Denmark
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Hasan MM, Tasnim F, Tariqujjaman M, Ahmed S, Cleary A, Mamun A. Examining the prevalence, correlates and inequalities of undiagnosed hypertension in Nepal: a population-based cross-sectional study. BMJ Open 2020; 10:e037592. [PMID: 33004393 PMCID: PMC7534699 DOI: 10.1136/bmjopen-2020-037592] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE To examine the prevalence, correlates and sociodemographic inequalities of undiagnosed hypertension in Nepal. DESIGN This study used cross-sectional 2016 Nepal Demographic and Health Survey (NDHS) data. Undiagnosed patients with hypertension were defined as an NDHS respondent who was diagnosed as hypertensive (systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg) during the survey, but never took any prescribed anti-hypertensive medicine to lower/control blood pressure and was never identified as having hypertension by a health professional prior the survey. Multiple binary logistic regression analysis was performed, and Concentration Index was measured. SETTING Nepal. PARTICIPANTS Adult patients with hypertension. RESULTS Among 3334 patients with hypertension, 50.4% remained undiagnosed during the survey in Nepal. Adjusted model reveals that patients who were male, belonged to households other than the highest wealth quintile, and lived in province 4 and province 5 were at higher risk of remaining undiagnosed for hypertension. Patients who were ≥65 years of age and were overweight/obese were at lower risk of remaining undiagnosed for hypertension. The poor-rich gap was 24.6 percentage points (Q1=64.1% vs Q5=39.6%) and poor:rich ratio was 1.6 (Q1/Q5=1.6) in the prevalence of undiagnosed hypertension. Undiagnosed hypertension was disproportionately higher among lower socioeconomic status groups (Concentration Index, C=-0.18). Inequalities in the prevalence of undiagnosed hypertension further varied across other geographic locations, including place of residence, ecological zones and administrative provinces. CONCLUSIONS Undiagnosed hypertension was highly prevalent in Nepal and there were substantial inequalities by sociodemographics and subnational levels. Increasing awareness, strengthening routine screening to diagnose hypertension at primary health service facilities and enactment of social health insurance policy may help Nepal to prevent and control this burden.
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Affiliation(s)
- Md Mehedi Hasan
- Institute for Social Science Research, The University of Queensland, Indooroopilly, Queensland, Australia
- ARC Centre of Excellence for Children and Families over the Life Course (The Life Course Centre), The University of Queensland, Indooroopilly, Queensland, Australia
| | - Fariha Tasnim
- Maternal and Child Health DIvision, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md Tariqujjaman
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sayem Ahmed
- Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Liverpool, UK
- Health Economics and Policy Research Group, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Anne Cleary
- Institute for Social Science Research, The University of Queensland, Indooroopilly, Queensland, Australia
| | - Abdullah Mamun
- Institute for Social Science Research, The University of Queensland, Indooroopilly, Queensland, Australia
- ARC Centre of Excellence for Children and Families over the Life Course (The Life Course Centre), The University of Queensland, Indooroopilly, Queensland, Australia
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10
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Nepali S, Rijal A, Olsen MH, McLachlan CS, Kallestrup P, Neupane D. Factors affecting the fruit and vegetable intake in Nepal and its association with history of self-reported major cardiovascular events. BMC Cardiovasc Disord 2020; 20:425. [PMID: 32972356 PMCID: PMC7517612 DOI: 10.1186/s12872-020-01710-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 09/20/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The World Health Organization recommends consumption of a minimum of 400 g of fruits and vegetables per day for prevention of cardiovascular disease. Low fruit and vegetable intake is associated with an increased risk of stroke by 11% and ischemic heart disease by 31%. The present study aims to explore factors affecting the fruit and vegetable intake in Nepal and its association with history of self-reported major cardiovascular events (myocardial infarction and stroke). METHOD Data for this cross-sectional study were collected as part of the study "Community Based Management of Hypertension in Nepal" initiated in the Lekhnath Municipality in 2013. Demographic and nutrition information were collected using the WHO STEPwise approach to a surveillance tool. Descriptive statistics identified the frequency and percentage of fruit and vegetable intake. A Chi-square test examined the association between fruit and vegetable intake and history of self-reported cardiovascular events, socio-demographic and cardiovascular risk factors. Binary logistic regression analysis identified odds ratio with 95% confidence intervals between fruit and vegetable intake and history of self-reported cardiovascular events. RESULTS The mean and median intake of fruits and vegetables were 3.3 ± 0.79 and 3 servings respectively. Of the 2815 respondents, 2% (59) reported having a history of major cardiovascular events. The adjusted odds of having a history of major cardiovascular events was 2.22 (95%CI, 1.06-4.66) for those who consumed < 3 servings compared to those who consumed ≥3 servings of fruits and vegetables a day. CONCLUSION The respondents who consumed < 3 servings of fruits and vegetables a day had higher odds of a history of major cardiovascular events in comparison to those who consumed ≥3 servings. This finding may carry a policy recommendation for those settings where the current recommendation of having ≥5 servings of fruits and vegetables a day is not possible. Our findings also suggest that surviving a major cardiovascular event was not enough in itself to modify nutritional intake. As many Nepali consumes low amount of fruits and vegetables, appropriate measures should be taken to increase this consumption to prevent cardiovascular morbidity and mortality.
