Culture and epidemiology of diabetes in South Asia

Enhanced or hindered research benefits? A realist review of community engagement and participatory research practices for non-communicable disease prevention in low- and middle-income countries

INTRODUCTION

Community engagement and participatory research are widely used and considered important for ethical health research and interventions. Based on calls to unpack their complexity and observed biases in their favour, we conducted a realist review with a focus on non-communicable disease prevention. The aim was to generate an understanding of how and why engagement or participatory practices enhance or hinder the benefits of non-communicable disease research and interventions in low- and middle-income countries.

METHODS

We retroductively formulated theories based on existing literature and realist interviews. After initial searches, preliminary theories and a search strategy were developed. We searched three databases and screened records with a focus on theoretical and empirical relevance. Insights about contexts, strategies, mechanisms and outcomes were extracted and synthesised into six theories. Five realist interviews were conducted to complement literature-based theorising. The final synthesis included 17 quality-appraised articles describing 15 studies.

RESULTS

We developed six theories explaining how community engagement or participatory research practices either enhance or hinder the benefits of non-communicable disease research or interventions. Benefit-enhancing mechanisms include community members' agency being realised, a shared understanding of the benefits of health promotion, communities feeling empowered, and community members feeling solidarity and unity. Benefit-hindering mechanisms include community members' agency remaining unrealised and participation being driven by financial motives or reputational expectations.

CONCLUSION

Our review challenges assumptions about community engagement and participatory research being solely beneficial in the context of non-communicable disease prevention in low- and middle-income countries. We present both helpful and harmful pathways through which health and research outcomes are affected. Our practical recommendations relate to maximising benefits and minimising harm by addressing institutional inflexibility and researcher capabilities, managing expectations on research, promoting solidarity in solving public health challenges and sharing decision-making power.

Prevalence of prediabetes and associated factors of prediabetic stages: a cross-sectional study among adults in Nepal

OBJECTIVES

To estimate the prevalence of prediabetes and to assess the association of prediabetic stages with sociodemographic, lifestyle and clinical factors DESIGN: Cross-sectional study at the screening and inclusion stage of a Diabetes Prevention Education Program (DiPEP) trial SETTING: The study was conducted in two urban communities in Nepal (October 2019-March 2020).

PARTICIPANTS

A total of 6222 residents of two study sites, aged 18-64 years and without a history of diabetes, were eligible for prediabetes screening. Exclusion criteria were pregnancy, history of diabetes and critical illness. A total of 291 participants with prediabetes were included in this study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence of prediabetes based on glycated haemoglobin (HbA1c) criteria (5.7%-6.4%) was the primary outcome of the study. Odds Ratio and 95% CI were estimated to assess the associations between the outcome prediabetic stages (5.7%-5.9% vs 6.0%-6.4%) and sociodemographic, lifestyle and clinical factors in both unadjusted and adjusted models.

RESULTS

Out of 6222 screened participants, 308 (5%, 95% CI: 4.4% to 5.5%) individuals were detected with prediabetes based on HbA1c. The mean age of 291 responded participants was 50.3±7.6 years and 67% were females. Among them, 78% aged 45-64 years, 97% had central obesity, 90% had high waist-hip ratio, 63% were hypertensive and 66% had no family history of diabetes. Approximately, 54% and 46% of individuals with prediabetes had HbA1c of 5.7%-5.9% and 6.0%-6.4%, respectively. Female gender was associated with prediabetes with HbA1c 6.0%-6.4% (OR, 1.98, 95% CI: 1.07 to 3.67) in the adjusted model.

CONCLUSION

The estimated prevalence of prediabetes was 5% among screened participants, and female gender was associated with the prediabetic stage. As a large proportion of the population with prediabetes were not aware of their status, this study demonstrates a need for regular community screening programmes to detect individuals with prediabetes and provide them a comprehensive lifestyle intervention for diabetes prevention.

TRIAL REGISTRATION NUMBER

NCT04074148, 2019/783.

The influence of patriarchy on Nepali-speaking Bhutanese women’s diabetes self-management

Introduction

The Nepali-speaking Bhutanese (NSB) community is a rapidly growing population in Central Pennsylvania. A community-based diabetes education pilot program found a large gender disparity with fewer women in attendance; participants reported that primary household cooks and caretakers were women. This may be an indication of women’s status in the NSB community, their healthcare access, autonomy, and ability to manage their diabetes. Hence, this study aims to understand the manifestations of patriarchy and its impact on NSB women’s diabetes self-management employing a conceptual framework based on Walby’s structures of patriarchy.

