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1.  Physical activity level and its sociodemographic correlates in a peri-urban Nepalese population: a cross-sectional study from the Jhaukhel-Duwakot health demographic surveillance site 
Physical inactivity is a leading risk factor for cardiovascular and other noncommunicable diseases in high-, low- and middle-income countries. Nepal, a low-income country in South Asia, is undergoing an epidemiological transition. Although the reported national prevalence of physical inactivity is relatively low, studies in urban and peri-urban localities have always shown higher prevalence. Therefore, this study aimed to measure physical activity in three domains—work, travel and leisure—in a peri-urban community and assess its variations across different sociodemographic correlates.
Adult participants (n = 640) from six randomly selected wards of the Jhaukhel-Duwakot Health Demographic Surveillance Site (JD-HDSS) near Kathmandu responded to the Global Physical Activity Questionnaire. To determine total physical activity, we calculated the metabolic equivalent of task in minutes/week for each domain and combined the results. Respondents were categorized into high, moderate or low physical activity. We also calculated the odds ratio for low physical activity in various sociodemographic variables and self-reported cardiometabolic states.
The urbanizing JD-HDSS community showed a high prevalence of low physical activity (43.3%; 95% CI 39.4–47.1). Work-related activity contributed most to total physical activity. Furthermore, women and housewives and older, more educated and self-or government-employed respondents showed a greater prevalence of physical inactivity. Respondents with hypertension, diabetes or overweight/obesity reported less physical activity than individuals without those conditions. Only 5% of respondents identified physical inactivity as a cardiovascular risk factor.
Our findings reveal a high burden of physical inactivity in a peri-urban community of Nepal. Improving the level of physical activity involves sensitizing people to its importance through appropriate multi-sector strategies that provide encouragement across all sociodemographic groups.
PMCID: PMC3984675  PMID: 24628997
Cardiovascular disease; Ethnicity; Occupation; Smoking; Hypertension; Diabetes
2.  Women’s experiences and health care-seeking practices in relation to uterine prolapse in a hill district of Nepal 
BMC Women's Health  2014;14:20.
Although uterine prolapse (UP) occurs commonly in Nepal, little is known about the physical health and care-seeking practices of women with UP. This study aimed to explore women’s experiences of UP and its effect on daily life, its perceived causes, and health care-seeking practices.
Using a convenience sampling method, we conducted 115 semi-structured and 16 in-depth interviews with UP-affected women during September–December 2012. All interviews occurred in outreach clinics in villages of the Dhading district.
Study participants were 23–82 years of age. Twenty-four percent were literate, 47.2% had experienced a teenage pregnancy, and 29% had autonomy to make healthcare decisions. Most participants (>85%) described the major physical discomforts of UP as difficulty with walking, standing, working, sitting, and lifting. They also reported urinary incontinence (68%) bowel symptoms (42%), and difficulty with sexual activity (73.9%). Due to inability to perform household chores or fulfill their husband’s sexual desires, participants endured humiliation, harassment, and torture by their husbands and other family members, causing severe emotional stress. Following disclosure of UP, 24% of spouses remarried and 6% separated from the marital relationship. Women perceived the causes of UP as unsafe childbirth, heavy work during the postpartum period, and gender discrimination. Prior to visiting these camps some women (42%) hid UP for more than 10 years. Almost half (48%) of participants sought no health care; 42% ingested a herb and ate nutritious food. Perceived barriers to accessing health care included shame (48%) and feeling that care was unnecessary (12.5%). Multiple responses (29%) included shame, inability to share, male service provider, fear of stigma and discrimination, and perceiving UP as normal for childbearing women.
UP adversely affects women’s daily life and negatively influences their physical, mental, and social well-being. The results of our study are useful to generate information on UP symptoms and female health care seeking practices. Our findings can be helpful for effective development of UP awareness programs to increase service utilization at early stages of UP and thereby might contribute to both primary and secondary prevention of UP.