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Affiliation(s)
| | - Anupa Rijal
- Department of Internal Medicine, Holbæk Hospital, Holbæk, Denmark
| | | | | | - Per Kallestrup
- Research Unit for Global Health, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Dinesh Neupane
- Nepal Development Society, Chitwan, Nepal
- Welch Center for Prevention, Epidemiology, and Clinical Research, Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
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11
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Greibe Andersen J, Shrestha AD, Gyawali B, Neupane D, Kallestrup P. Barriers and facilitators to cervical cancer screening uptake among women in Nepal - a qualitative study. Women Health 2020; 60:963-974. [PMID: 32643576 DOI: 10.1080/03630242.2020.1781742] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The global incidence of cervical cancer is approximately 570,000 cases and 311,000 deaths annually. Almost 90% of cervical cancer deaths occur in low and middle income countries. Screening is the most effective tool in prevention, early diagnosis, and treatment of cervical cancer. Nepal has no national cervical cancer screening programme, and data from 2003 showed that only 2.8% of Nepalese women had ever been screened. We conducted a qualitative study to obtain better insight into barriers and facilitators to cervical cancer screening among women in Nepal to generate data to inform interventions. In February 2019, four focus group discussions with previously screened and non-screened women, and Female Community Health Volunteers and four in-depth interviews with health workers were conducted in Pokhara Metropolitan City. Semi-structured interview guides were used, interviews were audio-recorded, transcribed verbatim, and analyzed using grounded theory approach with open coding. This resulted in five main themes: 1) lack of husband's support for screening, 2) prevalent stigma and discrimination, 3) lack of awareness about screening options, 4) getting screened, and 5) health care providers. We encourage policymakers and stakeholders apply these findings to improve awareness, access to information, and better screening services in Nepal.
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Affiliation(s)
| | | | - Bishal Gyawali
- Department of Public Health, Global Health Section, University of Copenhagen, Denmark
| | - Dinesh Neupane
- Department of Epidemiology, Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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12
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Krishnan A, Finkelstein EA, Kallestrup P, Karki A, Olsen MH, Neupane D. Cost-effectiveness and budget impact of the community-based management of hypertension in Nepal study (COBIN): a retrospective analysis. LANCET GLOBAL HEALTH 2020; 7:e1367-e1374. [PMID: 31537367 DOI: 10.1016/s2214-109x(19)30338-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 06/10/2019] [Accepted: 07/22/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND The greatest risk factor for cardiovascular disease is hypertension, which can be alleviated via diet, exercise, and adherence to medication. Yet, blood pressure control in Nepal is inadequate, which is partly hindered by a lack of evidence-based, low-cost, scalable, and cost-effective cardiovascular disease prevention programmes. The the community-based management of hypertension in Nepal (COBIN) study was a 12-month community-based hypertension management programme of blood pressure monitoring and lifestyle counselling intervention undertaken by female community health volunteers (FCHVs) in Nepal, against usual care, which showed success in reducing blood pressure. Here we aimed to retrospectively quantify the budget impact and cost-effectiveness of the scale-up of the programme. METHODS In this retrospective analysis, we collected participant-level data from the COBIN study; programme delivery cost data from programme administrators from the COBIN study group; and popualtion and other data from WHO, the World Bank, and the Nepalese Government. We estimated costs per participant and total costs of a national scale-up of the COBIN programme focusing on two scenarios: scenario A, delivery of the intervention to only people aged 25-65 years with hypertension; and scenario B, delivery of the intervention to all adults aged 25-65 years regardless of hypertension status. Effectiveness was based on in-trial blood pressure reductions converted to cardiovascular disease disability-adjusted life-years (DALYs) averted. The primary cost-effectiveness measure was incremental cost per averted cardiovascular disease DALY (calculated using the incremental cost-effectiveness ratio [ICER]) from a health system perspective, including programme delivery and incremental medication costs. We did univariate sensitivity analyses of scenario B to assess the effect of uncertainty in key parameter values in our calculations. FINDINGS From a health system perspective, the first-year budget impact was US$7·1 million in scenario A and $10·8 million in scenario B. With each subsequent year, the costs decreased by approximately 50%. In the base-case cost-effectiveness analysis, from the health system perspective, scenario A resulted in an ICER of $582 per DALY averted and scenario B resulted in an ICER of $411 per DALY averted. The ICER was most sensitive to uncertainty in the number of total avertable cardiovascular disease DALYs in the eligible population. INTERPRETATION The programme is projected to be highly cost-effective in both scenarios compared with the WHO thresholds for cost-effectiveness for Nepal. For policy makers intending to meet the UN Sustainable Development Goal of reducing premature mortality from non-communicible diseases, this intervention should be considered. FUNDING Duke-NUS Medical School, Singapore.
