Age and sex disparities in cardiovascular risk factor management prior to stroke: Linked registry and general practice data.

INTRODUCTION: There is limited evidence about the management of cardiovascular risk factors within 12 months before stroke/transient ischaemic attack (TIA) in Australian general practices. We evaluated whether age and sex disparities in cardiovascular risk factor management for primary prevention exist in general practice. METHODS: A retrospective cohort study using data from the Australian Stroke Clinical Registry (2014-2018) linked with general practice data from three primary health networks in Victoria, Australia. We included adults who had ≥2 encounters with a general practitioner within 12 months immediately before the first stroke/TIA. Cardiovascular risk factor management within 12 months before stroke/TIA was evaluated in terms of: assessment of risk factors (blood pressure [BP], serum lipids, blood glucose, body weight); prescription of prevention medications (BP, lipid-, glucose-lowering, antithrombotic agents); and attainment of risk factor targets. RESULTS: Of 2,880 patients included (median age 76.5 years, 48.4% women), 80.9% were assessed for BP, 49.9% serum lipids, 46.8% blood glucose, and 39.3% body weight. Compared to patients aged 65-84 years, those aged <65 or ≥85 years were less often assessed for risk factors, with women aged ≥85 years assessed for significantly fewer risk factors than their male counterparts. The most prescribed prevention medications were BP-lowering (64.9%) and lipid-lowering agents (42.0%). There were significant sex differences among those aged <65 years (34.7% women vs. 40.2% men) and ≥85 years (34.0% women vs. 44.3% men) for lipid-lowering agents. Risk factor target attainment was generally poorer in men than women, especially among those aged <65 years. CONCLUSION: Age-sex disparity exists in risk factor management for primary prevention in general practice, and this was more pronounced among younger patients and older women.

Enhancing primary stroke prevention: a combination approach.

Stroke can be prevented through effective management of risk factors. However, current primary stroke prevention approaches are insufficient and often fragmented. Primary stroke prevention strategies are predominantly targeted at behavioural (eg, smoking cessation and lifestyle modifications) and pharmacological interventions (ie, prevention medications). There is also a need to consider interrelating structural factors that support, or hinder, prevention actions and behaviours of individuals. Without addressing these structural factors, it is impossible to maximise the benefits of behavioural and pharmacological interventions at the population level. We propose a tripartite approach to primary stroke prevention, comprising behavioural, pharmacological, and structural interventions, which is superimposed on the socioecological model. This approach could minimise the current fragmentation and inefficiency of primary stroke prevention.

The Allure of Big Data to Improve Stroke Outcomes: Review of Current Literature.

PURPOSE OF REVIEW: To critically appraise literature on recent advances and methods using "big data" to evaluate stroke outcomes and associated factors. RECENT FINDINGS: Recent big data studies provided new evidence on the incidence of stroke outcomes, and important emerging predictors of these outcomes. Main highlights included the identification of COVID-19 infection and exposure to a low-dose particulate matter as emerging predictors of mortality post-stroke. Demographic (age, sex) and geographical (rural vs. urban) disparities in outcomes were also identified. There was a surge in methodological (e.g., machine learning and validation) studies aimed at maximizing the efficiency of big data for improving the prediction of stroke outcomes. However, considerable delays remain between data generation and publication. Big data are driving rapid innovations in research of stroke outcomes, generating novel evidence for bridging practice gaps. Opportunity exists to harness big data to drive real-time improvements in stroke outcomes.

Factors associated with HIV testing and counselling services among women and men in Nepal: a cross-sectional study using data from a nationally representative survey.

