May Measurement Month 2017: an analysis of blood pressure screening results in Nepal-South Asia

Stroke Care in South Asia - Identifying Gaps for Future Action

Stroke causes around 730,000 deaths in South Asia, nearly half of stroke-related deaths in developing countries. This highlights the need to address health system responses, considering poverty, service quality, and availability. The article identifies four key challenges in stroke management and rehabilitation in South Asia, emphasizing long-term monitoring, risk factor control, and community surveillance, drawing on experiences from Nepal.

May Measurement Month 2021: an analysis of blood pressure screening results from Nepal

Despite the well-recognized importance of prevention and early treatment of hypertension, the majority of adults in Nepal are not aware of their high blood pressure (BP) and are left untreated. In this paper, we report the result of the May Measure Month 2021 campaign in Nepal: a nationwide community-based hypertension screening campaign. An opportunistic cross-sectional survey was conducted in 15 districts between September 2021 and December 2021. An individual was included if aged 18 years or more and provided informed consent. Structured questionnaires were administered, and BP was measured three times in a sitting position by trained volunteers. A total of 5172 participants were included. The median age (interquartile range) was 37 (25-51), and 49.9% were female. The mean (SD) of the systolic and diastolic BP was 123.9 (14.9) and 80.2 (9.3) mmHg, respectively. A total of 1066 participants (20.6%) were identified as hypertensive (systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg or on antihypertensive medication), of whom 399 (39.5%) and 298 (29.5%) were aware of their BP status and treated with at least one antihypertensive medicine, respectively. Blood pressure control (<140/90 mmHg) was achieved in 15.6% of all hypertensives and in 56.0% of treated individuals. Multivariate logistic regression showed an association between hypertension and the following variables: every 1-year increase of age [odds ratio (OR) = 1.13 (1.11-1.15) if age < 40 and OR = 1.05 (1.04-1.06) if age ≥ 40], male [OR = 1.57 (1.33-1.89)], regular alcohol use [OR = 1.59 (1.30-1.93)], and diabetes [OR = 2.63 (1.93-3.58)]. Hypertension awareness, treatment, and control were suboptimal in Nepal. This study supports a strong need to scale up community-based hypertension programmes in Nepal and raises the possibility of task sharing with community health workers.

May Measurement Month 2021: an analysis of blood pressure screening campaign results from India

Raised blood pressure (BP) is the leading preventable risk factor for cardiovascular diseases that makes a major impact on early mortality and morbidity. Recognizing hypertension in the community, educating people about routine BP monitoring, and improving medication compliance are all important steps in detecting, controlling, and managing hypertension. During the course of 5 months, members of the Indian Society of Hypertension organized unique medical indoor and outdoor camps at 100 screening locations around India for the May Measurement Month (MMM) 2021 study. At every location, BP was measured three times, and a questionnaire was completed. Participants known to have hypertension before the study whether taking or not taking treatment were not included (not a normal pre-requisite for exclusion in MMM). The analysis included 15 045 participants in total. After calculating the average of the second and third BP measurements, 16.4% of participants were found to have hypertension based on ≥140/90 mmHg thresholds (2461 out of 15 045). 14.0% of females and 16.4% of males had hypertension. 16.4% of participants had undiagnosed hypertension and were not receiving treatment. The MMM screening campaign has the potential for identifying large numbers of people with undiagnosed hypertension and raising awareness of the importance of raised BP among the general public, medical professionals, policymakers, the government, and the media. Future BP screening campaigns should be larger in scope and involve follow-ups with past participants.

Prevalence, awareness, risk factors and control of hypertension in Nepal from 2000 to 2020: A systematic review and meta-analysis

Objective

To analyse published literatures on prevalence, awareness, risk factors and control of hypertension in Nepal.

Methods

We used electronic databases to search relevant articles from January 2000 till October 2020. All relevant data from selected studies were extracted into a standardized form designed in Excel. Statistical analysis was conducted using Comprehensive Meta-Analysis Software (CMA) version 3. Proportions or Odds Ratio (OR) was used to estimate the outcome with 95% confidence interval (CI). The I-squared (I²) test was used for the assessment of heterogeneity.