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Affiliation(s)
- Anirudh Krishnan
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | | | - Per Kallestrup
- Center for Global Health, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Arjun Karki
- Patan Academy of Health Sciences, Lagankhel, Lalitpur, Nepal
| | - Michael Hecht Olsen
- Department of Internal Medicine, Holbaek Hospital, University of Southern Denmark, Odense, Denmark
| | - Dinesh Neupane
- Nepal Development Society, Bharatpur-10, Chitwan, Nepal; Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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13
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Neupane D, Rijal A, Henry ME, Kallestrup P, Koirala B, Mclachlan CS, Ghimire K, Zhao D, Sharma S, Pokharel Y, Joseph K, Olsen MH, Schutte AE, Appel LJ. Mean dietary salt intake in Nepal: A population survey with 24-hour urine collections. J Clin Hypertens (Greenwich) 2020; 22:273-279. [PMID: 31967732 DOI: 10.1111/jch.13813] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 11/25/2019] [Accepted: 12/02/2019] [Indexed: 01/17/2023]
Abstract
High salt (sodium chloride) intake raises blood pressure and increases the risk of developing hypertension, a major risk factor for cardiovascular disease. Little is known about salt intake in Nepal, and no study has estimated salt consumption from 24-hour urinary sodium excretion. Participants (n = 451) were recruited from the Community-Based Management of Non-Communicable Diseases in Nepal (COBIN) cohort in 2018. Salt intake was estimated by analyzing 24-hour urinary sodium excretion. Multivariate linear regression was used to estimate differences in salt intake. The mean (±SD) age and salt intake were 49.6 (±9.8) years and 13.3 (±4.7) g/person/d, respectively. Higher salt intake was significantly associated with male gender (β for female = -2.4; 95% CI: -3.3, -1.4) and younger age (β10 years = -1.4; 95% CI: -1.4, -0.5) and higher BMI (β = 0.1; 95% CI: 0.0, 0.2). A significant association was also found between increase in systolic blood pressure and higher salt intake (β = 0.3; 95% CI: 0.0, 0.7). While 55% reported that they consumed just the right amount of salt, 98% were consuming more than the WHO recommended salt amount (<5 g/person/d). Daily salt intake in this population was over twice the limit recommended by the WHO, suggesting a substantial need to reduce salt intake in this population. It also supports the need of global initiatives such as WHO's Global Hearts Initiative SHAKE technical package and Resolves to Save Lives for sodium reduction in low- and middle-income countries like Nepal.