OBJECTIVES: This study is set up to explore the factors associated with Human Immunodeficiency Virus (HIV) testing among women and men in Nepal. STUDY DESIGN: Nepal Demographic and Health Survey, 2016 adopts a cross-sectional design. SETTING: Nepal. PARTICIPANTS: Women and men of age 15-49 years. PRIMARY OUTCOME MEASURES: Our primary outcome was ever tested for HIV. We used multivariable analysis at a 95% level of significance to measure the effect in outcome variables. RESULTS: About one in 10 women (10.8%) and one in five men (20.5%) ever tested for HIV. Women who had media exposure at least once a week ((adjusted odds ratio (aOR)=2.8; 95% CI: 1.4 to 5.3) were more likely to get tested for HIV compared with those who had no media exposure at all. Similarly, those who had their recent delivery in the health facility (aOR=3.9; 95% CI: 2.4 to 6.3) were more likely to get tests for HIV compared with those delivered elsewhere. Likewise, among men, compared with adolescents (15-19 years), those from older age groups were more likely to get tested for HIV. Compared with no education, secondary (aOR=2.3; 95% CI: 1.4 to 3.6) and higher education (aOR=1.7; 95% CI: 1.0 to 2.8) had higher odds of getting tested for HIV. Similarly, wealth quintiles in richer and richest groups were more likely to get tested for HIV compared with the poorest quintile. Other characteristics like media exposure, paid sex and 2+ sexual partners were positively associated with being tested for HIV. CONCLUSIONS: HIV testing is not widespread and more men than women are accessing HIV services. More than two-thirds of women who delivered at health facilities never tested for HIV. It is imperative to reach out to people engaging in risky sexual behaviour, people with lower educational attainment, and those in the lower wealth quintile for achieving 95-95-95 targets by 2030.

Availability and readiness to provide sexually transmitted infections and HIV testing and counselling services in Nepal: evidence from comprehensive health facility survey.

OBJECTIVE: We assessed the availability and readiness of health facilities to provide sexually transmitted infections (STI) and HIV testing and counselling (HTC) services in Nepal. DESIGN: This was a cross-sectional study. SETTING: We used data from the most recent nationally representative Nepal Health Facility Survey (NHFS) 2015. A total of 963 health facilities were surveyed with 97% response rate. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome of this study was to assess the availability and readiness of health facilities to provide STI and HTC services using the WHO Service Availability and Readiness Assessment (SARA) manual. RESULTS: Nearly three-fourths (73.8%) and less than one-tenth (5.9%) of health facilities reported providing STI and HTC services, respectively. The mean readiness score of STI and HTC services was 26.2% and 68.9%, respectively. The readiness scores varied significantly according to the managing authority (private vs public) for both STI and HTC services. Interestingly, health facilities with external supervision had better service readiness scores for STI services that were almost four points higher than compared with those facilities with no external supervision. Regarding HTC services, service readiness was lower at private hospitals (32.9 points lower) compared to government hospitals. Unlike STI services, the readiness of facilities to provide HTC services was higher (4.8 point higher) at facilities which performed quality assurance. CONCLUSION: The facility readiness for HTC service is higher than that for STI services. There are persistent gaps in staff, guidelines and medicine and commodities across both services. Government of Nepal should focus on ensuring constant supervision and quality assurance, as these were among the determining factors for facility readiness.

Implementing Federalism in the Health System of Nepal: Opportunities and Challenges.

Nepal moved from unitary system with a three-level federal system of government. As federalism accelerates, the national health system can also speed up its own decentralization process, reduce disparities in access, and improve health outcomes. The turn towards federalism creates several potential opportunities for the national healthcare system. This is because decision making has been devolved to the federal, provincial and local governments, and so they can make decisions that are more representative of their localised health needs. The major challenge during the transition phase is to ensure that there are uninterrupted supplies of medical commodities and services. This requires scaling up the ability of local bodies to manage drug procurement and general logistics and adequate human resource in local healthcare centres. This article documents the efforts made so far in context of health sector federalization and synthesizes the progress and challenges to date and potential ways forward. This paper is written at a time while it is critical to review the federalism initiatives and develop way forward. As Nepal progress towards the federalized health system, we propose that the challenges inherent with the transition are critically analysed and mitigated while unfolding the potential of federal health system.

Predictors of mortality in adult people living with HIV on antiretroviral therapy in Nepal: A retrospective cohort study, 2004-2013.