Results

We identified a total of 3726 studies after comprehensive database searching. We performed qualitative and quantitative analysis of 40 studies. Pooling data showed 28.52% of patients with hypertension (CI: 26.40–30.75); 45.28% (CI: 38.89–51.83) aware of their high blood pressure; 31.66% (CI: 23.18–41.56) under treatment; 44.4% (CI: 36.17–53.04) had their blood pressure under optimum range. 27.4% (CI: 21.57–34.11) had pre-hypertensive range elevated blood pressure. 25.99% (CI: 21.81–30.65) of females and 34.25% (CI: 30.49–38.21) of male were hypertensive (p ​= ​0.007).

The pooling of data showed smokers have 1.43 times (CI: 1.1429–1.7889); and alcohol users have 2.073 times (CI: 1.7154–2.5050) higher risk of having hypertension. Individuals with normal BMI have 53.15% (OR: 0.4685 CI: 0.3543–0.6195); with formal educated have 37.27% (OR: 0.6273, CI: 0.5485–0.7175); and with adequate exercise have 31.6% (OR: 0.6839, CI: 0.5203–0.8991) lower chance of having hypertension.

Conclusion

Our study shows the prevalence of hypertension in Nepal is high. However, awareness, treatment and subsequently control of high blood pressure are found to be alarmingly low. Hypertension was associated with male gender, smoking, alcohol use, high BMI, no education and inadequate exercise. It calls for more attention to address the burden of hypertension and associated risk factors in Nepal.

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We did this systematic review and meta-analysis on prevalence, awareness, risk factors and control of hypertension in Nepal.

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The prevalence of hypertension in Nepal is high.

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Awareness, treatment and subsequently control of high blood pressure are alarmingly low.

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Male, smoker, alcoholics, with high BMI, no education and inadequate exercise were risk factors for hypertension.

Simplified hypertension screening approaches with low misclassification and high efficiency in the United States, Nepal, and India

Standard triplicate blood pressure (BP) measurements pose time barriers to hypertension screening, especially in resource‐limited settings. We assessed the implications of simplified approaches using fewer measurements with adults (≥18 years old) not using anti‐hypertensive medications from the US National Health and Nutrition Examination Survey 1999‐2016 (n = 30 614), and two datasets from May Measurement Month 2017‐2018 (n = 14 795 for Nepal and n = 6 771 for India). We evaluated the proportion of misclassification of hypertension when employing the following simplified approaches: using only 1st BP, only 2nd BP, 2nd if 1st BP in a given range (otherwise using 1st), and average of 1st and 2nd BP. Hypertension was defined as average of 2nd and 3rd systolic BP ≥140 and/or diastolic BP ≥90 mm Hg. Using only the 1st BP, the proportion of missed hypertension ranged from 8.2%–12.1% and overidentified hypertension from 4.3%–9.1%. Using only 2nd BP reduced the misclassification considerably (corresponding estimates, 4.9%–6.4% for missed hypertension and 2.0%–4.4% for overidentified hypertension) but needed 2nd BP in all participants. Using 2nd BP if 1st BP ≥130/80 demonstrated similar estimates of missed hypertension (3.8%–8.1%) and overidentified hypertension (2.0%–3.9%), but only required a 2nd BP in 33.8%–59.8% of participants. In conclusion, a simplified approach utilizing 1st BP supplemented by 2nd BP in some individuals has low misclassification rates and requires approximately half of the total number of measurements compared to the standard approach, and thus can facilitate screening in resource‐constrained settings.