Methods

An exploratory feminist qualitative inquiry was conducted. Fifteen NSB women with Type 2 Diabetes were interviewed about their diabetes self-management. Transcripts were coded for key concepts that emerged from the data. A thematic analysis was conducted. Themes were developed inductively through those categories as well as through an a priori approach using the conceptual framework.

Results

Cultural influences such as family structure, religious beliefs, traditional healthcare and gender roles determined NSB women’s patriarchal upbringing and lifestyle. Unpaid household production was largely dependent on women. Multiple immigrations led to poor socioeconomic indicators and marginalization of NSB women. Women’s access to healthcare (including diabetes) was entirely reliant on other family members due to poor autonomy. Women experienced adverse physical and emotional symptoms related to diabetes and their ability and attempts to maintain a healthy diabetes lifestyle was determined by their physical health condition, knowledge regarding good dietary practices and self-efficacy.

Conclusion

Patriarchal practices that start early on within women’s lives, such as child marriage, religious restrictions as well as women’s access to education and autonomy impacted NSB women’s access to healthcare, knowledge regarding their diabetes and self-efficacy. Future interventions tailored for diabetes prevention and self-management among NSB women should factor in patriarchy as an important social determinant of health.

Effectiveness of health education intervention on diabetes mellitus among the teachers working in public sector schools of Pakistan

BACKGROUND

Diabetes Mellitus (DM) is considered as one of the major public health problems globally. Health education strategies can help in managing blood glucose level and complications among DM patients. Health education intervention is effective to manage and control the blood glucose levels among diabetic patients. This study explored the effectiveness of health education intervention on DM among school teachers in public sector schools of Pakistan.

METHODS

This was quasi-experimental study where baseline & end line assessments were conducted on teachers of public sector schools of Sindh province, Pakistan, from October to December 2019. Pretested structured questionnaire was used in this study. Participants (n = 136). were randomly selected from the list of government schools registered with district education department An intervention comprised of health education sessions with DM patients was undertaken after conducting baseline assessment followed by end line assessment. The institutional review board of Health Services Academy Pakistan ethically approved this study.

RESULTS

All the respondents completed post-test with mean ± SD age of participants being 39.2 ± 1.34 years. Female teachers comprised 65% out of which 70% were living in rural areas. Knowledge on DM pre-test score was 20.03 ± 3.31 that increased in post-test to 49.11 ± 2.21 (p < 0.05). Mean score of information on symptoms and causes of DM was 1.98 ± 0.21 for pre-test whereas for post-test it was 4.78 ± 0.12 (p < 0.05). The effect of intervention was significant on diabetes related complications (p < 0.05), symptoms (p < 0.05), overall score (p < 0.05) and preventive practices (p < 0.05).

CONCLUSIONS

The study provides evidence of the importance and effectiveness of health education intervention related to diabetes among school teachers, which has a positive impact on the knowledge and practices. We concluded that the health education session sensitized the teachers and they can bring cogent changes to enhance their knowledge about diabetes and its risks.

Burden of chronic kidney disease in the general population and high-risk groups in South Asia: A systematic review and meta-analysis

BACKGROUND

Chronic kidney disease (CKD) is an emerging public health issue globally. The prevalence estimates on CKD in South Asia are however limited. This study aimed to examine the prevalence of CKD among the general and high-risk population in South Asia.

METHODS

We conducted a systematic review and meta-analysis of population-level prevalence studies in South Asia (Afghanistan, Bangladesh, Bhutan, Maldives, Nepal, India, Pakistan, and Sri Lanka). Three databases namely PubMed, Scopus and Web of Science were systematically searched for published reports of kidney disease in South Asia up to 28 October 2020. A random-effect model for computing the pooled prevalence was used.

RESULTS

Of the 8749 identified studies, a total of 24 studies were included in the review. The pooled prevalence of CKD among the general population was 14% (95% CI 11-18%), and 15% (95% CI 11-20%) among adult males and 13% (95% CI 10-17%) in adult females. The prevalence of CKD was 27% (95% CI 20-35%) in adults with hypertension, 31% (95% CI 22-41%) in adults with diabetes and 14% (95% CI 10-19%) in adults who were overweight/obese. We found substantial heterogeneity across the included studies in the pooled estimates for CKD prevalence in both general and high-risk populations. The prevalence of CKD of unknown origin in the endemic population was 8% (95% CI 3-16%).

CONCLUSION

Our study reaffirms the previous reports that CKD represents a serious public health challenge in South Asia, with the disease prevalent among 1 in 7 adults in South Asian countries.

