Socioeconomic Determinants of Inequalities in the Use of Modern Contraception among Currently Married Women.

BACKGROUND: Despite interventions for over four decades, the unmet need for family planning is high in Nepal. This study aims to examine the status and the socioeconomic determinants of inequalities in modern contraception among currently married women. METHODS:  We applied a mixed-method design. We interviewed key informants for qualitative information and analyzed secondary data from the Nepal Multiple Indicator Cluster Survey, 2019, and different rounds of Nepal Demographic and Health Surveys. We calculated ratios, differences in percentages, and concentration indices to analyse the inequality. We ran a binary logistic regression model to estimate the adjusted effect of each factor on the use of modern contraception. RESULTS:  The richest-to-poorest difference in using modern contraception has decreased over 13 years. The richest-to-poorest difference decreased from 23.6 percentage points in 2006 to 13.3 percentage points in 2011 and further to 1.2 percentage points in 2016. The richest-to-poorest difference was negative in 2019, indicating poor people are using more contraception than the richest. Multivariate analysis showed the wealth is a significant predictor for using contraception. Women of richer households (aOR=1.29, 95% CI=1.13-1.48), middle (aOR=1.21, 95% CI=1.05-1.40), poorer (aOR=1.36, 95% CI 1.17-1.58) and poorest (aOR=1.18, 95% CI=1.05-1.34) were more likely to use contraception than women from the richest households. CONCLUSIONS: Poor people are increasingly using the modern contraception, and the gap between the poor and rich people has decreased. However, the trend of contraception use in each wealth quintile indicates that Nepal struggles to meet the sustainable development goal target of reducing the unmet need for family planning to less than 10% by 2030.

A prospective cohort study to assess the acceptability of Sayana Press among 18-49-year-old women in Nepal.

OBJECTIVE: We compared acceptability and continuation of Sayana Press, a subcutaneous formulation of depot-medroxyprogesteone acetate (DMPA) in a Uniject injection system, to intramuscular (IM) DMPA, among both current users of DMPA-IM and new users in Nepal. STUDY DESIGN: We recruited women seeking injectable contraception at 14 public health facilities in Nepal selected for geographic diversity. We enrolled women who self-selected either Sayana Press or DMPA-IM and used structured interviews to obtain baseline demographics and assess satisfaction and continuation rates at 1, 3, and 6 months. RESULTS: Seven hundred ninety-four women (71%) selected and received Sayana Press, while 318 women (28.6%) selected and received DMPA-IM. One hundred and seventy-eight (48%) women continuing Sayana Press injection reported that they experienced "no possible side effects" compared to 29 (22%) among DMPA-IM selectors during the previous 6 months. The continuation rate of Sayana Press at 6 months was higher than DMPA-IM (Sayana Press 46.5% vs DMPA-IM 34.4%; p < 0.001). Selection of Sayana Press method (ORadj. 1.74; 95% confidence interval 1.32-2.3) and approval from husband (ORadj. 1.59; 95% confidence interval 1.21-2.09) were associated with injection continuation. CONCLUSION: Sayana Press is acceptable to women in Nepal with the preference for Sayana Press over DMPA-IM (higher proportion chose the method when counseled and given the option, better continuation). IMPLICATIONS: The potential for self-injection with Sayana Press® may have implications for continuation and opportunity for future research and strategies to roll out this innovative technology must be explored.

Association of altitude and urbanization with hypertension and obesity: analysis of the Nepal Demographic and Health Survey 2016.

