Factors associated with depressive symptoms among returnee migrants and non-migrants working adults in Madi municipality in Nepal: a community-based cross-sectional study.

BACKGROUND: Mental health is a growing concern worldwide. It is not well understood whether international labour migrants from Nepal who return to Nepal are at higher risk of developing mental health problems. The purpose of our study was to determine the prevalence of and examine the associated factors for depressive symptoms among returnee migrants and non-migrant working male adults in Nepal. METHODS: A cross-sectional survey of a probability-based sample of 725 participants was conducted in February 2020. The sample was comprised of two groups based on migration status: returning migrants and non-migrants. The 21-item Beck Depression Inventory (BDI-21) questionnaire was used to assess depressive symptoms. Logistic regression was applied to investigate factors associated with symptoms of depression. RESULTS: The overall prevalence of depressive symptoms was 10.1%. However, the prevalence of depressive symptoms was lower (7%) among returnee migrants compared to non-migrants (13.7%). Men in the lower income group had a higher chance of having depressive (AOR = 5.88, 95% CI: 2.17-15.96) than those in the higher income group. Similarly, Buddhists and Christians were more likely to be depressed (AOR = 2.20, 95% CI: 1.03-4.68) than Hindus. Participants with more than two children had a higher chance of having of depressive symptoms (AOR = 4.80, 95% CI: 1.15-20.05) compared with those without children. Unmarried men were more likely to be depressed (AOR = 4.07, 95%, CI:1.11-14.92) than those who were married. CONCLUSION: The working Nepali adult male population in Nepal, including returning migrants, is at risk of depressive symptoms, but this association was lower in those in the higher income group, returnee migrants, those who were married, Hindus and those with no children. Our results highlight the need to monitor and develop national policies to ensure the mental health of the Nepali male adult population, including returnee migrants.

Parental depression and their children's marriage timing: The long-term consequences of parental mental disorders.

Although decades of research documents powerful associations between parents' characteristics and their children's marital behaviors, the role of parental mental health has largely been ignored, despite the high prevalence of mental disorders and their strong potential to shape multiple dimensions of family life. Many studies examine other consequences of mothers' mental disorders, particularly for young children, but rarely do studies investigate the consequences of fathers' mental disorders, especially the potential for long-term consequences. We construct a theoretical framework for the study of intergenerational influences on family formation behaviors, integrating parental mental health, and emphasizing the potential for father's disorders to shape their children's lives. To investigate these associations, we use new intergenerational panel data featuring clinically validated diagnostic measures of parental mental health for both mothers and fathers, assessed independently. Results demonstrate that fathers' major depressive disorder is associated with significantly earlier marriage timing among sons. These important new findings provide insights into key priorities for social research on family formation processes and intergenerational influences across many domains.

Community exposure to armed conflict and subsequent onset of alcohol use disorder.

AIMS: To measure the independent consequences of community-level armed conflict beatings on alcohol use disorders (AUD) among males in Nepal during and after the 2000-2006 conflict. DESIGN: A population-representative panel study from Nepal, with precise measures of community-level violent events and subsequent individual-level AUD in males. Females were not included because of low AUD prevalence. SETTING: Chitwan, Nepal. PARTICIPANTS: Four thousand eight hundred seventy-six males from 151 neighborhoods, systematically selected and representative of Western Chitwan. All residents aged 15-59 were eligible (response rate 93%). MEASUREMENTS: Measures of beatings in the community during the conflict (2000-2006), including the date and distance away, were gathered through neighborhood reports, geo-location and official resources, then linked to respondents' life histories of AUD (collected in 2016-2018) using the Nepal-specific Composite International Diagnostic Interview with life history calendar. Beatings nearby predict the subsequent onset of AUD during and after the armed conflict. Data were analyzed in 2021-2022. FINDINGS: Cohort-specific, discrete-time models revealed that within the youngest cohort (born 1992-2001), those living in neighborhoods where armed conflict beatings occurred were more likely to develop AUD compared with those in other neighborhoods (odds ratio = 1.66; 95% confidence interval = 1.02-2.71). In this cohort, a multilevel matching analysis designed to simulate a randomized trial showed the post-conflict incidence of AUD for those living in neighborhoods with any armed conflict beatings was 9.5% compared with 5.3% in the matched sample with no beatings. CONCLUSIONS: Among male children living in Chitwan, Nepal during the 2000-2006 armed conflict, living in a neighborhood where armed conflict beatings occurred is associated with increased odds of developing subsequent alcohol use disorder. This association was independent of personal exposure to beatings and other mental disorders.