Type 2 Diabetes Mellitus in Nepal from 2000 to 2020: A systematic review and meta-analysis

Aims: To evaluate the prevalence and risk factors of type 2 diabetes mellitus (T2DM) from 2000-2020 in various parts of Nepal.  Methods: PubMed, Embase, Scopus, and Google Scholar were searched using the appropriate keywords. All Nepalese studies mentioning the prevalence of T2DM and/or details such as risk factors were included. Studies were screened using Covidence. Two reviewers independently selected studies based on the inclusion criteria. Meta-analysis was conducted using Comprehensive Meta-Analysis Software v.3.  Results: A total of 15 studies met the inclusion criteria. The prevalence of T2DM, pre-diabetes, and impaired glucose tolerance in Nepal in the last two decades was 10% (CI, 7.1%- 13.9%), 19.4% (CI, 11.2%- 31.3%), and 11.0% (CI, 4.3%- 25.4%) respectively. The prevalence of T2DM in the year 2010-15 was 7.75% (CI, 3.67-15.61), and it increased to 11.24% between 2015-2020 (CI, 7.89-15.77). There were 2.19 times higher odds of having T2DM if the body mass index was ≥24.9 kg/m ². Analysis showed normal waist circumference, normal blood pressure, and no history of T2DM in a family has 64.1%, 62.1%, and 67.3% lower odds of having T2DM, respectively.  Conclusion: The prevalence of T2DM, pre-diabetes, and impaired glucose tolerance in Nepal was estimated to be 10%, 19.4%, and 11% respectively.

Salt intake and salt-reduction strategies in South Asia: From evidence to action

The World Health Organization recommends salt reduction as a cost-effective intervention to prevent noncommunicable diseases. Salt-reduction interventions are best tailored to the local context, taking into consideration the varying baseline salt-intake levels, population's knowledge, attitude, and behaviors. Fundamental to reduction programs is the source of dietary salt-intake. In South Asian countries, there is a paucity of such baseline evidence around factors that contribute to community salt intake. Upon reviewing the electronic literature databases and government websites through March 31, 2021, we summarized dietary salt intake levels and aimed to identify major sources of sodium in the diet. Information on the current salt reduction strategies in eight South Asian countries were summarized, namely Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka. One hundred twelve publications (out of identified 640) met our inclusion-exclusion criteria for full text review. Twenty-one studies were included in the review. Quality of the included studies was assessed using the US National Heart, Lung, and Blood Institute assessment tool. The primary result revealed that mean salt intake of South Asian countries was approximately twice (10 g/day) compared to WHO recommended intake (< 5 g/day). The significant proportion of salt intake is derived from salt additions during cooking and/or discretionary use at table. In most South Asian countries, there is limited data on population sodium intake based on 24-h urinary methods and sources of dietary salt in diet. While salt reduction initiatives have been proposed in these countries, they are yet to be fully implemented and evaluated. Proven salt reduction strategies in high-income countries could possibly be replicated in South Asian countries; however, further community-health promotion studies are necessary to test the effectiveness and scalability of those strategies in the local context.

Type 2 Diabetes Mellitus in Nepal from 2000 to 2020: A systematic review and meta-analysis

Aims: To evaluate the prevalence and risk factors of type 2 diabetes mellitus (T2DM) from 2000-2020 in various parts of Nepal.  Methods: PubMed, Embase, Scopus, and Google Scholar were searched using the appropriate keywords. All Nepalese studies mentioning the prevalence of T2DM and/or details such as risk factors were included. Studies were screened using Covidence. Two reviewers independently selected studies based on the inclusion criteria. Meta-analysis was conducted using Comprehensive Meta-Analysis Software v.3.  Results: A total of 15 studies met the inclusion criteria. The prevalence of T2DM, pre-diabetes, and impaired glucose tolerance in Nepal in the last two decades was 10% (CI, 7.1%- 13.9%), 19.4% (CI, 11.2%- 31.3%), and 11.0% (CI, 4.3%- 25.4%) respectively. The prevalence of T2DM in the year 2010-15 was 7.75% (CI, 3.67-15.61), and it increased to 11.24% between 2015-2020 (CI, 7.89-15.77). There were 2.19 times higher odds of having T2DM if the body mass index was ≥24.9 kg/m 2. Analysis showed normal waist circumference, normal blood pressure, and no history of T2DM in a family has 64.1%, 62.1%, and 67.3% lower odds of having T2DM, respectively.  Conclusion: The prevalence of T2DM, pre-diabetes, and impaired glucose tolerance in Nepal was estimated to be 10%, 19.4%, and 11% respectively.

