Health literacy among patients with non-communicable diseases at a tertiary level hospital in Nepal- A cross sectional study.

Health literacy (HL) is crucial in achieving the Sustainable Development Goal of reducing one-third of premature mortality by 2030 from Non-Communicable Diseases (NCDs) and improving Universal Health Coverage. Low health literacy is linked to poor health outcomes, and evidence shows that levels of limited HL are high, even among highly educated individuals. This study aims to assess HL levels and related factors among patients with NCDs at Tribhuvan University Teaching Hospital (TUTH) in Nepal. A cross-sectional survey was conducted at TUTH among 303 patients with NCDs with Cardiovascular Diseases, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, Hypertension, Epilepsy, Asthma and Cancer who came for follow-up from December 2022 to February 2023. Data was collected via face-to-face interviews by the trained enumerators using a structured Health Literacy Questionnaire (HLQ) containing 44 items (divided into nine domains). Multivariate logistic regression analysis was performed using SPSS version 26, with statistical significance at 0.05, to determine the associated factors of HL. The mean ±SD age of the respondents was 47.4±16.18 years. More than half of the respondents were female (56.1%). The patients had higher HL in all HL domains except 'Navigating the healthcare system'. Educational status was significantly associated with six out of nine HL domains. Co-morbidity, attendance at health-related seminars, regular physical activity, and social connectedness were associated with at least one of the domains of HL. This study identified the important factors of HL, such as socio-demographic and medical factors among patients with NCDs. This highlights the need for a comprehensive approach to address identified gaps in HL, considering its multifaceted and composite nature and promoting interventions to improve HL in high-risk populations.

Barriers and facilitators to self-care practices for sexual and reproductive health among women of reproductive age.

INTRODUCTION: Sexual and Reproductive Health and Rights (SRHR) have been promoted globally, yet sexual and reproductive health (SRH) interventions are seldom evaluated from the perspective of service users and service providers. Very little is known about whether and why various target groups including general women are (or are not) practicing SRH -related self-care practices. This study explored SRH self-care practices and facilitators and barriers to the adoption of SRH self-care among reproductive-age women of Nepal. METHODS: In this descriptive qualitative study, we conducted in-depth interviews in June 2022 with ten married women of reproductive age (service users) and four SRHR service providers (program managers and health service providers) in Nepal. Thematic analysis was conducted for data analysis. RESULTS: We found that commonly practiced self-care practices were self-administration of contraceptives, self-management of pain, self-monitoring of pregnancy, self-awareness and seeking medical abortions (tele-abortion), self-medication for pre-exposure prophylaxis for HIV, and self-testing for HIV and pregnancy. The multi-level barriers to SRH self-care were poor knowledge and perceived lack of need for SRH self-care, limited access, and negative behaviors from the service providers. The program-related barriers included lack of evidence, limited financial resources, lack of accountability, and limited knowledge and skills among service providers on SRH self-care measures. Peer support, an increasing number of service sites, and access to and use of digital (health) tools emerged as the facilitators of SRH self-care. CONCLUSIONS: The findings of this study suggest that addressing barriers such as poor knowledge, limited access, and negative attitudes while leveraging facilitators such as peer support and digital tools is essential for promoting and enabling effective SRH self-care among women. Population-wide awareness programs supplemented by increasing service sites are essential for increasing SRH self-care practices.

Long-Term Consumption of 6 Different Beverages and Cardiovascular Disease-Related Mortality: A Systematic Review and Meta-Analysis of Prospective Cohort Studies.