Alcohol use and internal migration in Nepal: a cross-sectional study.

BACKGROUND: Alcohol use is a leading cause of disease. Although low- and middle-income countries (LMICs) have lower per capita alcohol consumption, the alcohol-attributable disease burden is high in these settings with consumption increasing. LMICs are also experiencing unprecedented levels of internal migration, potentially increasing mental stress, changing social restrictions on drinking, and increasing alcohol availability. We assessed the relationship between internal migration, opportunity to drink, and the transition from first use to regular alcohol use and alcohol use disorders (AUD) in Nepal, a low-income, South Asian country. METHODS: A representative sample of 7435 individuals, aged 15-59 from Nepal were interviewed in 2016-2018 (93% response rate) with clinically validated measures of alcohol use and disorders and life history calendar measures of lifetime migration experiences. Discrete-time hazard models assessed associations between migration and alcohol use outcomes. RESULTS: Net of individual sociodemographic characteristics, internal migration was associated with increased odds of opportunity to drink (OR 1.32, 95% CI 1.14 to 1.53), onset of regular alcohol use given lifetime use (OR 1.29, 95% CI 1.13 to 1.48) and AUD given lifetime use (OR 1.24, 95% CI 0.99 to 1.57). The statistically significant association between internal migration and opportunity to drink was specific to females, whereas the associations between migration and regular use and disorder were statistically significant for males. CONCLUSIONS: Despite high rates of internal migration worldwide, most research studying migration and alcohol use focuses on international migrants. Findings suggest that internal migrants are at increased risk to transition into alcohol use and disorders. Support services for internal migrants could prevent problematic alcohol use among this underserved population.

The transition to parenthood, opportunity to drink, drinking, and alcohol use disorder.

BACKGROUND: This study used life histories from a setting of near universal marriage and childbearing (Nepal) to identify associations between both marital transitions and the transition into parenthood and alcohol use and disorder (AUD). METHODS: A retrospective, cross-sectional survey using life history calendars documented lifetime marital and childbearing histories of 4876 men and 5742 women aged 15-59 in 2016-18. The clinically validated, Nepal-specific Composite International Diagnostic Interview assessed first alcohol use opportunity, use, and disorder. RESULTS: Being never married increased the odds of having the opportunity to drink for men (OR=1.30, 95% CI=1.14 - 1.48, p < 0.001) and women (OR=1.24, 95% CI=1.08 - 1.43, p = 0.003) compared to being married. While men were never married, widowed, or divorced they were at a greater risk of developing AUD. The transition to parenthood significantly increased the odds of AUD onset for men (OR=1.71, 95% CI=1.12 - 2.61, p = 0.013), independent of marital transitions. For women in this setting, becoming divorced increased the odds of having their first drink (OR=1.77, 95% CI=1.14 - 2.75, p = 0.011). Giving birth to a first child also increased the odds of first opportunity to drink for women (OR=1.30, 95% CI=1.07 - 1.57, p = 0.008). CONCLUSIONS: We found associations between marital transitions and AUD that are consistent with findings worldwide. In this setting of near universal childbearing, the transition into fatherhood increased the odds of postpartum AUD among men.

Drivers of prohibited natural resource collection in Chitwan National Park, Nepal.

Protected areas (PAs) are critical for achieving conservation, economic and development goals, but the factors that lead households to engage in prohibited resource collection in PAs are not well understood. We examine collection behaviours in community forests and the protected Chitwan National Park in Chitwan, Nepal. Our approach incorporates household and ecological data, including structured interviews, spatially explicit data on collection behaviours measured with computer tablets and a systematic field survey of invasive species. We pair our data with a framework that considers factors related to a household's demand for resources, barriers to prohibited resource collection, barriers to legal resource collection and alternatives to resource collection. The analysis identifies key drivers of prohibited collection, including sociodemographic variables and perceptions of an invasive plant (Mikania micrantha). The social-ecological systems approach reveals that household perceptions of the presence of M. micrantha were more strongly associated with resource collection decisions than the actual ecologically measured presence of the plant. We explore the policy implications of our findings for PAs and propose that employing a social-ecological systems approach leads to conservation policy and scientific insights that are not possible to achieve with social or ecological approaches alone.