PMCID: PMC3913953  PMID: 24490616
Uterine prolapse; Health seeking practice; Nepal
3.  Barriers to using skilled birth attendants’ services in mid- and far-western Nepal: a cross-sectional study 
Skilled birth attendants (SBAs) provide important interventions that improve maternal and neonatal health and reduce maternal and neonatal mortality. However, utilization and coverage of services by SBAs remain poor, especially in rural and remote areas of Nepal. This study examined the characteristics associated with utilization of SBA services in mid- and far-western Nepal.
This cross-sectional study examined three rural and remote districts of mid- and far-western Nepal (i.e., Kanchanpur, Dailekh and Bajhang), representing three ecological zones (southern plains [Tarai], hill and mountain, respectively) with low utilization of services by SBAs. Enumerators assisted a total of 2,481 women. All respondents had delivered a baby within the past 12 months. We used bivariate and multivariate analyses to assess the association between antenatal and delivery care visits and the women’s background characteristics.
Fifty-seven percent of study participants had completed at least four antenatal care visits and 48% delivered their babies with the assistance of SBAs. Knowing the danger signs of pregnancy and delivery (e.g., premature labor, prolonged labor, breech delivery, postpartum hemorrhage, severe headache) associated positively with four or more antenatal care visits (OR = 1.71; 95% CI: 1.41-2.07). Living less than 30 min from a health facility associated positively with increased use of both antenatal care (OR = 1.44; 95% CI: 1.18-1.77) and delivery services (OR = 1.25; CI: 1.03-1.52). Four or more antenatal care visits was a determining factor for the utilization of SBAs.
Less than half of the women in our study delivered babies with the aid of SBAs, indicating a need to increase utilization of such services in rural and remote areas of Nepal. Distance from health facilities and inadequate transportation pose major barriers to the utilization of SBAs. Providing women with transportation funds before they go to a facility for delivery and managing transportation options will increase service utilization. Moreover, SBA utilization associates positively with women’s knowledge of pregnancy danger signs, wealth quintile, and completed antenatal care visits. Nepal’s health system must develop strategies that generate demand for SBAs and also reduce financial, geographic and cultural barriers to such services.
PMCID: PMC3878020  PMID: 24365039
Antenatal care; Delivery care; Utilization; Skilled birth attendant; Barrier; Nepal
4.  Do non-communicable diseases such as hypertension and diabetes associate with primary open-angle glaucoma? Insights from a case–control study in Nepal 
Global Health Action  2013;6:10.3402/gha.v6i0.22636.
Non-communicable diseases (NCDs) such as hypertension and diabetes are rapidly emerging public health problems worldwide, and they associate with primary open-angle glaucoma (POAG). POAG is the most common cause of irreversible blindness. The most effective ways to prevent glaucoma blindness involve identifying high-risk populations and conducting routine screening for early case detection. This study investigated whether POAG associates with hypertension and diabetes in a Nepalese population.
To explore the history of systemic illness, our hospital-based case–control study used non-random consecutive sampling in the general eye clinics in three hospitals across Nepal to enroll patients newly diagnosed with POAG and controls without POAG. The study protocol included history taking, ocular examination, and interviews with 173 POAG cases and 510 controls. Data analysis comprised descriptive and inferential statistics. Descriptive statistics computed the percentage, mean, and standard deviation (SD); inferential statistics used McNemar's test to measure associations between diseases.
POAG affected males more frequently than females. The odds of members of the Gurung ethnic group having POAG were 2.05 times higher than for other ethnic groups. Hypertension and diabetes were strongly associated with POAG. The overall odds of POAG increased 2.72-fold among hypertensive and 3.50-fold among diabetic patients.
POAG associates significantly with hypertension and diabetes in Nepal. Thus, periodic glaucoma screening for hypertension and diabetes patients in addition to opportunistic screening at eye clinics may aid in detecting more POAG cases at an early stage and hence in reducing avoidable blindness.