The relationship between beverage consumption and risk of cardiovascular disease has been extensively examined in cross-sectional studies. However, limited studies have investigated beverage consumption as a longer-term habitual behavior, which is important owing to potential cumulative harmful or beneficial cardiovascular effects. We examined the association between the long-term consumption of 6 types of beverages (sugar-sweetened or artificially sweetened beverages, tea, coffee, fruit juice, energy drinks, and alcohol) and cardiovascular mortality, by considering sex differences. We conducted a systematic search of MEDLINE, EMBASE, CINAHL, Web of Science, and Scopus databases from 2010 to December 2023. Of 8049 studies identified, 20 studies were included for meta-analysis. Summary hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated with the use of a random-effects model. We found that long-term coffee consumption was related to reduced cardiovascular disease-related mortality in males (pooled HR: 0.63; 95% CI: 0.46, 0.87; P = 0.005) but not in females (HR: 0.78; 95% CI: 0.60, 1.02; P = 0.07). Long-term higher intake of tea was associated with lower risk of cardiovascular disease-related mortality in all adults (pooled HR: 0.81; 95% CI: 0.72, 0.92; P ≤ 0.001). Higher alcohol intake was linked to higher stroke in both males (pooled HR: 1.44; 95% CI: 1.06, 1.94; P = 0.02) and females (pooled HR: 2.26; 95% CI: 1.34, 3.81; P = 0.002). Higher sugar-sweetened beverage intake was in relation to higher cardiovascular disease-related mortality (pooled HR: 1.31; 95% CI: 1.16, 1.46; P ≤ 0.0001). We concluded that long-term habitual coffee consumption is beneficial for males, and tea consumption is beneficial for all adults. Long-term high alcohol and sugar-sweetened beverage consumption increased risk of cardiovascular disease-related mortality for both males and females. However, we were unable to draw conclusions on the potential benefit or harm of the long-term consumption of fruit juice and energy drinks on cardiovascular disease-related mortality owing to the limited number of studies available. This review was registered at PROSPERO as CRD42020214679.

A systematic review of the evidence for effectiveness of interventions to address transport and other unintentional injuries among adolescents.

INTRODUCTION: Globally, injuries are a leading cause of mortality and morbidity for adolescents, which disproportionately affect the disadvantaged. To build an investment case for adolescent injury prevention, evidence is needed as to effective interventions. METHODS: A systematic review of peer-reviewed original research published between 2010-2022 was conducted. CINAHL, Cochrane Central, Embase, Medline and PsycINFO databases were searched for studies reporting the effectiveness of unintentional injury prevention interventions for adolescents (10-24 years), with assessment of study quality and equity (e.g., age, gender, ethnicity, socio-economic status). RESULTS: Sixty-two studies were included; 59 (95.2%) from high-income countries (HIC). Thirty-eight studies (61.3%) reported no aspect of equity. Thirty-six studies (58.1%) reported prevention of sports injuries (commonly neuromuscular training often focused on soccer-related injuries, rule changes and protective equipment). Twenty-one studies (33.9%) reported prevention of road traffic injury, with legislative approaches, commonly graduated driver licensing schemes, found to be effective in reducing fatal and nonfatal road traffic injury. Seven studies reported interventions for other unintentional injuries (e.g., falls). DISCUSSION: Interventions were strongly biased towards HIC, which does not reflect the global distribution of adolescent injury burden. Low consideration of equity in included studies indicates current evidence largely excludes adolescent populations at increased risk of injury. A large proportion of studies evaluated interventions to prevent sports injury, a prevalent yet low severity injury mechanism. Findings highlight the importance of education and enforcement alongside legislative approaches for preventing adolescent transport injuries. Despite drowning being a leading cause of injury-related harm among adolescents, no interventions were identified. CONCLUSION: This review provides evidence to support investment in effective adolescent injury prevention interventions. Further evidence of effectiveness is needed, especially for low- and middle-income countries, populations at increased risk of injury who would benefit from greater consideration of equity and for high lethality injury mechanisms like drowning.

Long-Term Consumption of 10 Food Groups and Cardiovascular Mortality: A Systematic Review and Dose Response Meta-Analysis of Prospective Cohort Studies.

A large body of evidence exists on diet and cardiovascular mortality, but limited studies have investigated the long-term intake of food groups, which may have cumulative effects on cardiovascular health in the long term. This review therefore evaluated the relationship between the long-term consumption of 10 food groups and cardiovascular mortality. We conducted a systematic search in Medline, Embase, Scopus, CINAHL, and Web of Science till January 2022. Of the 5318 studies initially identified, 22 studies with a total of 70,273 participants with cardiovascular mortality were included. Summary HRs and 95% CIs were estimated using a random effects model. We found that a long-term high intake of whole grains (HR: 0.87; 95% CI: 0.80, 0.95; P = 0.001), fruits and vegetables (HR: 0.72; 95% CI: 0.61, 0.85; P < 0.0001), and nuts (HR: 0.73; 95% CI: 0.66, 0.81; P < 0.00001) significantly reduced cardiovascular mortality. Each 10-gram increase in whole grain consumption per day was associated with a 4% reduction in the risk of cardiovascular mortality, whereas each 10-gram increase in red/processed meat consumption per day was associated with a 1.8% increase in the risk of cardiovascular mortality. Compared with the lowest intake category, red/processed meat consumption in the highest category was associated with an increased risk of cardiovascular mortality (HR: 1.23; 95% CI: 1.09, 1.39; P = 0.006). High intake of dairy products (HR: 1.11; 95% CI: 0.92, 1.34; P = 0.28), and legumes (HR: 0.86; 95% CI: 0.53, 1.38; P = 0.53) were not associated with cardiovascular mortality. However, in the dose-response analysis, each 10-gram increase in legume intake per week was associated with a 0.5% reduction in cardiovascular mortality. We conclude that the long-term high intake of whole grains, vegetables, fruits, nuts, and a low intake of red/processed meat are associated with reduced cardiovascular mortality. More data on the long-term effects of legumes on cardiovascular mortality are encouraged. This study was registered at PROSPERO as CRD42020214679.