Community-Level Social Support Infrastructure and Adult Onset of Major Depressive Disorder in a South Asian Postconflict Setting.

IMPORTANCE: Individual-level social support protects against major depressive disorder (MDD) among adults exposed to trauma. Little is known about the consequences of community-level interventions in the general population. OBJECTIVE: To determine the potential consequences of neighborhood social infrastructure on incident MDD in a high-risk general population. DESIGN, SETTING, AND PARTICIPANTS: This longitudinal, multilevel study estimated associations between a neighborhood-level program in a case-control design and subsequent individual outcomes across 10 years (2006-2015) in a cohort of young adults. Exogenously placed social programs simulate natural experiment conditions in a high-poverty population experiencing armed conflict (1998-2006). The western Chitwan valley in Nepal has a general population at high risk of MDD, with neighborhoods exposed to interventions to improve social support. From a random sample (response rate 93%) selected to represent the general population in 2016, participants aged 25 to 34 years in 2006 were studied. These individuals resided within 149 neighborhoods that varied in their availability of active social support programs. The analyses were conducted between October 2020 and November 2021. EXPOSURES: The Small Farmers Development Program (SFDP) uses shared, joint liability financial credit among neighbors to build social capital and cohesion within neighborhoods. MAIN OUTCOMES AND MEASURES: Onset of DSM-IV MDD after the conflict, assessed by the Nepal-specific, clinically validated World Mental Health Composite International Diagnostic Interview with a life history calendar. The hypothesis tested was that exposure to SFDP reduced adult onset of MDD. RESULTS: Of the 1917 survey participants, 886 (46.2%) were women, and 856 (44.7%) were of Brahmin or Chhetri ethnicity. Of the 149 neighborhoods, 21 had an active SFDP group, and 156 of 1917 (8.1%) participants experienced MDD between 2006 and 2015. Discrete-time hazard models showed participants living in neighborhoods with an SFDP experienced incident MDD at nearly half the rate as others (odds ratio = 0.55; 95% CI, 0.30-1.02; P = .06). A multivariate, multilevel matching analysis showed the incidence of MDD among adults living in neighborhoods with an SFDP was 19 of 256 (7.4%), compared with 33 of 256 (12.9%) in the matched sample with no SFDP (z = 2.05; P = .04). CONCLUSIONS AND RELEVANCE: Living in a neighborhood with community-level social support infrastructure was associated with reduced subsequent rates of adult-onset MDD, even in this high-risk population. Investments in such infrastructure may reduce population-level MDD, supporting clinical focus on potentially unpreventable cases.

Social Change, Out-migration, and Exit from Farming in Nepal.

Though international out-migration is widespread, little evidence exists regarding the consequences for economic change in sending countries, particularly in the densely populated agricultural areas of Asia. We examine associations between labor out-migration, remittances, and agricultural change in Nepal. Existing studies of this important population-environment relationship generally ignore the role of local community context, which is known to shape demographic behavior and likely exit from farming as well. Research offers opposing views of the consequences of out-migration for agricultural change - (1) loss of farm labor reduces engagement in agriculture, versus (2) loosening credit constraints from remittances increases engagement in agriculture - and indicates that both mechanisms likely operate simultaneously. Both of these mechanisms are likely to be shaped by changes in local context. Using multilevel dynamic models, we estimate associations between out-migration and remittances by household members and subsequent exit from farming, controlling for variations in community context. Results suggest international out-migration is associated with higher odds of exit from farming and simultaneously remittances are associated with lower odds of exit from farming. Results are robust against several key variations in model specification, including controls for household characteristics and local community context. However, local community context exerts an important independent influence on the hazard of exit from farming.

A Good Age to Marry? An Intergenerational Model of the Influence of Timing Attitudes on Entrance into Marriage.