BACKGROUND: Nepal's Himalayan range attracts mountaineers, climbers and tourists from all across the globe. Limited recent evidence suggests that exposure to hypoxia at a higher altitude may be a risk factor for hypertension and a protective factor for obesity. The existing urban-rural disparities in Nepal in health and economic resources may be anticipated in the burden of hypertension and obesity, two rapidly growing public health issues, but they remain largely unstudied. Therefore this study aims to assess the association of altitude and urbanization with hypertension and overweight/obesity in Nepal. METHODS: Data on 10 473 participants from a nationally representative survey, the 2016 Nepal Demographic and Health Survey (NDHS), was used. The NDHS assessed/measured blood pressure, height, weight, urbanization and the altitude of participants' households by following standard procedures. Logistic and linear regression models were used to study the association of altitude (per 100 m increases) and urbanization with hypertension and obesity, or their continuous measurements (i.e. systolic and diastolic blood pressure [SBP and DBP, respectively] and body mass index [BMI]). RESULTS: The prevalence of hypertension, overweight and obesity was 25.6%, 19.6% and 4.8%, respectively. After controlling for covariates, residents of metropolitan cities had a 30% higher prevalence of overweight/obesity (adjusted prevalence ratio 1.30 [95% confidence interval {CI} 1.11 to 1.52]) than their rural counterparts. For altitude, there was a marginally increased odds of hypertension and overweight/obesity with elevation. Consistently, DBP (ß = 0.18 [95% CI 0.09 to 0.27]) and BMI increased with altitude (ß = 0.11 [95% CI 0.08 to 0.13]). CONCLUSION: Urbanization was positively associated with BMI, while altitude showed a marginally positive association with hypertension and overweight/obesity. Given the role of obesity and hypertension in the aetiology of other chronic diseases and subsequently associated mortality and health care costs, residents in urban areas and at higher altitudes may benefit from weight control interventions and BP monitoring, respectively.

Spousal Separation and Use of and Unmet Need for Contraception in Nepal: Results Based on a 2016 Survey.

Nepal is facing a large-scale labour migration-both internal and international-driven by economic and employment opportunities. There is sparse literature available at the national level which examines the link between migration and contraceptive use. This study aimed at identifying contraceptive use and the unmet need for family planning (FP) and exploring its correlates among the married women of reproductive age (MWRA) by their husbands' residence status, using data from Nepal Demographic Health Survey 2016-a nationally representative cross-sectional survey. A stratified two-stage cluster sampling in rural and a three-stage sampling in urban areas were used to select the sampling clusters, and data from 11,040 households were analyzed. Reported values were weighted by sample weights to provide national-level estimates. The adjusted odds ratio (aOR) was calculated using multiple logistic regressions using complex survey design, considering clusters, and stratification by ecological zones. All analyses were performed using Stata 15.0. Among the total MWRA, 53% were using a contraceptive method, whereas the proportion of contraceptive use among the cohabiting couple was 68%. The unmet need for contraceptive use was 10% among cohabiting couples and 50% among the noncohabiting couples. Contraceptive use was significantly low among the women reporting an induced abortion in the last five years and whose husbands were currently away. A strong negative association of spousal separation with contraceptive use was observed (aOR:0.14; p < 0.001) after controlling other covariates, whereas a positive association was observed with the unmet need (aOR:8.00; p < 0.001). Cohabiting couples had a significantly higher contraceptive use and lower unmet need compared with the couples living apart. Between 2006 and 2016, contraceptive use increased by 1% per year among cohabiting couples, although this increase is hugely attributable to the use of traditional methods, compared with modern methods. The labour migration being a significant and indispensable socioeconomic phenomenon for Nepal, it is necessary to monitor fertility patterns and contraceptive use by cohabitation status in order to ensure that the national family planning interventions are targeted to address the contraceptive and fertility needs of the migrant couples.

Medical abortion can be provided safely and effectively by pharmacy workers trained within a harm reduction framework: Nepal.

OBJECTIVES: To examine the treatment efficacy, safety and satisfaction of women using medical abortion (MA) pills provided by pharmacists following an education intervention based on a harm reduction approach. STUDY DESIGN: This was an operations research study over a six-month period in 2015, using a non-inferiority design. We provided training to dispense MA pills, based on a harm reduction approach, to a group of pharmacy workers in Makwanpur district (GROUP 2). We compared selected outcomes with women who bought the pills from pharmacy workers in Chitwan district (GROUP 1), who had received similar training in 2010. The primary endpoint measured in 992 women in both districts was complete abortion within 30 days of using the pills. We assessed the efficacy of MA (self-reported complete abortion) and safety (no reported adverse event). To determine complete abortion, we asked women about passage of the products of conception, cessation of abdominal cramps, vaginal bleeding, need for manual vacuum aspiration or repeated doses of misoprostol. We used a four-point Lickert Scale to determine level of satisfaction with MA use. Pearson Chi-Square test was used to examine any differences in proportion of complete abortions between women who were served by the two groups of pharmacy workers. RESULTS: The difference in the rate of complete abortions between the two groups of women, 96.9% and 98.8%, was not statistically significant. The women reported no serious complications, and there was little difference in their satisfaction levels. CONCLUSIONS: Trained pharmacy workers dispensed MA safely and effectively to the satisfaction of almost all women clients, and the positive results of training had continued several years later. IMPLICATIONS: The role of pharmacy workers as providers of correct and complete information on safe and effective use of MA needs to be recognized and policies formulated to allow them to provide MA drugs for first trimester use.