May Measurement Month 2019: an analysis of blood pressure screening results from Nepal

May Measurement Month (MMM) is a global initiative to screen high blood pressure (BP) in the community and increase awareness at the population level. High BP is the leading risk factor for mortality worldwide and in Nepal. This study presents the results of the 2019 MMM in Nepal. Opportunistic BP screening was conducted in 30 out of 77 districts across Nepal and aged ≥18 years at the community and public places. BP was measured three times in a seated position. A total of 74 205 individuals participated in the study, mean age 39.9 years, and 58% were male. BP measurements for the second and third readings were available for 69 292 (93.3%) individuals. The proportion of the population that were hypertensive was 27.5% (n = 20 429). Among those hypertensives, 46.3% were aware of their hypertensive status and of these, 37.5% were on antihypertensive medication. Only 54.3% of those on antihypertensive medication had their BP controlled. Of the community screened, those self reporting to have diabetes, current tobacco users, and current alcohol drinkers were 6.7%, 23.6%, and 31.9%, respectively; 20.6% of the participants were overweight, and 6.5% were obese. Since the first BP screening campaign, MMM 2017 in Nepal, the number of participants screened has largely increased over the years. MMM’s success in Nepal is through a coordinated mobilization of trained health science students and volunteers in the communities. The Nepal MMM data demonstrates that large community-based BP screening campaigns are possible in low resource settings.

Health System Capacity and Access Barriers to Diagnosis and Treatment of CVD and Diabetes in Nepal

Background:

Universal access to essential medicines and routine diagnostics is required to combat the growing burden of cardiovascular disease (CVD) and diabetes. Evaluating health systems and various access dimensions availability, affordability, accessibility, acceptability, and quality is crucial yet rarely performed, especially in low- and middle-income countries.

Objective:

To evaluate health system capacity and barriers in accessing diagnostics and essential medicines for CVD and diabetes in Nepal.

Methods:

We conducted a WHO/HAI nationally-representative survey in 45 health-facilities (public-sector: 11; private-sector: 34) in Nepal to collect availability and price data for 21 essential medicines for treating CVD and diabetes, during MayJuly 2017. Data for 13 routine diagnostics was obtained in 12 health facilities. Medicines were considered unaffordable if the lowest paid worker spends >1 days wage to purchase a monthly supply. To evaluate accessibility, we conducted facility exit interviews among 636 CVD patients. Accessibility (e.g., private-public health facility mix, travel to hospital/pharmacy) and acceptability (i.e. Nepals adoption of WHO Essential Medicine List, and patient medication adherence) were summarized using descriptive statistics, and we conducted a systematic review of relevant literature. We did not evaluate medicine quality.

Results:

We found that mean availability of generic medicines is low (<50%) in both public and private sectors, and less than one-third medicines met WHOs availability target (80%). Mean (SD) availability of diagnostics was 73.1% (26.8%). Essential medicines appear locally unaffordable. On average, the lowest-paid worker would spend 1.03 (public-sector) and 1.26 (private-sector) days wages to purchase a monthly supply. For a person undergoing CVD secondary preventive-interventions in the private sector, the associated expenditure would be 7.511.2% of monthly household income. Exit-interviews suggest that a long/expensive commute to health-facilities and poor medicine affordability constrain access.

Conclusions:

This study highlights critical gaps in Nepals health system capacity to offer basic health services to CVD and diabetes patients, owing to low availability, poor affordability and accessibility of essential medicines and diagnostics. Research and policy initiatives are needed to ensure uninterrupted supply of affordable essential medicines and diagnostics.

Trends in the Prevalence, Awareness, Treatment, and Control of Hypertension in Nepal between 2000 and 2025: A Systematic Review and Meta-Analysis

BACKGROUND

Understanding the burden and trend of hypertension and the associated care cascade can provide direction to the development of interventions preventing and controlling hypertension. This study aimed to assess prevalence and trends of hypertension and its awareness, treatment, and control in Nepal.

METHODS

We systematically searched CINAHL, Embase, ProQuest, PubMed, Web of Science, WorldCat, and government and health agency-owned websites to identify studies reporting prevalence of hypertension, awareness, treatment, and control in Nepal between 2000 and 2020. We applied the random-effects model to compute the pooled prevalence in the overall population and among subgroups in each 5-year interval period between 2000 and 2020. We used linear meta-regression analysis to predict hypertension from 2000 to 2025.