Do timing attitudes-subjective evaluations of particular ages as good ages to marry-influence entrance into marriage? To address this question, we formulated an intergenerational model of how parents' and children's timing attitudes influence children's marriage behavior. We theorized that both parents' and children's timing attitudes influence expectations of when children will marry. In turn, both parents' and children's marital expectations would influence children's actual entrance into marriage. We tested the model using intergenerational panel data from Nepal collected in 2008-2014. Timing attitudes of young people and their parents did influence expectations, as well as entrance into marriage. Young people's own attitudes were more influential than their parents' attitudes in determining children's expectations, but not behavior. Further, while the influence of parents was relatively even, mothers appear slightly more influential than fathers.

Resilience to mental disorders in a low-income, non-Westernized setting.

BACKGROUND: Cross-national studies have found, unexpectedly, that mental disorder prevalence is higher in high-income relative to low-income countries, but few rigorous studies have been conducted in very low-income countries. This study assessed mental disorders in Nepal, employing unique methodological features designed to maximize disorder detection and reporting. METHODS: In 2016-2018, 10714 respondents aged 15-59 were interviewed as part of an ongoing panel study, with a response rate of 93%. The World Mental Health version of the Composite International Diagnostic Interview (WMH-CIDI 3.0) measured lifetime and 12-month prevalence of selected anxiety, mood, alcohol use, and impulse control disorders. Lifetime recall was enhanced using a life history calendar. RESULTS: Lifetime prevalence ranged from 0.3% (95% CI 0.2-0.4) for bipolar disorder to 15.1% (95% CI 14.4-15.7) for major depressive disorder. The 12-month prevalences were low, ranging from 0.2% for panic disorder (95% CI 0.1-0.3) and bipolar disorder (95% CI 0.1-0.2) to 2.7% for depression (95% CI 2.4-3.0). Lifetime disorders were higher among those with less education and in the low-caste ethnic group. Gender differences were pronounced. CONCLUSIONS: Although cultural effects on reporting cannot be ruled out, these low 12-month prevalences are consistent with reduced prevalence of mental disorders in other low-income countries. Identification of sociocultural factors that mediate the lower prevalence of mental disorders in low-income, non-Westernized settings may have implications for understanding disorder etiology and for clinical or policy interventions aimed at facilitating resilience.

Predictors of transitions across stages of alcohol use and disorders in an adult population with heterogeneous ethnic restrictions regarding drinking.

AIMS: To disaggregate associations with alcohol use disorder relative to those with early alcohol use stages in an adult population. We estimated prevalence rates and socio-demographic correlates for the opportunity to drink and transitions into life-time alcohol use, regular use and alcohol use disorder. DESIGN: A retrospective, cross-sectional population survey within a family panel study. SETTING: Chitwan in Nepal, an ethnically diverse setting with heterogeneous ethnic restrictions regarding alcohol. PARTICIPANTS: A total of 10 714 individuals aged 15-59 years (response rate = 93%). MEASUREMENTS: The Nepal-specific Composite International Diagnostic Interview assessed life-time alcohol use opportunity, any use, regular use, disorder and socio-demographic characteristics. FINDINGS: Seventy per cent [95% confidence interval (CI) = 69.08-70.82%] of the population had the opportunity to drink, 38.06% (95% CI = 37.14-38.99%) had life-time alcohol use, 32.37% (95% CI = 31.48-33.27%) had regular alcohol use and 6.04% (95% CI = 5.60-6.50%) developed an alcohol use disorder. Compared with high-caste Hindus, all other ethnicities had greater odds of early stage transitions [odds ratios (OR) ranged from 1.31, 95% CI = 1.16-1.47 to 1.98, 95% CI = 1.81-2.18)], but not of development of disorder. Male sex was associated with greater odds of all transitions, from opportunity (OR = 5.71, 95% CI = 5.41-6.03) to development of disorder (OR = 1.95, 95% CI = 1.35-2.81). The youngest cohort had higher odds of all transitions, from opportunity (OR = 4.86, 95% CI = 4.47-5.29) to development of disorder (OR = 9.34, 95% CI = 6.88-12.70). Higher education was associated with lower odds of all transitions except opportunity [from use (OR = 0.77, 95% CI = 0.71-0.83) to the development of disorder (OR = 0.73, 95% CI = 0.59-0.89)]. CONCLUSIONS: The prevalence of life-time alcohol use among adults in Nepal appears to be low, but the overall prevalence of disorder is similar to other countries. Socio-demographic correlates of early alcohol use transitions differ from those associated with later transitions; while sex and age cohort were associated with all transitions, ethnicity was associated with early transitions (opportunity, life-time use, regular use), but not later transitions (use and regular use to disorder).