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Affiliation(s)
- Dinesh Neupane
- Nepal Development Society, Bharatpur, Chitwan, Nepal.,Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
| | - Anupa Rijal
- Nepal Development Society, Bharatpur, Chitwan, Nepal.,Department of Internal Medicine, Holbaek Hospital, Holbaek, Denmark
| | - Megan E Henry
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
| | - Per Kallestrup
- Department of Public Health, Center for Global Health, Aarhus University, Aarhus, Denmark
| | - Bhagawan Koirala
- Manmohan Cardiothoracic Vascular and Transplant Center, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | | | - Kamal Ghimire
- Nepal Development Society, Bharatpur, Chitwan, Nepal
| | - Di Zhao
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
| | - Shailendra Sharma
- Department of Medicine, The George Washington University, Washington, DC, USA
| | - Yashashwi Pokharel
- Saint Luke's Mid America Heart Institute, University of Missouri, Kansas City, MO, USA
| | - Kristy Joseph
- Global Noncommunicable Disease Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Michael Hecht Olsen
- Department of Internal Medicine, Holbaek Hospital, Holbaek, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Aletta E Schutte
- Hypertension in Africa Research Team, South African Medical Research Council, North-West University, Potchefstroom, South Africa
| | - Lawrence J Appel
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
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14
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Pesticide exposure and diabetes mellitus in a semi-urban Nepali population: a cross-sectional study. Int Arch Occup Environ Health 2019; 93:513-524. [DOI: 10.1007/s00420-019-01508-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 12/07/2019] [Indexed: 11/26/2022]
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15
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The burden and correlates of multiple cardiometabolic risk factors in a semi-urban population of Nepal: a community-based cross-sectional study. Sci Rep 2019; 9:15382. [PMID: 31653888 PMCID: PMC6814741 DOI: 10.1038/s41598-019-51454-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 10/01/2019] [Indexed: 01/21/2023] Open
Abstract
This study assessed the burden and correlates of three cardiometabolic risk factors, (hypertension, diabetes, and overweight/obesity), and their possible clustering patterns in a semi-urban population of Nepal. Data were obtained from a community-based management of non-communicable disease in Nepal (COBIN) Wave II study, which included 2,310 adults aged 25-64 years in a semi-urban area of Pokhara Metropolitan City of Nepal, using the World Health Organization-STEPS questionnaire. Unadjusted and adjusted binary logistic regression models were used to study the correlates of the individual risk factors and their clustering. The prevalence of hypertension, diabetes, and overweight/obesity was 34.5%, 11.7%, and 52.9%, respectively. In total, 68.2% of the participants had at least one risk factor and many participants had two risks in combination: 6.8% for 'hypertension and diabetes', 7.4% for 'diabetes and overweight/obesity' and 21.4% for 'hypertension and overweight/obesity'. In total, 4.7% had all three risk factors. Janajati ethnicity (1.4-2.1 times), male gender (1.5 times) and family history of diabetes (1.4-3.4 times) were associated with presence of individual risk factors. Similarly, Janajati ethnicity (aOR: 4.31, 95% CI: 2.53-7.32), current smoking (aOR: 4.81, 95% CI: 2.27-10.21), and family history of diabetes (aOR: 4.60, 95% CI: 2.67-7.91) were associated with presence of all three risk factors. Our study found a high prevalence of all single and combined cardiometabolic risk factors in Nepal. It underlines the need to manage risk factors in aggregate and plan prevention activities targeting multiple risk factors.
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Adhikari TB, Rijal A, Kallestrup P, Neupane D. Alcohol consumption pattern in western Nepal: findings from the COBIN baseline survey. BMC Psychiatry 2019; 19:283. [PMID: 31510948 PMCID: PMC6740022 DOI: 10.1186/s12888-019-2264-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 08/29/2019] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Harmful use of alcohol is a global public health problem. Differences in alcohol consumption patterns may add valuable information to the design of public health interventions to prevent excessive use of alcohol, which is yet missing in Nepal. Hence, the purpose of the study is to determine the prevalence, patterns of alcohol consumption and socio-economic correlates of lifetime alcohol consumption and binge drinking in the semi-urban area of Pokhara Municipality. METHODS The cross-sectional data used in this study were collected as part of the COBIN study to understand alcohol consumption patterns and frequency and to determine correlates of lifetime alcohol consumption and binge drinking in the semi-urban area of Pokhara Municipality, Nepal. RESULTS Out of 2815 study participants, 35.6% had ever used alcohol in their lifetime (Male 67.2% and Female 18.9%). Among 571 respondents who drank alcohol within the past 30 days, 77.1% male, and 46.9% female reported binge drinking behaviour. On average, males consumed 8.8 ± 0.3 standard alcohol drinks on one occasion, while females consumed only 4.4 ± 0.3 alcoholic drinks. Male (OR = 16; 95% CI: 12.1-21.1), older adults (OR = 1.5; 95% CI: 1.2-1.7) and people belonging to disadvantaged ethnic group (OR = 6.1; 95% CI: 4.9-6.3) had higher odds of lifetime alcohol consumption than their respective counterparts. Whereas, male (OR = 7.9; 95% CI: 4.3-14.6), having higher educational status and agriculture as the occupation had higher odds of binge drinking. CONCLUSION Alcohol consumption frequency was significantly higher among males than females in Western Nepal. Although national program and policies should recommend reducing alcohol consumption in general, targeted interventions are needed for males aged 45-65 years of age and certain ethnic groups (Dalit and Janajati).