RESULTS

We identified 23 studies having a total of 84,006 participants. The pooled prevalence of hypertension, awareness, treatment, and control for 2016-2020 was 32% (95% CI: 23-40%), 50% (95% CI: 30-69%), 27% (95% CI: 19-34%), and 38% (95% CI: 28-48%), respectively. The prevalence of hypertension varied by age, gender, education, and geographical area. Hypertension increased by 6 percentage points (pp), awareness increased by 12 pp, treatment increased by 11 pp, and control increased by 3 pp over the 20 years studied. Since 2000, the rate of increment of hypertension has been 3.5 pp per decade, where 44.7% of men are expected to suffer from hypertension by 2025.

CONCLUSION

The markedly increased prevalence of hypertension and relatively poor progress in hypertension awareness, treatment, and control in Nepal suggest that there is a need for hypertension preventive approaches as well as strategies to optimize hypertension care cascade.

May Measurement Month 2018: an analysis of blood pressure screening results from Nepal

Raised blood pressure (BP) is a leading risk factor for mortality globally and in Nepal. May Measurement Month (MMM) is a global initiative aimed at screening for hypertension and raising awareness on high BP worldwide. This study provides the results of the 2018 MMM (MMM18) in Nepal. An opportunistic cross-sectional survey of volunteers aged ≥18 years was carried out in May 2018 nationwide. The standard MMM protocol was followed for BP measurement, the definition of hypertension, and statistical analysis. The campaign was publicized through various social media for recruiting volunteers and inviting participation. A total of 15 561 (58.7% male) from 35 districts of Nepal were screened in MMM18, of which 4 321 (27.8%) had hypertension. A total of 2 633 (19.0%) of 13 873 individuals who were not on antihypertensive treatment were found to be hypertensive. Of those on medication, 799 (47.4%) had uncontrolled BP. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were significantly higher in people on antihypertensive treatment, smokers, and alcohol drinkers compared with those who were not on antihypertensive treatment, smokers, and alcohol drinkers, respectively. Likewise, SBP and DBP steadily increased across increasing body mass index categories. MMM18 was the largest BP screening campaign undertaken in Nepal. MMM has highlighted the importance of a periodic public health program at the national level to increase awareness on hypertension detection and control rate, and thus, the prevention of cardiovascular diseases.

Study, Design, and Rationale of Noncommunicable Diseases in Nepal (NCD Nepal) Study: A Community-Based Prospective Epidemiological and Implementation Study in Rural Nepal

BACKGROUND

Noncommunicable diseases (NCDs) are the leading causes of deaths globally. Currently, there are limited high-quality data on the epidemiology and usefulness of community-based screening and treatment of NCDs in low-to-middle-income countries (LMIC), like Nepal. We describe the protocol of a community-based, longitudinal epidemiological study of screening and management of NCDs in rural Nepal.

METHODS

We organize monthly mobile health clinics to screen NCDs among 40- to 75-year-old residents from municipal subdivision wards 3, 4, 6, and 7 of Ghorahi submetropolitan city, Dang, Nepal (approximately 406 km west of the capital, Kathmandu). We estimate a total of 7052 eligible participants. After obtaining informed consent, trained personnel will collect sociodemographic and lifestyle data, medical, medication, and family history using validated questionnaires, plus anthropometric measures and capillary glucose levels. We will screen for hypertension, diabetes, obesity, dyslipidemia, tobacco and alcohol use, self-reported physical activity, dietary habits, cardiovascular disease, stroke, chronic lung disease, cancer, and chronic kidney disease. We will also check hemoglobin A1C, lipid panel, serum creatinine, sodium, potassium, urine dipstick, and urine albumin-to-creatinine ratio in high-risk participants. We will offer lifestyle counseling, pharmacotherapy or refer to higher level care, where appropriate; routinely follow participants with NCDs for continuity of care; and follow individuals without NCDs but with elevated glucose, prehypertension or other risk factors every year, and those without risk factors every 2 years. We will monitor participants in the community to reduce attrition and to track all-cause and disease-specific mortality.

DISCUSSION

Understanding the community burden of NCDs in resource-limited setting and testing effectiveness of community-based screening and management of NCDs will provide insights to develop national policy to address NCD burden in LMIC like Nepal.