The association between marital transitions and the onset of major depressive disorder in a south asian general population.

BACKGROUND: Marriage in general is associated with better mental health in high-income industrialized countries, but it is unknown to what extent this is also the case in South Asia. METHODS: The Chitwan Valley Family Study (CVFS) in Nepal is a 24-year family panel study with a recent representative survey to investigate the association between sociodemographic changes and mental health (N = 10,516). We investigated timing of marital transitions and timing of onset of MDD in both male and female respondents, controlling for key confounders. RESULTS: In this setting the transition to marriage is associated with increased odds of subsequent MDD first onset (median OR=2.28). For female respondents, divorce (OR=2.68), early widowed (OR=11.25), and even getting married significantly increased the odds of subsequent MDD onset (OR=3.03). For male respondents, only becoming widowed increased the odds of subsequent MDD (OR=16.32), but marriage did not reduce the odds of MDD. LIMITATIONS: Limitations of the study include large-scale protocol that may have resulted in underreporting of MDD and the exclusion of sub-threshold cases that may otherwise have qualified as a case in a clinical setting. CONCLUSIONS: In the Nepalese general population, marital transitions increase the odds of subsequent depression, especially among the female population. Results provide basic but essential vital health data that can guide clinicians to proactively plan sustainable healthcare both within South Asia and among many South Asians living in other places.

Parents' Marital Quality and Children's Transition to Adulthood.

Unique longitudinal measures from Nepal allow us to link both mothers' and fathers' reports of their marital relationships with a subsequent long-term record of their children's behaviors. We focus on children's educational attainment and marriage timing because these two dimensions of the transition to adulthood have wide-ranging, long-lasting consequences. We find that children whose parents report strong marital affection and less spousal conflict attain higher levels of education and marry later than children whose parents do not. Furthermore, these findings are independent of each other and of multiple factors known to influence children's educational attainment and marriage timing. These intriguing results support theories pointing toward the long-term intergenerational consequences of variations in multiple dimensions of parents' marriages.

Bio-mechanical risk factors for uterine prolapse among women living in the hills of west Nepal: A case-control study.

OBJECTIVE: To investigate whether heavy load carrying, wearing a patuka, and body position at work are risk factors for uterine prolapse among Nepali women. METHODS: Community-based case-control study of 448 women (170 cases of uterine prolapse; 278 controls) aged 18-60 years in Kaski district, Nepal was conducted. Women diagnosed with uterine prolapse were cases. Two controls were recruited for each case, frequency-matched by residential area and age. Multivariate logistic regression was used to investigate associations between outcome and exposures. RESULTS: No association of heavy load carrying with uterine prolapse was observed; women who never used a patuka had lower odds of uterine prolapse (odds ratio = 0.18, 95% confidence interval = 0.05-0.71). Women working in a sitting position had higher odds than those working in a standing position (odds ratio = 2.94, 95% confidence interval = 1.74-4.96), as did women who mainly worked in a bending position (odds ratio = 2.45, 95% confidence interval = 1.12-5.34). Housewives were more prone to uterine prolapse than women engaged in farming (odds ratio = 2.13, 95% confidence interval = 1.31-3.47). CONCLUSION: Using a patuka, occupation, and body position during work were all associated with uterine prolapse. No association was found with heavy load carrying, although that might be attributable to the cross-sectional nature of study recruitment.

Using life history calendars to improve measurement of lifetime experience with mental disorders.