PMCID: PMC3818480  PMID: 24192283
non-communicable disease (NCD); hypertension; diabetes mellitus; blindness; primary open-angle glaucoma (POAG)
5.  Cardiovascular health knowledge, attitude and practice/behaviour in an urbanising community of Nepal: a population-based cross-sectional study from Jhaukhel-Duwakot Health Demographic Surveillance Site 
BMJ Open  2013;3(10):e002976.
This study determined the knowledge, attitude and practice/behaviour of cardiovascular health in residents of a semiurban community of Nepal.
To increase the understanding of knowledge, attitude and practice/behaviour towards cardiovascular health, we conducted in-home interviews using a questionnaire based on the WHO STEPwise approach to surveillance and other resources, scoring all responses. We also recorded blood pressure and took anthropometric measurements.
Our study was conducted as part of the Heart-Health-Associated Research and Dissemination in the Community project in the Jhaukhel-Duwakot Health Demographic Surveillance Site in two urbanising villages near Kathmandu.
The study population included 777 respondents from six randomly selected clusters in both villages.
Seventy per cent of all participants were women and 26.9% lacked formal education. The burden of cardiovascular risk factors was high; 20.1% were current smokers, 43.3% exhibited low physical activity and 21.6% were hypertensive. Participants showed only poor knowledge of heart disease causes; 29.7% identified hypertension and 11% identified overweight and physical activity as causes, whereas only 2.2% identified high blood sugar as causative. Around 60% of respondents did not know any heart attack symptoms compared with 20% who knew 2–4 symptoms. Median percentage scores for knowledge, attitude and practice/behaviour were 79.3, 74.3 and 48, respectively. Nearly 44% of respondents had insufficient knowledge and less than 20% had highly satisfactory knowledge. Among those with highly satisfactory knowledge, only 14.7% had a highly satisfactory attitude and 19.5% and 13.9% had satisfactory and highly satisfactory practices, respectively.
Our study demonstrates a gap between cardiovascular health knowledge, attitude and practice/behaviour in a semiurban community in a low-income nation, even among those already affected by cardiovascular disease.
PMCID: PMC3808775  PMID: 24157816
Public Health; Preventive Medicine; Epidemiology
6.  Perceived risks and benefits of cigarette smoking among Nepalese adolescents: a population-based cross-sectional study 
BMC Public Health  2013;13:187.
The perceived risks and benefits of smoking may play an important role in determining adolescents’ susceptibility to initiating smoking. Our study examined the perceived risks and benefits of smoking among adolescents who demonstrated susceptibility or non susceptibility to smoking initiation.
In October–November 2011, we conducted a population-based cross-sectional study in Jhaukhel and Duwakot Villages in Nepal. Located in the mid-hills of Bhaktapur District, 13 kilometers east of Kathmandu, Jhaukhel and Duwakot represent the prototypical urbanizing villages that surround Nepal’s major urban centers, where young people have easy access to tobacco products and are influenced by advertising. Jhaukhel and Duwakot had a total population of 13,669, of which 15% were smokers. Trained enumerators used a semi-structured questionnaire to interview 352 randomly selected 14- to 16-year-old adolescents. The enumerators asked the adolescents to estimate their likelihood (0%–100%) of experiencing various smoking-related risks and benefits in a hypothetical scenario.
Principal component analysis extracted four perceived risk and benefit components, excluding addiction risk: (i) physical risk I (lung cancer, heart disease, wrinkles, bad colds); (ii) physical risk II (bad cough, bad breath, trouble breathing); (iii) social risk (getting into trouble, smelling like an ashtray); and (iv) social benefit (looking cool, feeling relaxed, becoming popular, and feeling grown-up). The adjusted odds ratio of susceptibility increased 1.20-fold with each increased quartile in perception of physical Risk I. Susceptibility to smoking was 0.27- and 0.90-fold less among adolescents who provided the highest estimates of physical Risk II and social risk, respectively. Similarly, susceptibility was 2.16-fold greater among adolescents who provided the highest estimates of addiction risk. Physical risk I, addiction risk, and social benefits of cigarette smoking related positively, and physical risk II and social risk related negatively, with susceptibility to smoking.