Effectiveness and Acceptability of a Mobile Phone Text Messaging Intervention to Improve Blood Pressure Control (TEXT4BP) among Patients with Hypertension in Nepal: A Feasibility Randomised Controlled Trial.

Background: Uncontrolled blood pressure (BP) is the leading cause of preventable deaths in low- and middle-income countries. mHealth interventions, such as mobile phone text messaging, are a promising tool to improve BP control, but research on feasibility and effectiveness in resource-limited settings remains limited. Objective: This feasibility study assessed the effectiveness and acceptability of a mobile phone text messaging intervention (TEXT4BP) to improve BP control and treatment adherence among patients with hypertension in Nepal. Methods: The TEXT4BP study was a two-arm, parallel-group, unblinded, randomised controlled pilot trial that included 200 participants (1:1) (mean age: 50.5 years, 44.5% women) with hypertension at a tertiary referral hospital in Kathmandu, Nepal. Patients in the intervention arm (n = 100) received text messages three times per week for three months. The control arm (n = 100) received standard care. The COM-B model informed contextual co-designed text messages. Primary outcomes were change in BP and medication adherence at three months. Secondary outcomes included BP control, medication adherence self-efficacy and knowledge of hypertension. A nested qualitative study assessed the acceptability of the intervention. Results: At three months, the intervention group had greater reductions in systolic and diastolic BP vs usual care [-7.09/-5.86 (p ≤ 0.003) vs -0.77/-1.35 (p ≥ 0.28) mmHg] [adjusted difference: systolic ß = -6.50 (95% CI, -12.6; -0.33) and diastolic BP ß = -4.60 (95% CI, -8.16; -1.04)], coupled with a greater proportion achieving target BP (70% vs 48%, p = 0.006). The intervention arm showed an improvement in compliance to antihypertensive therapy (p < 0.001), medication adherence (p < 0.001), medication adherence self-efficacy (p = 0.023) and knowledge on hypertension and its treatment (p = 0.013). Participants expressed a high rate of acceptability and desire to continue the TEXT4BP intervention. Conclusion: The TEXT4BP study provides promising evidence that text messaging intervention is feasible, acceptable, and effective to improve BP control in low-resource settings. Trial registration: anzctr.org.au Identifier ACTRN12619001213134.

Impact of antimicrobial stewardship program on antimicrobial-resistance and prescribing in nursing homes: a systematic review and meta-analysis.

OBJECTIVES: The success of the antimicrobial stewardship program (ASP) is more often measured in antimicrobial use in the literature; however, there is limited evidence regarding antimicrobial resistance (AMR). This study aims to systematically review the impact of urinary tract infection-targeted ASP on overall AMR, antimicrobial use, and specific to fluoroquinolone (FQ) use in nursing homes (NHs). METHODS: This systematic review and meta-analysis included studies published in EMBASE, PubMed, Scopus, Medline, and Cochrane Central Register of Controlled Trials. Two reviewers independently extracted data in standard forms in "Covidence." The outcome was presented in percent change and rate ratio. Meta-analysis was done using DerSimonian and Laird random-effects model with inverse variance weighting. RESULTS: A total of 216 NHs participated in 16 included studies. Most of the ASP was educational, targeted to nurses and physicians. Four studies reported information about uropathogens resistance, 10 FQ-related, 13 antimicrobials prescribed, and 11 urine cultures. ASP had a positive impact on reducing overall and FQ-related AMR. However, fewer studies representation with varying information did not allow us to generalise. ASP performance was impressive in reducing antimicrobial prescribing (pooled rate ratio = 0.69, 95% CI 0.60-0.81, P ≤ 0.001) and urine culture rate (pooled rate ratio = 0.64, 95% CI 0.61-0.67, P ≤ 0.001) in NHs. CONCLUSION: The findings are encouraging despite the limited studies reported ASP impact on AMR. However, it takes years to see the impact of ASP on AMR. Therefore, future research should allocate a long-term follow-up and at least an outcome related to AMR to generate concrete evidence.