BACKGROUND: In Nepal, since 2004, 19,388 people living with HIV (PLHIV) have been enrolled on antiretroviral therapy (ART). The aim of this study was to measure mortality rate and to identify predictors of mortality in adult (≥15 years) PLHIV who initiated ART between 2004 and 2013 in five large ART centers of Nepal. METHODS: This retrospective cohort study of 3,799 (60.5% male) adult PLHIV uses secondary data collected from standard ART registers. Time from ART initiation (baseline) to death or censoring (loss to follow-up or December 31, 2013) was assessed. Mortality rates per 100 person-years were calculated. Kaplan-Meier models were used to estimate the probability of mortality over time. Predictors of mortality were determined using Cox-regression models. RESULTS: The overall mortality rate was 6.98 (95% CI: 6.46-7.54) per 100 person-years, 4.11 (95% CI: 3.53-4.79) in females and 9.14 (95% CI: 8.36-9.99) in males. Mortality rates were higher in early months after ART initiation, particularly in the first three months. Baseline predictors of mortality were ART center, male gender (adjusted HR = 2.08, 95% CI: 1.69-2.57), residence outside the ART district (AHR = 1.45, 95% CI:1.19-1.76), World Health Organization clinical stage III (AHR = 1.67, 95% CI: 1.13-2.46) and IV (AHR = 2.21, 95% CI: 1.45-3.36), bedridden <50% time in the last month (AHR = 1.92, 95% CI: 1.52-2.41), bedridden >50% time in the last month (AHR = 3.82, 95% CI: 2.95-4.94), lower bodyweight/kg (AHR = 1.04, 95% CI: 1.03-1.05), CD4 count <150 cell/mm3 (AHR = 2.14, 95% CI: 1.05-4.34) and treatment not switched to second-line regimen (AHR = 3.05, 95% CI: 1.35-6.90). CONCLUSIONS: Mortality rates were higher soon after ART initiation, particularly in males and gradually decreased over time. Poor baseline clinical characteristics were significantly associated with higher mortality. Increased ART coverage with decentralization of sites to lower levels including community dispensing, differentiated and improved service delivery and initiation of ART at a less advanced disease stage may reduce early mortality.

Socio-demographic characteristics and the utilization of HIV testing and counselling services among the key populations at the Bhutanese Refugees Camps in Eastern Nepal.

OBJECTIVES: This cross-sectional study was conducted to describe the socio-demographic characteristics, assess the utilization of HIV testing and counselling services, and to explore the reasons for the non-utilization of HIV testing and counselling services among the key populations at the Bhutanese refugee camps in eastern Nepal. RESULTS: The HIV testing and counselling services are utilized by less than a third (29%) of the key population among the Bhutanese Refugees. The prime source of information about the HIV testing and counselling sites has been health workers followed by peer/outreach educators and neighbors. Common self-reported barriers for utilization of HIV testing and counselling services by the Bhutanese refugees were self-perceived stigma about HIV, the fear of being discriminated and the lack of knowledge about HIV testing and counselling services. There is a need to analyze the gap between availability and utilization through more qualitative approaches in order to identify interventions to increase the uptake of the HIV testing and counselling services.

Nutritional status and its association with quality of life among people living with HIV attending public anti-retroviral therapy sites of Kathmandu Valley, Nepal.

BACKGROUND: Little evidence exists on the connections between nutrition, diet intake, and quality of life (QoL) among people living with HIV (PLHIV). The study aimed to estimate the prevalence of under-nutrition among PLHIV in Nepal, and identify risk factors and assess correlations with PLHIVs' QoL and nutritional status. METHODS: This quantitative cross-sectional study used Body Mass Index (BMI) as an indicator for nutritional status, and additional information on opportunistic infections (OIs), CD4 count, and World Health Organization (WHO) clinical staging was collected from medical records. Participants were asked to complete surveys on food security and QoL. Descriptive analysis was used to estimate the prevalence of under nutrition. To assess associations between nutrition status and independent variables, bivariate and multivariate analysis was completed. Spearman's rank correlation test was used to assess the association between nutritional status and QoL. RESULTS: One in five PLHIVs was found to be under nourished (BMI <18.5 kg/m(2)). Illiteracy, residence in care homes, CD4 cells count <350 cells/mm(3), OIs, and illness at WHO clinical stages III and IV were found to be significant predictors of under nutrition. BMI was significantly correlated with three domains of QoL (psychological, social and environmental). CONCLUSION: Nutrition interventions should form an integral part of HIV care programs. Understanding the presence of OI, decline in CD4 count, and advancing WHO clinical stages as risk factors can be helpful in preventing under nutrition from developing. Longitudinal research is necessary to further explicate associations between nutritional status and QoL.

Strengthening adherence to Anti Retroviral Therapy (ART) monitoring and support: operation research to identify barriers and facilitators in Nepal.