To discourage or prevent adolescents from initiating smoking, future intervention programs should focus on communicating not only the health risks but also the social and addiction risks as well as counteract the social benefits of smoking.
PMCID: PMC3599383  PMID: 23452549
Susceptibility to smoking; Physical risks; Social risks; Addiction risk; Social benefits
7.  Hepatitis B and C viruses and survival from hepatocellular carcinoma in the Arkhangelsk region: a Russian registry-based study 
International Journal of Circumpolar Health  2013;72:10.3402/ijch.v72i0.20282.
Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide. The prevalence of hepatitis B (HBV) and C (HCV) in Russia was 7.6 and 5.4 per 100,000, respectively. The aim of this study was to assess the proportion of HCV and HBV infection among HCC patients, to evaluate associations between HCV, HBV and stage of HCC and to compare survival of HCC patients by their HBV/HCV status in the Arkhangelsk region of northwest Russia.
Materials and methods
A retrospective cohort study was conducted using data on all histologically confirmed HCC cases. Proportions of infected and non-infected HCC cases were calculated by Wilson's method. The associations between HBV, HCV and severity of HCC were assessed by Pearson's Chi-squared test. Survival data were presented using Kaplan–Meier curves and median survival. Survival time between the groups was compared using log-rank tests. Adjustment for potential confounders (sex, age groups, stage of HCC and cirrhosis stage by Child-Paquet scale) was performed using Cox regression.
There were 583 histologically confirmed HCC cases. The viral status was registered in 311 of patients with pre-mortem diagnosis, where 124 or 39.9% (95% confidence interval (CI), 34.4–45.4) had HBV, 54 or 17.4% (95% CI, 13.5–21.9) had HCV and 16 or 5.1% (95% CI, 3.2–8.2) were infected with both HBV and HCV. The median survival rates of patients were 3 months (95% CI, 2.3–3.8), 3 months (95% CI, 2.0–3.9) and 1 month (95% CI, 0.0–0.6) for patients with HBV, HCV and HBV and HCV, respectively. For virus-free patients, it was 5 months (95% CI, 3.5–6.5), log-rank test=10.74, df=3, p=0.013. Crude Cox regression showed increased risk of death for HBV and HBV and HCV groups in comparison with virus-free patients, and not reaching the level of statistical significance for HCV. After adjustment, the hazard ratios (HRs) decreased to non-significant levels or even reversed, with only exception for the group of patients infected with both hepatitis viruses.
We found that more than half of HCC patients were infected with HBV or HCV. The study did not reveal an association between viral status of HCC patients and stage of HCC. The viral hepatitis may have an impact on survival of HCC patients.
PMCID: PMC3654160  PMID: 23687637
hepatocellular carcinoma; hepatitis B; hepatitis C; survival; Northwest Russia
8.  Establishing a health demographic surveillance site in Bhaktapur district, Nepal: initial experiences and findings 
BMC Research Notes  2012;5:489.
A health demographic surveillance system (HDSS) provides longitudinal data regarding health and demography in countries with coverage error and poor quality data on vital registration systems due to lack of public awareness, inadequate legal basis and limited use of data in health planning. The health system in Nepal, a low-income country, does not focus primarily on health registration, and does not conduct regular health data collection. This study aimed to initiate and establish the first HDSS in Nepal.