Acceptability of a mHealth strategy for hypertension management in a low-income and middle-income country setting: a formative qualitative study among patients and healthcare providers.

BACKGROUND: Understanding contextual needs and preferences is important for a successful design and effective outcome of a mHealth strategy. OBJECTIVES: This formative study aimed to explore the perspectives of patients and providers on the acceptability of a mHealth (text message) strategy and elicit preferred features of a mHealth strategy for hypertension management. DESIGN: A qualitative study was conducted using in-depth interviews and focus group discussions guided by the technology acceptance model. SETTING: The study was conducted at primary healthcare facilities and at a tertiary level referral hospital in Kathmandu, Nepal. PARTICIPANTS: A total of 61 participants, patients with hypertension (n=41), their family members (n=5), healthcare workers (n=11) and key informants (n=4) were included. We purposively recruited patients with hypertension aged 30-70 who attended the selected healthcare facilities to obtain maximum variation based on their age, sex and literacy. RESULTS: The respondents perceived the mHealth strategy to be useful as it would reinforce medication compliance and behaviour change. Participants valued the trustworthiness of information from health authorities that could be delivered privately. Some implementation challenges were identified including a lack of technical manpower, resources for software development, gaps in recording a patient's essential information and digital illiteracy. Solutions proposed were having system-level preparedness for recording the patient's details, establishing a separate technical department in the hospital and involving a family member to assist illiterate/elderly patients. In addition, participants preferred text messages in the local language, containing comprehensive contextual content (disease, treatment, cultural foods and misconceptions) delivered at regular intervals (2-3 times/week) preferably in the morning or evening. CONCLUSIONS: We found that a simple text messaging strategy was acceptable for hypertension management in this low/middle-income country setting. However, meticulous planning must address the needs of a diverse range of participants to ensure the mHealth strategy is acceptable to wider groups.

Barriers and facilitators for treatment and control of high blood pressure among hypertensive patients in Kathmandu, Nepal: a qualitative study informed by COM-B model of behavior change.

BACKGROUND: Nepal has a high prevalence of hypertension which is a major risk factor for cardiovascular diseases globally. It is inadequately controlled even after its diagnosis despite the availability of effective treatment of hypertension. There is a need for an in-depth understanding of the barriers and facilitators using theory to inform interventions to improve the control of hypertension. This formative study was conducted to address this gap by exploring the perceived facilitators and barriers to treatment and control of hypertension in Nepal. METHODS: We conducted in-depth interviews (IDIs) among hypertensive patients, their family members, healthcare providers and key informants at primary (health posts and primary health care center) and tertiary level (Kathmandu Medical College) facilities in Kathmandu, Nepal. Additionally, data were collected using focus group discussions (FGDs) with hypertensive patients. Recordings of IDIs and FGDs were transcribed, coded both inductively and deductively, and subthemes generated. The emerging subthemes were mapped to the Capability, Opportunity, and Motivation-Behaviour (COM-B) model using a deductive approach. RESULTS: Major uncovered themes as capability barriers were misconceptions about hypertension, its treatment and difficulties in modifying behaviour. Faith in alternative medicine and fear of the consequences of established treatment were identified as motivation barriers. A lack of communication between patients and providers, stigma related to hypertension and fear of its disclosure, and socio-cultural factors shaping health behaviour were identified as opportunity barriers in the COM-B model. The perceived threat of the disease, a reflective motivator, was a facilitator in adhering to treatment. CONCLUSIONS: This formative study, using the COM-B model of behaviour change identified several known and unknown barriers and facilitators that influence poor control of blood pressure among people diagnosed with hypertension in Kathmandu, Nepal. These findings need to be considered when developing targeted interventions to improve treatment adherence and blood pressure control of hypertensive patients.

Comparison of Radial and Femoral Percutaneous Coronary Intervention.