Barriers to and facilitators of diabetes self-management practices in Rupandehi, Nepal- multiple stakeholders' perspective

BACKGROUND

Self-management of diabetes is associated with glycaemic control and adherence to medication and healthy lifestyle practices. There is lack of information on the barriers to and facilitators of diabetes self-management practices in low income country, Nepal. This study aimed to explore the barriers to and facilitators of Type 2 diabetes self-management practices taking multiple stakeholders' perspectives in Nepal.

METHODS

Four focus group discussions and 16 semi-structured interviews with people with Type 2 diabetes, caregivers, health care providers and health managers were conducted from April to May 2018 in Rupandehi district of Western Nepal. They were audio-recorded, transcribed, and analysed using a thematic approach.

RESULTS

Five main themes emerged that influenced diabetes self-management practices: individual factors, socio-cultural and economic factors, health system and policy factors, availability and accessibility of resources, and environmental factors. The important barriers were: lack of knowledge about diabetes self-management practices, cultural practices, insufficient counselling, lack of guidelines and protocols for counselling, and financial problems. The major facilitators were: motivation; support from family, peers, and doctors; and availability of resources in the community.

CONCLUSION

Based on our findings, a multilevel approach is needed to address these barriers and facilitators. These findings will help guide strategies to develop programs that impart knowledge and skills to improve the diabetes self-management practices of people with Type 2 diabetes.

Diabetes among tuberculosis patients and its impact on tuberculosis treatment in South Asia: a systematic review and meta-analysis

The escalating burden of diabetes is increasing the risk of contracting tuberculosis (TB) and has a pervasive impact on TB treatment outcomes. Therefore, we conducted this systematic review and meta-analysis to examine the burden of diabetes among TB patients and assess its impact on TB treatment in South Asia (Afghanistan, Bangladesh, Bhutan, Maldives, Nepal, India, Pakistan, and Sri Lanka). PubMed, Excerpta Medica Database (EMBASE), and CINAHL databases were systematically searched for observational (cross-sectional, case-control and cohort) studies that reported prevalence of diabetes in TB patients and published between 1 January 1980 and 30 July 2020. A random-effect model for computing the pooled prevalence of diabetes and a fixed-effect model for assessing its impact on TB treatment were used. The review was registered with PROSPERO number CRD42020167896. Of the 3463 identified studies, a total of 74 studies (47 studies from India, 10 from Pakistan, four from Nepal and two from both Bangladesh and Sri-Lanka) were included in this systematic review: 65 studies for the prevalence of diabetes among TB patients and nine studies for the impact of diabetes on TB treatment outcomes. The pooled prevalence of diabetes in TB patients was 21% (95% CI 18.0, 23.0; I2 98.3%), varying from 11% in Bangladesh to 24% in Sri-Lanka. The prevalence was higher in studies having a sample size less than 300 (23%, 95% CI 18.0, 27.0), studies conducted in adults (21%, 95% CI 18.0, 23.0) and countries with high TB burden (21%, 95% CI 19.0, 24.0). Publication bias was detected based on the graphic asymmetry of the funnel plot and Egger's test (p < 0.001). Compared with non-diabetic TB patients, patients with TB and diabetes were associated with higher odds of mortality (Odds Ratio (OR) 1.7; 95% CI 1.2, 2.51; I2 19.4%) and treatment failure (OR 1.7; 95% CI 1.1, 2.4; I2 49.6%), but not associated with Multi-drug resistant TB (OR 1.0; 95% CI 0.6, 1.7; I2 40.7%). This study found a high burden of diabetes among TB patients in South Asia. Patients with TB-diabetes were at higher risk of treatment failure and mortality compared to TB alone. Screening for diabetes among TB patients along with planning and implementation of preventive and curative strategies for both TB and diabetes are urgently needed.

Cardiometabolic risk factors among patients with tuberculosis attending tuberculosis treatment centers in Nepal

BACKGROUND

The co-morbidity of cardiometabolic diseases in patients with Tuberculosis adds a significant burden in current health systems in developing countries including Nepal. The main objective of this study was to explore cardiometabolic risk factors among patients with Tuberculosis.

METHODS

This was a cross-sectional study conducted among patients with tuberculosis in 12 tuberculosis treatment centers from eight districts of Nepal between May and July 2017. Interviews with participants were conducted using a structured questionnaire and were supplemented by anthropometric measurements and on-site blood glucose tests. Data were analyzed using descriptive and inferential statistics.