We conducted a baseline survey in Jhaukhel and Duwakot, two villages in Bhaktapur district. The study surveyed 2,712 households comprising a total population of 13,669. The sex ratio in the study area was 101 males per 100 females and the average household size was 5. The crude birth and death rates were 9.7 and 3.9/1,000 population/year, respectively. About 11% of births occurred at home, and we found no mortality in infants and children less than 5 years of age. Various health problems were found commonly and some of them include respiratory problems (41.9%); headache, vertigo and dizziness (16.7%); bone and joint pain (14.4%); gastrointestinal problems (13.9%); heart disease, including hypertension (8.8%); accidents and injuries (2.9%); and diabetes mellitus (2.6%). The prevalence of non-communicable disease (NCD) was 4.3% (95% CI: 3.83; 4.86) among individuals older than 30 years. Age-adjusted odds ratios showed that risk factors, such as sex, ethnic group, occupation and education, associated with NCD.
Our baseline survey demonstrated that it is possible to collect accurate and reliable data in a village setting in Nepal, and this study successfully established an HDSS site. We determined that both maternal and child health are better in the surveillance site compared to the entire country. Risk factors associated with NCDs dominated morbidity and mortality patterns.
PMCID: PMC3494612  PMID: 22950751
9.  Obesity Prevalence in Nepal: Public Health Challenges in a Low-Income Nation during an Alarming Worldwide Trend 
The future toll of the obesity epidemic will likely hit hardest in low- and middle-income countries. Ongoing urbanization promotes risk factors including sedentary lifestyle and fat- and sugar-laden diets. Low-income countries like Nepal experience a double disease burden: infectious diseases as well as rising incidence of noncommunicable diseases (e.g., cardiovascular disease and diabetes mellitus) frequently characterized by obesity. Nepal currently directs efforts towards curing disease but pays little attention to preventive actions. This article highlights obesity prevalence in Nepal, delineates the challenges identified by our pilot study (including low health literacy rates), and suggests strategies to overcome this trend.
PMCID: PMC2905575  PMID: 20644698
obesity; Nepal; epidemic; diabetes; cardiovascular disease
10.  Human macrophages limit oxidation products in low density lipoprotein 
This study tested the hypothesis that human macrophages have the ability to modify oxidation products in LDL and oxidized LDL (oxLDL) via a cellular antioxidant defence system. While many studies have focused on macrophage LDL oxidation in atherosclerosis development, less attention has been given to the cellular antioxidant capacity of these cells.
Compared to cell-free controls (6.2 ± 0.7 nmol/mg LDL), macrophages reduced TBARS to 4.42 ± 0.4 nmol/mg LDL after 24 h incubation with LDL (P = 0.022). After 2 h incubation with oxLDL, TBARS were 3.69 ± 0.5 nmol/mg LDL in cell-free media, and 2.48 ± 0.9 nmol/mg LDL in the presence of macrophages (P = 0.034). A reduction of lipid peroxides in LDL (33.7 ± 6.6 nmol/mg LDL) was found in the presence of cells after 24 h compared to cell-free incubation (105.0 ± 14.1 nmol/mg LDL) (P = 0.005). The levels of lipid peroxides in oxLDL were 137.9 ± 59.9 nmol/mg LDL and in cell-free media 242 ± 60.0 nmol/mg LDL (P = 0.012). Similar results were obtained for hydrogen peroxide. Reactive oxygen species were detected in LDL, acetylated LDL, and oxLDL by isoluminol-enhanced chemiluminescence (CL). Interestingly, oxLDL alone gives a high CL signal. Macrophages reduced the CL response in oxLDL by 45% (P = 0.0016). The increased levels of glutathione in oxLDL-treated macrophages were accompanied by enhanced catalase and glutathione peroxidase activities.
Our results suggest that macrophages respond to oxidative stress by endogenous antioxidant activity, which is sufficient to decrease reactive oxygen species both in LDL and oxLDL. This may suggest that the antioxidant activity is insufficient during atherosclerosis development. Thus, macrophages may play a dual role in atherogenesis, i.e. both by promoting and limiting LDL-oxidation.
PMCID: PMC555960  PMID: 15745457
Macrophages; LDL; lipid peroxides; antioxidant enzymes

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