Perceived Discrimination Is an Independent Risk Factor for Suicidal Ideation among Sexual and Gender Minorities in Nepal.

Sexual and gender minorities experience an elevated burden of suicidality compared with the general population. Still, little is known about that burden and the factors generating it in the context of low- and middle-income countries. The present study assessed the prevalence of suicidal ideation, planned suicide, and attempted suicide among men who have sex with men (MSM) and transgender people (TG) in Nepal, and examined the association of perceived discrimination on the basis of sexual orientation with suicidal ideation and with attempted suicide. Data were obtained from a surveillance survey among MSM and TG in Nepal in 2012. A sample of 400 MSM and TG, recruited using respondent-driven sampling, completed a structured face-to-face interview. Throughout their lifetime, 26.8% of the participants had experienced suicidal ideation, 12.0% had made a suicide plan, and 9.0% had attempted suicide. In particular, more TG than MSM had experienced suicidal ideation (39.8% vs. 21.3%), had made a suicide plan (19.5% vs. 8.9%), and had attempted suicide (15.3% vs. 6.4%). Overall, the odds of having experienced suicidal ideation was significantly higher among the 38.3% of participants who had perceived discrimination based on their sexual orientation (AOR: 3.17; 95% CI: 1.83-5.48). Moreover, the odds of suicidal ideation was significantly higher as the extent of perceived discrimination increased (AOR: 1.35; 95% CI: 1.15-1.60). However, the odds of attempted suicide was not significantly associated with perceived discrimination (AOR: 1.40; 95% CI: 0.62-3.15). The findings highlight perceived discrimination as an independent risk factor for suicidal ideation. Future suicide prevention programs should target sexual and gender minorities and include elements focusing on discrimination.

Micro-level social and structural factors act synergistically to increase HIV risk among Nepalese female sex workers.

OBJECTIVES: Sex workers face stigma, discrimination, and violence across the globe and are almost 14 times more likely to be HIV-infected than other women in low- and middle-income countries. In Asia, condom campaigns at brothels have been effective in some settings, but for preventive interventions to be sustainable, it is important to understand micro-level social and structural factors that influence sexual behaviours of sex workers. This study assessed the syndemic effects of micro-level social and structural factors of unprotected sex and the prevalence of HIV among female sex workers (FSWs) in Nepal. METHODS: This quantitative study included 610 FSWs who were recruited using two-stage cluster sampling from September to November 2012 in 22 Terai Highway districts of Nepal. Rapid HIV tests and face-to-face interviews were conducted to collect biological and behavioural information. A count of physical (sexual violence and other undesirable events), social (poor social support and condom negotiation skills), and economic (unprotected sex to make more money) factors that operate at the micro-level was calculated to test the additive relationship to unprotected sex. RESULTS: The HIV prevalence was 1%; this is presumably representative, with a large sample of FSWs in Nepal. The prevalence of unprotected sex with clients was high (24%). For each additional adverse physical, social, and economic condition, the probability of non-use of condoms with clients increased substantially: one problem = 12% (p<0.005), two problems = 19% (p<0.001), and three to five problems = 38% (p<0.001). CONCLUSIONS: Interactions between two or more adverse conditions linked to physical, social, and economic environments increased the risk of unprotected sex among Nepalese FSWs.

Low knowledge and perceived Hepatitis C risk despite high risk behaviour among injection drug users in Kathmandu, Nepal.

