Understanding the social determinants of non-communicable diseases in Nepal : a systems perspective : a thesis presented in the partial fulfilment of the requirements for the degree of Doctor of Philosophy (PhD) in Health Sciences at Massey University, Wellington Campus, New Zealand

Figures are re-used with permission.Non-communicable diseases (NCDs) constitute more than half of the total disease burden in Nepal. Global evidence indicates the problem of NCDs is influenced by the complex interaction of social determinants including behavioural, socio-economic and environmental. These determinants are the focus of global prevention strategies for tackling NCDs. The health system of Nepal, however, is yet to adopt this comprehensive prevention strategies. The main objective of this research was to understand the social determinants of NCDs in Nepal and identify leverage points for systemic actions in Nepal. The study utilized a systems thinking methodology which enabled a creative combination of case study methods and qualitative causal loop diagramming. In each of the two selected case districts (Bhaktapur and Morang), semi-structured interviews (n=39) and focus group discussions (n=12) were conducted with key stakeholders and community members. These case studies were informed by policy level interviews (n=24). Thematic analysis, guided by the adapted social determinants of health framework, helped to identify key themes and develop causal loop diagrams (CLDs). The findings of the thematic analysis, and CLDs, were then validated through local and policy sense-making workshops. The analysis showed four key interlinked thematic areas, each of which is being published as separate papers. The first paper describes the community and stakeholders’ perception and experience of the rising burden of NCDs. The social experience of NCDs metabolic risks such as hypertension and diabetes were shown to be normalised. Moreover, differences in social experience were observed based on gender and socio-economic circumstances. The second paper described the critical role played by tobacco and alcohol in the interaction of social determinants of NCDs. The analysis indicates that socio-economic circumstances was root cause of changing, and damaging alcohol and tobacco practices, and increased the vulnerability to exploitation by industries. The third paper revealed that poor dietary practices and physical inactivity were resulting due to changes in social practices shaped by worsening dietary and physical environment. Socio-economic circumstances, urbanisation and migration all contributed to the population being exposed to an obesogenic environment. While all three papers discussed specific health system challenges, the fourth paper elaborated on health sector challenges, including the curative focus and limited capacity of the health system both at district and policy or national level to prevent NCDs in Nepal. Three key leverage points for health system action on the social determinant of NCDs were identified by viewing the final CLD through the lens of Donella Meadows’ framework for identifying key health system action on the social determinants of health. These leverage points indicated that the health sector should focus on the development of a robust prevention system for effective NCDs action. Overall, the study highlighted the interactions of socio-economic, gender, commercial and health system determinants driving the NCDs problem in Nepal. The leverage analysis indicated that the health sector should focus on the development of a robust prevention system for effective action on complex problem like NCDs. The Ministry of Health could play a proactive role in creating the prevention system that could effectively guide all sectors towards collective action to impacting social and commercial determinants of health

Non-communicable disease prevention in Nepal:Systemic challenges and future directions

Developing countries like Nepal are experiencing double burden of communicable and non-communicable diseases (NCD) resulting in social and economic losses. In Nepal, more than half of the disease burden is due to NCD. The major NCD in Nepal are cardiovascular diseases, cancers, chronic respiratory diseases and diabetes. Behavioural factors such as tobacco use, alcohol consumption, physical inactivity and unhealthy diet are driving the epidemic of NCD which are further influenced by social, economic and environmental determinants. The health system of Nepal has not been able to address the ever increasing burden of NCD. With the formulation of the Multisectoral Action Plan for Prevention and Control of NCD 2014-2020, there has been some hope for tackling the NCD and their social determinants in Nepal through a primary prevention approach. This paper discusses the systemic challenges and recommends two key actions for the prevention and control of NCD in Nepal

Comparison of the Oswestry Disability Index and Magnetic Resonance Imaging Findings in Lumbar Canal Stenosis: An Observational Study

Study DesignCross-sectional study.PurposeThe aim of the study was to determine relationship between the degrees of radiologically demonstrated anatomical lumbar canal stenosis using magnetic resonance imaging (MRI) and its correlation with the patient's disability level, using the Oswestry Disability Index (ODI).Overview of LiteratureThe relationship between the imaging studies and clinical symptoms has been uncertain in patients suffering from symptomatic lumbar canal stenosis. There is a limited number of studies which correlates the degree of stenosis with simple reproducible scoring methods.MethodsFifty patients were selected from 350 patients who fulfilled the inclusion criteria. The patients answered the national-language translated form of ODI. The ratio of disability was interpreted, and the patients were grouped accordingly. They were subjected to MRI; and the anteroposterior diameters of the lumbar intervertebral disc spaces and the thecal sac cross sectional area were measured. Comparison was performed between the subdivisions of the degree of lumbar canal stenosis, based on the following: anteroposterior diameter (three groups: normal, relative stenosis and absolute stenosis); subdivisions of the degree of central canal stenosis, based on the thecal sac cross-sectional area, measured on axial views (three groups: normal, moderately stenotic and severely stenotic); and the ODI outcome, which was also presented in 20 percentiles.ResultsNo significant correlation was established between the radiologically depicted anatomical lumbar stenosis and the Oswestry Disability scores.ConclusionsMagnetic resonance imaging alone should not be considered in isolation when assessing and treating patients diagnosed with lumbar canal stenosis

Low birth weight at term and its determinants in a tertiary hospital of Nepal: a case-control study.