RESULTS

Among 221 study participants, 138 (62.4%) had new smear-positive pulmonary tuberculosis, 24 (10.9%) had new smear-negative pulmonary tuberculosis and 34 (15.4%) had new extra- pulmonary tuberculosis. Overall, 43.1% of the patients with tuberculosis had at least one cardiometabolic risk factor. The prevalence of at least one cardiometabolic risk factor was more in male than female (47.8% versus 33.8%). Prevalence of tobacco (18.9% versus 4.8%), and alcohol (12.6% versus 6.5%) use was proportionately higher in male compared to female. The prevalence of hypertension (17% vs. 21%) and obesity (11.9% vs. 12.9%) was lower in male compared to females. Female (AOR = 0.47; CI: 0.23-0.94), those from Gandaki Province (AOR = 0.32; CI: 0.13-0.79) and literate (AOR = 0.49; CI: 0.25-0.96) had reduced risk of cardiometabolic disease risk factors.

CONCLUSIONS

This study highlights the role of gender and socio-demographic characteristics associated with the risk of cardiometabolic diseases in patients with Tuberculosis. The findings from this study can guide medical practitioners and policy makers to consider clinical suspicion, diagnosis and treatment. National treatment guideline can benefit by integrating the management of non-communicable diseases in Tuberculosis treatment centers.

Burden of Diabetes and Prediabetes in Nepal: A Systematic Review and Meta-Analysis

BACKGROUND

Unhealthy behaviors, such as energy-dense food choices and a sedentary lifestyle, both of which are established risk factors for diabetes, are common and increasing among Nepalese adults. Previous studies have reported a wide variation in the prevalence of prediabetes and diabetes in Nepal, and thus a more reliable pooled estimate is needed. Furthermore, Nepal underwent federalization in 2015, and the province-specific prevalence, which is necessary for the de novo provincial government to formulate local health policies, is lacking. This study aims to provide a comprehensive summary of the current literature on various aspects of diabetes in Nepal, i.e., the prevalence of prediabetes and diabetes as well as of the awareness, treatment, and control of diabetes in Nepal.

METHODS

This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched three electronic databases-PubMed, Scopus, and Web of Science-using a comprehensive search strategy to identify eligible studies published up to April 2, 2020. Data on prevalence estimates of prediabetes and diabetes were extracted and pooled in a meta-analysis using a random effect model. Subgroup analyses and meta-regression were conducted to assess heterogeneity across the studies. The quality of included studies was assessed using the New Castle-Ottawa scale.

RESULTS

We included 14 eligible studies that comprised a total of 44,129 participants and 3517 diabetes cases. Half of the included studies had good quality. Overall, the prevalence of prediabetes and diabetes was 9.2% (95% CI 6.6-12.6%) and 8.5% (95% CI 6.9-10.4%), respectively. Among the participants with diabetes, only 52.7% (95% CI 41.7-63.4%) were aware of their diabetes status, and 45.3% (95% CI 31.6-59.8%) were taking antidiabetic medications. Nearly one-third of those under antidiabetic treatment (36.7%; 95% CI 21.3-53.3%) had their blood glucose under control. The prevalence of prediabetes and diabetes gradually increased with increasing age and was more prevalent among males and urban residents. There was a wide variation in diabetes prevalence across the provinces in Nepal, the lowest 2% in Province 6 to the highest 10% in Province 3 and Province 4.

CONCLUSIONS

The prevalence of prediabetes and diabetes was high in Nepal, while its awareness, treatment, and control were low. Our findings call for urgent nationwide public health action in Nepal.

A Retrospective Analysis of Mortality From 2015 Gorkha Earthquakes of Nepal: Evidence and Future Recommendations

OBJECTIVE

The aim of this study was to explore the mortality pattern due to Gorkha earthquakes in 2015 and review the response and recovery efforts immediately following the earthquakes.

METHODS

Data from published reports of the Nepal Police showed over 8000 deaths. These death counts were categorized by gender, ethnicity, and age groups (interval of 5 years). The mortality rate was calculated (per 100 000 population), using the projected population as the denominator as of April 2015.

RESULTS

Children < 10 years and older adults > 55 years showed a higher rate of deaths, with similar trends for the most affected districts. Almost 8 more females' deaths were reported per 100 000 population compared with their male counterparts. There was a higher death rate from Province 3 with a notable gender difference: Nearly 20 more females' deaths were reported per 100 000 population compared with their male counterparts. There was a higher death rate in mountains (542.4 per 100 000) compared with hills (55.0 per 100 000) and the southern Terai region (0.96 per 100 000) of Nepal.

CONCLUSIONS

Young and older adults, female, and residents of remote, mountainous regions of Nepal were vulnerable to the earthquakes. Future earthquake preparedness should focus on the vulnerable population by age and gender and the geographical accessibility.