BACKGROUND: The use of radial access for percutaneous coronary intervention is increasing in Nepal. However, there is limited study on the comparison of radial and femoral access in Nepal. This is the study comparing net adverse clinical events of radial with femoral access for intervention. METHODS: This prospective study was conducted at Shahid Gangalal National Heart Center from January 2014 to June 2015 among 849 participations who underwent percutaneous coronary interventions, and 418 radial interventions were compared with 418 femoral interventions. A comparison was done in terms of 30- day rate of net adverse clinical events defined as the composite of death, myocardial infarction, stroke, target lesion revascularization and major bleeding. RESULTS: Incidence of net adverse clinical events was significantly lower in radial compared to femoral approach 18(4.30%) vs. 51 (12.2%), p= <0.001). Mortality observed in the radial approach was significantly lower (p=<0.001) compared to femoral. Procedure success was not significantly different p=0.629.  The trans-radial approach had significantly higher crossover rate (p=0.001). Observed vascular access site complications (p=0.026) and hospital stay (p=<0.0001) were lower in the radial group. Radiation exposure measured by fluoroscopy exposure time was not significantly different between the two groups (p=0.290). CONCLUSIONS: Radial access is associated with a lower rate of net adverse clinical events at 30 days compared to femoral access. Radial access is safer and equally effective compared to femoral access in the context of Nepal.

Theory-based mobile phone text messaging intervention for blood pressure control (TEXT4BP) among hypertensive patients in Nepal: study protocol for a feasibility randomised controlled trial.

INTRODUCTION: Uncontrolled blood pressure is one of the main risk factors for cardiovascular disease and death in Low-income and middle-income countries. Improvements to medication adherence and lifestyle changes can be assisted by using mobile phone text messaging interventions. This study aims to test the feasibility and acceptability of a text messaging intervention for blood pressure control '(TEXT4BP)', developed based on behavioural change theory to improve treatment adherence and lifestyle change among hypertensive patients in Nepal. METHODS AND ANALYSIS: The TEXT4BP intervention will be tested using a two-arm parallel-group, unblinded, individually randomised controlled trial. This feasibility study would recruit 200 clinically diagnosed hypertensive patients aged 18-69 years, currently receiving blood pressure-lowering medication for more than 3 months, visiting a tertiary healthcare facility in Kathmandu, Nepal. A nested qualitative study will assess the acceptability of the short message service intervention. The intervention group will receive text messages containing information on hypertension, diet, medication and physical activity three times a week for 3 months. The control group will receive standard care. At baseline and 3 months, measures of medication adherence, salt intake, physical activity and blood pressure will be collected. Feasibility measures, such as differential rates of recruitment and attrition rates, will be calculated. Acceptability of text message interventions will be studied using usability measures and in-depth interviews among intervention group participants. This pilot study is not funded. ETHICS AND DISSEMINATION: This study has received ethics approval from the University of New South Wales Human Research Ethics Committee B (HC190357), Nepal Health Research Council (302/2019) and Institutional Review Committee of Kathmandu Medical College and Teaching Hospital Kathmandu, Nepal (030520192). The findings of the study will be disseminated through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER: ACTRN12619001213134.

Improving Safety Among Pregnant Women Reporting Domestic Violence in Nepal-A Pilot Study.

Introduction: Domestic violence (DV) during pregnancy is associated with poor health outcomes for both the mother and newborn, and sometimes death. In a low-income country like Nepal, women have few options to leave abusive situations. Therefore, there is a need for interventions to improve their safety. The aim of our study was to explore the use of safety measures before and after an educational intervention among women who have reported DV during pregnancy. Materials and methods: Of 1010 pregnant women screened consecutively for DV using the Abuse Assessment Screen (AAS) during routine antenatal care, 181 women reported domestic violence. All 1010 participating pregnant women were taught 15 safety measures using a locally developed flipchart. We obtained contact with 80 of the 181 eligible women postpartum, of whom 62 completed the follow-up assessment. We explored and described the use of safety measures at baseline and follow-up, using a standardized instrument called the Safety Behavior Checklist. Results: At follow-up, less than half of the women (n = 30, or 48.3%) reported any form of DV. Of the women who reported DV at follow-up, significantly more reported the experience of both violence and fear at baseline (21.9%, p = 0.01) compared with the women who did not report DV at follow-up (3.3%, p = 0.01). Women reporting DV at baseline and follow-up used more safety measures at baseline (56) and follow-up (80) compared with women reporting DV at baseline only (36 and 46). Women reporting DV at baseline and follow-up used more safety measures for the first time at follow-up, 57 new measures compared with the 28 new measures used by women reporting DV at baseline only. Conclusions: The use of a flipchart teaching session on safety measures within antenatal care may increase the number of safety measures women use to protect themselves during pregnancy and decrease the risks of adverse health effects of DV.