BACKGROUND: In Nepal, prevalence of Hepatitis C (HCV) among injecting drug users (IDUs) has been measured at 50% and knowledge of the virus is low. Rehabilitation and harm reduction attendees constitute populations to whom health care providers can deliver services. As such, characterizing their drug use and risk profiles is important for developing targeted service delivery. We measured drug use and risk patterns of IDUs participating in residential rehabilitation as well as those contacted through needle exchanges to identify correlates of drug use frequency, risky injection practices as well as HCV testing, knowledge and perceived risk. METHODS: We collected cross-sectional data from one-on-one structured interviews of IDUs contacted through needle-exchange outreach workers (n=202) and those attending rehabilitation centres (behaviour immediately prior to joining rehabilitation) (n=167). RESULTS: Roughly half of participants reported injecting at least 30 times in the past 30 days and individuals with previous residential rehabilitation experience reported frequent injection far more than those without it. About one in fourteen respondents reported past week risky injection practices. Participants were over three times as likely to report risky injection if they consumed alcohol daily (17.2%) than if they did not (5.0%) (p=0.002). Those who reported injecting daily reported risky injection practices (11.9%) significantly more than non-daily injectors (1.8%) (p<0.001). Respondents reported high HCV infection rates, low perceived risk, testing history and knowledge. HCV knowledge was not associated with differences in risky injecting. CONCLUSION: Treatment centres should highlight the link between heavy drinking, frequent injection and risky injecting practices. The link between rehabilitation attendance and frequent injection may suggest IDUs with more severe use patterns are more likely to attend rehabilitation. Rehabilitation centres and needle exchanges should provide testing and education for HCV. Education alone may not be sufficient to initiate change since knowledge did not predict lower risk.

Sexual behaviour of people living with HIV attending a tertiary care government hospital in Kathmandu, Nepal: a cross sectional study.

BACKGROUND: Clinical improvements that follow antiretroviral therapy (ART) may lead to increase or resumption of high risk activities that could unintentionally result in HIV transmission. The objective was to investigate whether treatment status is a significant predictor of sexual risk behaviour (unprotected sex). METHODS: A cross sectional study was conducted among 160 people living with HIV (PLHIV) (89 ART experienced and 71 ART naïve) attending Sukraraj Tropical and Infectious Disease Hospital in Kathmandu, Nepal. A structured questionnaire was used for data collection. Logistic regression with stepwise modeling was used to obtain adjusted odds ratios (OR) with 95 % CI. RESULTS: In this study, 92 % of sexually active respondents reported sex with a regular partner. ART experienced PLHIV were significantly more likely to report consistent condom use with their regular partners compared to ART naïve PLHIV (83 vs. 53 %; P = 0.006) during the past six months. In multivariate analysis, sex (OR = 4.59, 95 % CI: 1.15-18.39), treatment status (OR = 4.76, 95 % CI: 1.29-17.52) and alcohol consumption during last sex with regular partners (OR = 14.75, 95 % CI: 2.75-79.29) were significantly associated with unprotected sex. CONCLUSION: ART naïve PLHIV were five times more likely to exhibit sexual risk behaviour (have unprotected sex) than ART experienced PLHIV. Thus the study provided no evidence to suggest that ART experienced PLHIV exhibit greater sexual risk behaviour compared to ART naïve PLHIV. Prevention programmes need to emphasize on counselling to PLHIV and their regular partners with focused interventions such as couple counselling and education programmes.

National health insurance policy in Nepal: challenges for implementation.

The health system in Nepal is characterized by a wide network of health facilities and community workers and volunteers. Nepal's Interim Constitution of 2007 addresses health as a fundamental right, stating that every citizen has the right to basic health services free of cost. But the reality is a far cry. Only 61.8% of the Nepalese households have access to health facilities within 30 min, with significant urban (85.9%) and rural (59%) discrepancy. Addressing barriers to health services needs urgent interventions at the population level. Recently (February 2015), the Government of Nepal formed a Social Health Security Development Committee as a legal framework to start implementing a social health security scheme (SHS) after the National Health Insurance Policy came out in 2013. The program has aimed to increase the access of health services to the poor and the marginalized, and people in hard to reach areas of the country, though challenges remain with financing. Several aspects should be considered in design, learning from earlier community-based health insurance schemes that suffered from low enrollment and retention of members as well as from a pro-rich bias. Mechanisms should be built for monitoring unfair pricing and unaffordable copayments, and an overall benefit package be crafted to include coverage of major health services including non-communicable diseases. Regulations should include such issues as accreditation mechanisms for private providers. Health system strengthening should move along with the roll-out of SHS. Improving the efficiency of hospital, motivating the health workers, and using appropriate technology can improve the quality of health services. Also, as currently a constitution drafting is being finalized, careful planning and deliberation is necessary about what insurance structure may suit the proposed future federal structure in Nepal.

Risk of HIV infection among men having sex with men in Kathmandu Valley, Nepal.