Birth weight of a child is an important indicator of its vulnerability for childhood illness and chances of survival. A large number of infant deaths can be averted by appropriate management of low birth weight babies and prevention of factors associated with low birth weight. The prevalence of low birth weight babies in Nepal is estimated to be about 12-32%.Our study aimed at identifying major determinants of low birth weight among term babies in Nepal. A hospital-based retrospective case control study was conducted in maternity ward of Tribhuvan University Teaching Hospital from February to July 2011. A total of 155 LBW babies and 310 controls were included in the study. Mothers admitted to maternity ward during the study period were interviewed, medical records were assessed and anthropometric measurements were done. Risk factors, broadly classified into proximal and distal factors, were assessed for any association with birth of low-birth weight babies. Regression analysis revealed that a history of premature delivery (adjusted odds ratio; aOR5.24, CI 1.05-26.28), hard physical work during pregnancy (aOR1.48, CI 0.97-2.26), younger age of mother (aOR1.98, CI 1.15-3.41), mothers with haemoglobin level less than 11gm/dl (aOR0.51, CI0.24-1.07) and lack of consumption of nutritious food during pregnancy (aOR1.99, CI 1.28-3.10) were significantly associated with the birth of LBW babies. These factors should be addressed with appropriate measures so as to decrease the prevalence of low birth weight among term babies in Nepal

Cardio-metabolic disease risk factors among South Asian labour migrants to the Middle East: a scoping review and policy analysis

This paper aims to explore the burgeoning burden of cardiovascular and metabolic disease (CMD) risk factors among South Asian labor migrants to the Middle East. We conducted a qualitative synthesis of literature using PubMed/Medline and grey literature searches, supplemented by a policy review of policies from the South Asian countries. We found a high burden of cardio-metabolic risk factors among the migrants as well as among the populations in the home and the host countries. For example, two studies reported the prevalence of diabetes mellitus (DM) ranging between 9 and 17% among South Asian migrants. Overweight and obesity were highly prevalent amongst South Asian male migrants; prevalence ranged from 30 to 66% (overweight) and 17-80% (obesity) respectively. The home country population had a significant CMD risk factor burden. Nearly 14 to 40% have three or more risk factors: such as hypertension (17 to 37%), diabetes (3 to 7%), overweight (18 to 41%), and obesity (2 to 15%). The host country also exhibited similar burden of risk factors: hypertension (13 to 38%), diabetes (8 to 17%), overweight (33 to 77%) and obesity (35 to 41%). Only Nepal, Bangladesh and Sri Lanka have some provisions related to screening of CMDs before labor migration. Further, analysis of policy papers showed that none of the reviewed documents had requirements for screening of any specific CMDs, but chronic diseases were used generically, failing to specify specific screening target. Given the high burden of risk factors, migrants' health should become an urgent priority. The lack of specific focus on screening during different stages of labor migration should receive attention. The International Labour Organization and the International Office for Migration, through their country coordination teams should engage local stakeholders to create policies and plans to address this concern. Similarly, there is a need for the host country to become an equal partner in these efforts, as migrant's better cardiometabolic health is in the benefit of both host and home countries

The role of tobacco and alcohol use in the interaction of social determinants of non-communicable diseases in Nepal: a systems perspective

Background: tobacco and alcohol use are major behavioural risks in developing countries like Nepal, which are contributing to a rapid increase in non-communicable diseases (NCDs). This causal relationship is further complicated by the multi-level social determinants such as socio-political context, socio-economic factors and health systems. The systems approach has potential to facilitate understanding of such complex causal mechanisms. The objective of this paper is to describe the role of tobacco and alcohol use in the interaction of social determinants of NCDs in Nepal.Method: the study adopted a qualitative study design guided by the Systemic Intervention methodology. The study involved key informant interviews (n = 63) and focus group discussions (n = 12) at different levels (national, district and/or community) and was informed by the adapted Social Determinants of Health Framework. The data analysis involved case study-based thematic analysis using framework approach and development of causal loop diagrams. The study also involved three sense-making sessions with key stakeholders.Results: three key themes and causal loop diagrams emerged from the data analysis. Widespread availability of tobacco and alcohol products contributed to the use and addiction of tobacco and alcohol. Low focus on primary prevention by health systems and political influence of tobacco and alcohol industries were the major contributors to the problem. Gender and socio-economic status of families/communities were identified as key social determinants of tobacco and alcohol use.Conclusion: tobacco and alcohol use facilitated interaction of the social determinants of NCDs in the context of Nepal. Socio-economic status of families was both driver and outcome of tobacco and alcohol use. Health system actions to prevent NCDs were delayed mainly due to lack of system insights and commercial influence. A multi-sectoral response led by the health system is urgently needed

Description of distal factors and their association with low birth weight.

<p>Description of distal factors and their association with low birth weight.</p