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Affiliation(s)
- Tara Ballav Adhikari
- Nepal Development Society, Bharatpur, Chitwan, Nepal. .,Department of Public Health, Aarhus University, Aarhus, Denmark.
| | - Anupa Rijal
- Nepal Development Society, Bharatpur, Chitwan Nepal ,0000 0001 0728 0170grid.10825.3eDepartment of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Per Kallestrup
- 0000 0001 1956 2722grid.7048.bDepartment of Public Health, Aarhus University, Aarhus, Denmark
| | - Dinesh Neupane
- Nepal Development Society, Bharatpur, Chitwan Nepal ,0000 0001 2171 9311grid.21107.35Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
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Goehner A, Kricheldorff C, Bitzer EM. Trained volunteers to support chronically ill, multimorbid elderly between hospital and domesticity - a systematic review of one-on-one-intervention types, effects, and underlying training concepts. BMC Geriatr 2019; 19:126. [PMID: 31046693 PMCID: PMC6498473 DOI: 10.1186/s12877-019-1130-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 04/05/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND New approaches are needed to address the challenges of demographic change, staff shortages, and societal change in the care of the elderly. While volunteering has barely been established as a pillar of the welfare state in several countries, legislators and nonprofit or community-based organizations in some countries favor the increased integration of volunteers, as they can rely on many dedicated people. When caring for the multimorbid elderly, the transition from hospital to domesticity involves certain risks. Currently, no systematic knowledge exists on whether and how elderly benefit from volunteer support after a hospital stay. Objectives of this systematic review were to (1) identify evaluated approaches with trained volunteers supporting chronically ill, multimorbid elderly one-on-one at the interface between hospital and domesticity; (2) investigate the patient-related effectiveness of the approaches; (3) present the characteristics of the supporting volunteers; and (4) present the underlying teaching and training concepts for the volunteers. METHODS A systematic search of the following online databases was conducted in April 2017: the Cochrane Library, Medline (PubMed), CINAHL, and PsycINFO (Ebscohost). We included (cluster/quasi-) randomized controlled trials, controlled clinical trials and single-group pre-post design. An institutional search was conducted on eight national institutions from research and practice in Germany. Screening was conducted by one researcher, risk of bias was assessed. Study authors were contacted for study and training details. RESULTS We identified a total of twelve studies, eight of which evaluated treatment following hospital stay: psychosocial-coordinative support (n = 2), physical-cognitive activation (n = 4), and assistance with medication intake (n = 2). We saw short-term effects with small and medium effect sizes. Most volunteers were women aged between 45 and 61 years. Their training lasted 12-26 h and took place prior to first patient contact. During the intervention, volunteers could rely on permanent supporting structures. CONCLUSIONS Few studies exist that have evaluated one-on-one-volunteer support following hospitalization, and the effects are inconsistent. As such, further, well-designed studies are needed. The suitability and transferability of the interventions in country-specific settings should be examined in feasibility studies. Furthermore, an international discussion on the appropriate theoretical backgrounds of volunteer training is needed.
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Affiliation(s)
- Anne Goehner
- Center for Geriatric Medicine and Gerontology Freiburg, Medical Center, Faculty of Medicine, University of Freiburg, Lehener Str. 88, 79106 Freiburg, Germany
- University of Education Freiburg, Public Health & Health Education, Kunzenweg 21, 79117 Freiburg, Germany
| | - Cornelia Kricheldorff
- Catholic University of Applied Sciences Freiburg, Karlstr. 63, 79104 Freiburg, Germany
| | - Eva Maria Bitzer
- University of Education Freiburg, Public Health & Health Education, Kunzenweg 21, 79117 Freiburg, Germany
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Ghimire K, Adhikari TB, Rijal A, Kallestrup P, Henry ME, Neupane D. Knowledge, attitudes, and practices related to salt consumption in Nepal: Findings from the community-based management of non-communicable diseases project in Nepal (COBIN). J Clin Hypertens (Greenwich) 2019; 21:739-748. [PMID: 31026125 DOI: 10.1111/jch.13544] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/22/2019] [Accepted: 04/03/2019] [Indexed: 11/29/2022]
Abstract
High salt/sodium intake is associated with an increased risk of hypertension, which is a major risk factor for cardiovascular diseases. This paper aims to examine the association between salt consumption and salt-related knowledge, attitudes, and practices (KAP) in Nepal. The cross-sectional data used in this study were collected as part of the community-based management of non-communicable diseases project (COBIN) to understand the amount and KAP related to salt consumption in Nepal. Multivariate hierarchical logistic regression was performed to assess the association of salt-related KAP and determinants of high salt consumption in Nepal. The mean per capita salt intake was 8.0 (±3.7) g/day, with 81.6% of the population reporting higher intake than the WHO recommendation of <5 g/day. People of upper castes [adjusted odds ratio (aOR) = 0.7; 95% confidence interval (CI): 0.5-0.9], people in large families (aOR = 0.6; 95% CI: 0.5-0.7), respondents who were advised to lower salt intake (aOR = 0.6; 95% CI: 0.4-0.9) and who checked salt/sodium labels in food (aOR = 0.6; 95% CI: 0.4-0.9) were less likely to consume higher amounts of salt. Similarly, people who added extra salt to their food at the table (aOR = 1.4; 95 CI: 1.1-1.9) and who reported consuming high amounts of salt (aOR = 1.5; 95% CI: 1.1-2.3) were more likely to have high salt intake. High salt intake was documented in this population. This study suggests the need for culturally tailored community-based behavior modification through health education and dietary counseling to effectively reduce salt consumption and thereby support a reduction in hypertension and cardiovascular diseases in Nepal.