Despite extensive distribution of free condoms and lubricants to prevent HIV transmission among men having sex with men (MSM) in Nepal, the prevalence of HIV and risky sexual behaviors remain high. The influence of individual-level, social-capital, and social-structural factors on HIV risk has been insufficiently explored in MSM. The authors assessed association of these factors with HIV risk among 150 MSM enrolled using snowball sampling in the Kathmandu Valley. HIV risk was calculated on the basis of number and type of sexual partners and condom use during anal sex. Multivariate analysis showed a high risk of HIV infection was significantly associated with being involved in sex work, having no knowledge of male sexually transmitted infection (STI) symptoms, and having a history of STI symptoms. HIV prevention could be made more effective by targeting MSM who are involved in sex work and by improving their knowledge of male STI symptoms and early diagnosis and treatment.

Survival on antiretroviral treatment among adult HIV-infected patients in Nepal: a retrospective cohort study in Far-western region, 2006-2011.

BACKGROUND: Though financial and policy level efforts are made to expand antiretroviral treatment (ART) service free of cost, survival outcome of ART program has not been systematically evaluated in Nepal. This study assesses the mortality rates and determinants among adult HIV-infected patients on ART in Far-western region of Nepal. METHODS: This retrospective cohort study included 1024 (51.2% men) HIV-infected patients aged ≥15 years, who started ART between May 15th 2006 and May 15th 2011 in five ART sites in the Far-western region, Nepal. Follow-up time was calculated from the date of ART initiation to date of death or censoring (loss to follow-up, transferred out, or 15 November 2011). Mortality rates (per 100 person-years) were calculated. Kaplan-Meier and Cox-regression models were used to estimate survival and explore determinants of mortality. RESULTS: The median follow-up time was 19.1 months. The crude mortality rate was 6.3 (95% confidence interval (CI) 5.3-7.6) but more than three-times higher in first 3 months after ART initiation (21.9 (95% CI 16.6- 28.8)). About 12% (83% men) of those newly initiated on ART died during follow-up. The independent determinants of mortality were male sex (hazard ratio (HR) 4.55, 95% CI 2.43-8.51), poor baseline performance scale (bedridden <50% of the day during the past month, HR 2.05, 95% CI 1.19-3.52; bedridden >50% of the day during the past month, HR 3.41, 95% CI 1.67-6.98 compared to normal activity), one standard deviation decrease in baseline bodyweight (HR 1.04, 95% CI 1.01-1.07), and poor WHO clinical stage (stage III, HR 2.96, 95% CI 1.31-6.69; stage IV, HR 3.28, 95% CI 1.30-8.29 compared to WHO clinical stage I or II). CONCLUSIONS: High mortality was observed within the first 3 months of ART initiation. Patients with poor baseline clinical characteristics had higher mortality, especially men. Earlier initiation of ART through expanded testing and counselling should be encouraged in HIV-infected patients.

Psychosocial health problems associated with increased HIV risk behavior among men who have sex with men in Nepal: a cross-sectional survey.

BACKGROUND: Men who have sex with men (MSM) are marginalized, hidden, underserved and at high risk for HIV in Nepal. We examined the association between MSM sub-populations, psychosocial health problems and support, access to prevention and non-use of condoms. METHODS: Between September-November of 2010, a cross-sectional survey on HIV-related risk behavior was performed across Nepal through snowball sampling facilitated by non-governmental organizations, recruiting 339 MSM, age 15 or older. The primary outcomes were: (a) non-use of condoms at least once in last three anal sex encounters with men and (b) non-use of condoms with women in the last encounter. The secondary outcome was participation in HIV prevention interventions in the past year. RESULTS: Among the 339 MSM interviewed, 78% did not use condoms at their last anal sex with another man, 35% did not use condoms in their last sex with a woman, 70% had experienced violence in the last 12 months, 61% were experiencing depression and 47% had thought of committing suicide. After adjustment for age, religion, marital status, and MSM subpopulations (bisexual, ta, meti, gay), non-use of condoms at last anal sex with a man was significantly associated with non-participation in HIV interventions, experience of physical and sexual violence, depression, repeated suicidal thoughts, small social support network and being dissatisfied with social support. Depression was marginally associated with non-use of condoms with women. The findings suggest that among MSM who reported non-use of condoms at last anal sex, the ta subgroup and those lacking family acceptance were the least likely to have participated in any preventive interventions. CONCLUSIONS: MSM in Nepal have a prevalence of psychosocial health problems in turn associated with high risk behavior for HIV. Future HIV prevention efforts targeting MSM in Nepal should cover all MSM subpopulations and prioritize psychosocial health interventions.