BACKGROUND: Retrospective reports of lifetime experience with mental disorders greatly underestimate the actual experiences of disorder because recall error biases reporting of earlier life symptoms downward. This fundamental obstacle to accurate reporting has many adverse consequences for the study and treatment of mental disorders. Better tools for accurate retrospective reporting of mental disorder symptoms have the potential for broad scientific benefits. METHODS: We designed a life history calendar (LHC) to support this task, and randomized more than 1000 individuals to each arm of a retrospective diagnostic interview with and without the LHC. We also conducted a careful validation with the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition. RESULTS: Results demonstrate that-just as with frequent measurement longitudinal studies-use of an LHC in retrospective measurement can more than double reports of lifetime experience of some mental disorders. CONCLUSIONS: The LHC significantly improves retrospective reporting of mental disorders. This tool is practical for application in both large cross-sectional surveys of the general population and clinical intake of new patients.

Household migration and children's diet in Nepal: an exploratory study.

OBJECTIVE: Individuals from low-income countries often migrate abroad for employment. The association between such migration and investment in education as well as other societal and familial outcomes has previously been examined. However, we have a limited understanding of the association between migration and children's nutrition. We aim to determine the extent to which migration of household members influences children's diet in a semi-urban region of Nepal. RESULTS: In our study setting, children in households with a migrant had higher dietary diversity scores, 0.69 on average, than their counterparts in households without a migrant. These children were approximately 43% points more likely to meet a minimum requirement for dietary diversity. These differences originated primarily from higher consumption of meat (41% points) and eggs (20% points). Approximately 37 percent of children in the sample consumed processed food during the 24 h preceding the survey. However, we found no evidence that migration was associated with the consumption of processed foods or with reduced frequency of breastfeeding. Our finding that migration is associated with higher consumption of meat and eggs is particularly encouraging, given that the protein deficiency in Nepal is estimated to be nearly 43 percent.

Strategies for origin-based surveying of international migrants.

This paper addresses methodological challenges of investigations of international migration, including difficulties in obtaining information about representative samples of migrants and both their origin and destination location. Our project used an origin-based sample with a destination focused survey and interviewed 91% of migrants from a community in Nepal to any destination and shares techniques employed. Our procedures and high response rate constitute a significant improvement in survey methods that permit the creation of unbiased data on migrants and allow the study of migration in conjunction with origin communities.

Early Women, Late Men: Timing Attitudes and Gender Differences in Marriage.

Around the world, women marry earlier than men, but it is not well understood why this gender gap exists. Using panel data collected in Nepal, the authors investigate whether attitudes about marital timing held by unmarried youth and their parents account for women marrying earlier than men. They also examine whether the influence of timing attitudes differs by gender. On average, unmarried youth and their parents viewed 20 to 25 as acceptable ages for women to marry, while ages 23 to 30 were appropriate for men. In turn, women entering the acceptable marriage age range earlier than men accounted for a third of the gender gap in marital timing. The influence of youth and parents' timing attitudes did differ by gender, but only at the extreme. When they were much too young for marriage, both genders were less likely to marry, but this dampening effect was substantially larger for women.

Postmarital Living Arrangements in Historically Patrilocal Settings: Integrating Household Fission and Migration Perspectives.

This study integrates theory and research on household fission (or partition) and migration to better understand living arrangements following marriage, especially in historically patrilocal and primarily agricultural settings. Using panel data from the Chitwan Valley Family Study to analyze the sequential decision-making process that influences men's living arrangements subsequent to first marriage, we demonstrate the importance of distinguishing among extended family living, temporary migration, and the establishment of an independent household. We find that community economic characteristics, such as access to markets or employment, as well as household wealth affect the initial decision to leave the natal home. Household resources and use of farmland, along with the young men's own education, media exposure, travel, and marital behavior, influence the decision to make the departure from the natal home permanent. Our findings explain why previous results regarding household fission and those focused on migration have provided such mixed results, and we establish a new framework for thinking about how families and individuals manage living situations.

Emotional Variation and Fertility Behavior.

Emotional influences on fertility behaviors are an understudied topic that may offer a clear explanation of why many couples choose to have children even when childbearing is not economically rational. With setting-specific measures of the husband-wife emotional bond appropriate for large-scale population research matched with data from a long-term panel study, we have the empirical tools to provide a test of the influence of emotional factors on contraceptive use to limit fertility. This article presents those tests. We use long-term, multilevel community and family panel data to demonstrate that the variance in levels of husband-wife emotional bond is significantly associated with their subsequent use of contraception to avert births. We discuss the wide-ranging implications of this intriguing new result.