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Affiliation(s)
| | - Tara Ballav Adhikari
- Nepal Development Society, Chitwan, Nepal.,Center for Global Health, Department of Public Health, Aarhus University, Aarhus, Denmark
| | | | - Per Kallestrup
- Center for Global Health, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Megan E Henry
- The Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Dinesh Neupane
- Nepal Development Society, Chitwan, Nepal.,The Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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19
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Gyawali B, Hansen MRH, Povlsen MB, Neupane D, Andersen PK, McLachlan CS, Sandbæk A, Vaidya A, Kallestrup P. Awareness, prevalence, treatment, and control of type 2 diabetes in a semi-urban area of Nepal: Findings from a cross-sectional study conducted as a part of COBIN-D trial. PLoS One 2018; 13:e0206491. [PMID: 30388140 PMCID: PMC6214524 DOI: 10.1371/journal.pone.0206491] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 10/15/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Type 2 diabetes is an escalating public health problem in Nepal. The current study aims to assess the prevalence, associated factors, awareness, treatment, and control of type 2 diabetes in a semi-urban area of Nepal. METHODS A population-based cross-sectional survey was conducted including 2,310 adults aged 25 years or above from a semi-urban area of Lekhnath Municipality of Nepal, during October 2016 to April 2017 using the World Health Organization (WHO) STEPS approach. Data on demographics, behavioral risk factors, blood pressure, anthropometric measurements (weight, height, waist and hip circumference), and fasting blood glucose were collected by face-to-face interviews during a door-to-door visit. Participants were considered to have type 2 diabetes if they had previously been diagnosed by a physician and/or were on antidiabetic medications and/or had fasting blood glucose ≥ 7.0 mmol/L. Participants were classified as being aware of their diabetes conditions if they had earlier been told that they had type 2 diabetes. Treatment of diabetes among those aware was if participants received any kind of medication treatment or counseling, and control of diabetes among those treated was defined as fasting blood glucose level was <7.0 mmol/L. Odds Ratio (OR) with 95% Confidence Interval (CI) was used to determine the strength of association. RESULTS The prevalence of type 2 diabetes was 11.7% (95% CI: 10.5-13.1). Among type 2 diabetes participants, 65% were aware of their disease, 94% of those who were aware received treatment, and 21% of the treated subjects had their diabetes under control. Factors significantly associated with type 2 diabetes were older age (OR = 3.2 for age group 45-54 years, OR = 3.8 for age group 55-64 years), Janajati ethnicity (OR = 1.4), abdominal obesity (OR = 2.3), being overweight or obese (OR = 1.4), and hypertension (OR = 2.0), while protective factors included being a female (OR = 0.4), medium physical activity (OR = 0.3), high physical activity (OR = 0.2), and not having family history of diabetes (OR = 0.3). CONCLUSIONS The study revealed a high prevalence of type 2 diabetes among adults. Older age, male gender, Janajati ethnicity, abdominal obesity, overweight or obesity, hypertension, low physical activity, and family history of diabetes were associated with type 2 diabetes. Immediate public health and individual measures are warranted to reduce further burden of type 2 diabetes.