BACKGROUND: Anti Retroviral Therapy (ART) is the cornerstone for comprehensive health sector response to Human Immunodeficiency Virus (HIV) treatment, care and support. Adherence of at least 95% is needed to keep HIV under control, as per World Health Organization (WHO) guidelines. This study was aimed at identifying the overall adherence level of, and barriers and facilitators to adherence for patients taking ART in different clinics in all five development regions of Nepal. METHODS: A descriptive cross-sectional study was conducted among ART clients receiving free ART from Government of Nepal ART clinics. A total of 435 clients taking ART from twelve ART clinics in different regions of Nepal, aged fifteen years and above were interviewed on one-and-one basis using questionnaires developed in reference to Adult AIDS Clinical Trial Group (AACTG) toolkit among them data from 404 were analyzed after cleaning. Data was entered and analyzed using Statistical Package for Social Sciences (SPSS) software where the P value of < 0.05 was accepted as being statistically significant. RESULTS: The overall adherence in the last month (missed less than three pills total) was 94.8% (383 out of 404). The main barrier to ART adherence was the fear of side effects (among 61.9% of the non adherent population) which included dizziness (18.1%) and headaches (15.4%). The standard wristwatch (39%) was found to be the most useful aid in enabling timely consumption of medication. Educational status (P = 0.018), drug using habits (P = 0.039) and the conducive environment at ART clinics (P = 0.004) were significantly associated with ART adherence. CONCLUSION: Improving better adherence may require a more holistic approach to treatment regimen and adapting it to patient daily routines. This study identifies issues such as pill count for assessing adherence, better access to health care facilities by clients, better access to medication, as well as improved nutritional support issues for better adherence by the population in the future.

Illness perception of tuberculosis (TB) and health seeking practice among urban slum residents of Bangladesh: a qualitative study.

BACKGROUND: Combating tuberculosis (TB) in urban slums is more complex than in rural areas due to reasons such as over-crowding, unhygienic living conditions and poverty. This study aimed to assess illness perception of TB and identify barriers and facilitators for health seeking practice among the residents of Badda slum, Dhaka, Bangladesh. METHODS: The Badda slum was purposively selected. Convenience sampling was carried out to select participants aged 18 years and above. Twenty two in-depth interviews, two key informants' interviews and participatory rapid appraisal (PRA) were conducted. Data were analyzed manually by using defined a priori codes and color coding of the quotes in data matrix table. RESULTS: TB was commonly recognized as Jokkha (pulmonary TB), Sas rog (disease associated to breathing) followed by TB. More females than males had knowledge about TB related illness. Very few perceived of being at risk of TB despite the high risk behavior and environment. Prime barriers for health seeking practice of TB were cost along with other barriers like prevailing stigma on TB, lack of information on service sites and unavailability of accompanying person. Training and orientation to community organizations and people, awareness on TB and free treatment through advertisements/media, community level diagnostic and home based care were identified as the facilitators for the health seeking practice of TB. CONCLUSIONS: Perceptions of TB and knowledge associated with the disease shape the health seeking practice, therefore promotion of media awareness campaign, targeting the people of urban slums for reducing misconceptions and promotion of home based service is needed to encourage health seeking practice in the future.

Sexual behavior and condom use among seasonal Dalit migrant laborers to India from Far West, Nepal: a qualitative study.

BACKGROUND: Around 41% of Human Immunodeficiency Virus (HIV) cases in Nepal occur in seasonal migrant laborers. Dalit migrant laborers represent the largest proportion of reported HIV cases in the Far Western Region (Sudur Pashchimanchal, or Far West), Nepal. The study's objectives were to assess sexual behavior, condom use status and HIV risk perception among Dalit migrant laborers to India from Far West Region, Nepal. METHODS: The study was conducted among Dalit male migrant laborers aged 15 years and above who had migrated for at least six months of the last two years to India. For the sampling the village development committees (VDCs) from Achham, Doti and Kanchanpur districts of Nepal were purposively selected. The data were collected in March and April 2011 via ten in-depth interviews and four focus group discussions and analyzed using content analysis. RESULTS: Poor socio-economic status, caste-related discrimination, and lack of employment opportunities push large groups of young Dalits to migrate to India for employment, where they engage in sex with female sex workers (FSWs). The participants described unmarried status, peer influence, alcohol use, low-priced sex with FSWs and unwillingness to use condoms as common factors of their migration experience. Lack of awareness on HIV/AIDS was common among study participants. Awareness of HIV/AIDS and faithful, monogamous partnerships are reported as factors influencing safer sexual behavior. CONCLUSIONS: Dalits are an especially vulnerable population among migrant laborers and may be over-represented in new HIV infections in Nepal. Comprehensive surveying and health promotion programs targeted to this population are urgently needed and potent methods of stopping HIV spread.