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Affiliation(s)
- Bishal Gyawali
- Department of Public Health, Aarhus University, Aarhus C, Denmark
| | - Martin Rune Hassan Hansen
- Department of Public Health, Aarhus University, Aarhus C, Denmark
- National Research Center for the Working Environment, Copenhagen, Denmark
| | - Mia Buhl Povlsen
- Department of Public Health, Aarhus University, Aarhus C, Denmark
| | - Dinesh Neupane
- Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research Johns Hopkins Bloomberg School of Public Health, Baltimore, United States of America
| | | | | | - Annelli Sandbæk
- Department of Public Health, Aarhus University, Aarhus C, Denmark
| | - Abhinav Vaidya
- Department of Community Medicine, Kathmandu Medical College and Teaching Hospital, Kathmandu, Nepal
| | - Per Kallestrup
- Department of Public Health, Aarhus University, Aarhus C, Denmark
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20
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Gyawali B, Neupane D, Vaidya A, Sandbæk A, Kallestrup P. Community-based intervention for management of diabetes in Nepal (COBIN-D trial): study protocol for a cluster-randomized controlled trial. Trials 2018; 19:579. [PMID: 30348188 PMCID: PMC6196417 DOI: 10.1186/s13063-018-2954-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 09/29/2018] [Indexed: 11/15/2022] Open
Abstract
Background Type 2 diabetes is one of the fastest emerging chronic diseases in low- and middle-income countries. Population-based approaches, such as involvement of lay health workers offering culturally appropriate diabetes health promotion, may be the blueprint for the management of type 2 diabetes. This study aims to examine the effectiveness of a family-based home health education intervention on type 2 diabetes provided by female community health volunteers (FCHVs) in a semi-urban area of Lekhnath Municipality of Nepal. Methods The COmmunity-Based INtervention for management of Diabetes in Nepal (COBIN-D) trial is a community-based, open-label, two-armed, cluster-randomized trial with seven randomly selected intervention and seven wait-list control clusters. A total of 112 subjects with type 2 diabetes will be recruited from the intervention clusters and 112 subjects from the wait-list control clusters. Based on the Health Belief Model and Social Support Theory, a 12-month family-based lifestyle intervention will be administered through FCHVs. Wait-list control clusters will continue to manage their glycemic condition as usual and their intervention will be delayed for 12 months. Participants will be measured at the beginning of the study and 12 months later. The primary outcome measure of the study will be difference in mean change (from baseline to 1 year) in fasting blood glucose between the two study arms. Impacts will be estimated using intention-to-treat analysis. Discussion The COBIN-D is the first study investigating the effect of family-based home health education and screening on blood sugar levels in adults by FCHVs at community level in Nepal. The perspective of this study is to develop and implement, in collaboration with the community, a community-based, culturally sensitive diabetes prevention and control program. It is anticipated that the study can act as a feasible and affordable tool for evidence-based integrated care for improvement of diabetes management and outcomes in Nepal as well as in other low- and middle-income countries. Trial registration ClinicalTrials.gov, Identifier: NCT03304158. Registered retrospectively on 03 October 2017. Electronic supplementary material The online version of this article (10.1186/s13063-018-2954-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bishal Gyawali
- Department of Public Health, Aarhus University, Aarhus, Denmark.
| | - Dinesh Neupane
- Nepal Development Society, Bharatpur, Nepal.,Department of Epidemiology Welch Center for Prevention, Epidemiology, and Clinical Research Johns Hopkins Bloomberg School of Public Health Baltimore, Maryland, Baltimore, USA
| | - Abhinav Vaidya
- Department of Community Medicine, Kathmandu Medical College, Kathmandu, Nepal
| | - Annelli Sandbæk
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Per Kallestrup
- Department of Public Health, Aarhus University, Aarhus, Denmark
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Gyawali B, Mishra SR, Neupane D, Vaidya A, Sandbæk A, Kallestrup P. Diabetes management training for female community health volunteers in Western Nepal: an implementation experience. BMC Public Health 2018; 18:641. [PMID: 29783961 PMCID: PMC5963054 DOI: 10.1186/s12889-018-5562-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Accepted: 05/11/2018] [Indexed: 11/10/2022] Open
Abstract
Background In the backdroup of a rapidly increasing burden of diabetes in Nepal, a community-based diabetes management program is implemented involving female community health volunteers (FCHVs) under the government run FCHVs program. FCHVs received an intensive one-week training workshop on prevention, control and management of diabetes. The training program was implemented and evaluated to enhance diabetes knowledge of FCHVs and matched according to their literacy level. Methods A range of teaching methods were applied, including desk review, active participation, lectures, presentations, discussions, role plays, demonstration and field test. Evaluation of the knowledge attained was done by testing before and after the workshop. Major milestones in the development of the training module were presented from desk review and ending in stakeholder’s participation in reviewing and revising the training package. The qualitative interview transcripts of FCHVs were analyzed thematically. Results A 5-day training package was developed through a desk review of interventions using community health workers (CHWs) on diabetes management from similar settings. Training module included home-based blood glucose monitoring and home-based health education on life style counselling delivered through a participatory learning approach. There were 20 participants with a mean age of 47 years (SD ± 5.7). The overall assessment of knowledge of diabetes before-after the training, evaluated by the Diabetes Knowledge Questionnaire (DKQ) showed increases in mean score from 40.4% before training to a mean score of 63.3% after training (Paired t-test: t = − 11.1, P < 0.001, and Wilcoxon test for paired samples: z = − 3.930, P = 0.0001). Focus group discussions (FGDs) revealed that FCHVs had a favorable perception of the training program’s effectiveness. Conclusions If FCHVs are appropriately trained they may be instrumental in providing counseling and screening for diabetes management in their communities.
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Affiliation(s)
- Bishal Gyawali
- Nepal Development Society (NEDS), Bharatpur, Nepal. .,Department of Public Health, Aarhus University, Aarhus, Denmark.
| | | | | | - Abhinav Vaidya
- Department of Community Medicine, Kathmandu Medical College, Kathmandu, Nepal
| | - Annelli Sandbæk
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Per Kallestrup
- Department of Public Health, Aarhus University, Aarhus, Denmark
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Effectiveness of a lifestyle intervention led by female community health volunteers versus usual care in blood pressure reduction (COBIN): an open-label, cluster-randomised trial. LANCET GLOBAL HEALTH 2018; 6:e66-e73. [DOI: 10.1016/s2214-109x(17)30411-4] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 09/15/2017] [Accepted: 09/20/2017] [Indexed: 12/16/2022]
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Neupane D, Shrestha A, Mishra SR, Bloch J, Christensen B, McLachlan CS, Karki A, Kallestrup P. Awareness, Prevalence, Treatment, and Control of Hypertension in Western Nepal. Am J Hypertens 2017; 30:907-913. [PMID: 28531244 DOI: 10.1093/ajh/hpx074] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 04/06/2017] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Hypertension is a significant contributor to cardiovascular and renal diseases. In low-income settings like Nepal, there are few epidemiological studies assessing hypertension burden. Thus, the purpose was to determine prevalence, awareness, treatment, and control of hypertension in Nepal. METHODS A cross-sectional survey was conducted in semi-urban area of western Nepal among randomly selected participants, aged between 25 and 65 years. Systolic blood pressure (BP) ≥140 mm Hg and/or diastolic BP of ≥90 mm Hg and/or taking current antihypertensive medicine defined as hypertension. RESULTS Study included 2,815 participants, 1,844 were women. The age- and sex-adjusted prevalence of hypertension was 28%. Of the study participants, 17% were daily smokers, 12% harmful alcohol drinkers, 90% consuming low levels of fruit and/or vegetable, and 7% reported low physical activity. Among hypertensive participants, 46% were aware of their preexisting hypertension, 31% were on hypertensive medication, and 15% met BP control targets. Increasing age (odds ratio [OR]: 1.07, 95% confidence interval [CI]: 1.06; 1.08), higher body mass index (OR: 1.09, 95% CI: 1.06; 1.12), men (OR: 1.63, 95% CI: 1.25; 2.14), harmful alcohol intake (Or: 2.46; 95% CI: 1.73; 3.51), family history of hypertension (OR: 1.42; 95% CI: 1.14; 1.76), and diabetes (OR: 2.08, 95% CI: 1.30; 3.33) were independently associated with hypertension. CONCLUSIONS The prevalence of hypertension was found high in western Nepal. A number of risk factors were identified as possible drivers of this burden. Thus, there is an urgent need to address modifiable risk factors in semi-urban settings of western Nepal.
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Affiliation(s)
- Dinesh Neupane
- Center for Global Health, Aarhus University, Aarhus, Denmark
| | - Archana Shrestha
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, USA
| | | | - Joakim Bloch
- Faculty of Health and Medical Sciences, Copenhagen University, Copenhagen, Denmark
| | | | - Craig S McLachlan
- Rural Clinical School, University of New South Wales, Sydney, Australia
| | - Arjun Karki
- Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Per Kallestrup
- Center for Global Health, Aarhus University, Aarhus, Denmark
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