Non-Communicable Diseases (NCDs) in Nepal: Bridging Evidence-Based Policies Making

NCD: Linking evidence to
policy in National Context
Kusumsheela Bhatta (403)
26 JULY
2022
Presented
by
MPH, PAHS

• Introduction to NCD
• NCD Related Policies in Nepal
• Linking evidence with policy action (NCD
MSAP 2021-2025)
 Tobbaco
 Alcohol
 Diet
 Physical Activity
 Health Promotion
 Indoor Air Pollution
 Health System Strengthening
 Mental Health
 Oral Health
• Critical Appraisal
• Conclusion
• References
Table of Contents

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Introduction
• Non communicable diseases (NCDs) kill 41 million people each year,
equivalent to 71% of all deaths globally.
• Each year, more than 15 million people die from a NCD between the ages
of 30 and 69 years; 85% of these "premature" deaths occur in low- and
middle-income countries.
• 77% of all NCD deaths are in low- and middle-income countries.
• Nepal has also experienced a marked epidemiological transition from
communicable diseases to non-communicable diseases (NCDs) in the
past two decades.
Linking evidence to policy in National Context: Group 2
Source: WHO Factsheet, 2020

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Nepal Burden of Disease
Source: Global Burden of Disease 2019 Report

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Attribution of NCD in All Causes of Deaths – NBoD, 2019
• 66% of all deaths in Nepal are caused by
NCDs
• 25% are due to communicable, maternal,
neonatal, and nutritional (CMNN) diseases
• 9% due to injuries
5
Source: NBoD Policy Brief, 2019

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NCD Attributable Death Trend and Projection (1990 - 2040)
By 2040, almost
79% of all death in
Nepal will be due to
NCDs
Pandey AR, Chalise B, Shrestha N, Ojha B, Maskey J, Sharma D, Godwin P, Aryal KK. Mortality and risk factors of disease in Nepal:
Trend and projections from 1990 to 2040. Plos one. 2020 Dec 3;15(12):e0243055.

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Risk factors
Source:NCDI Povery Comission, 2018

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Source:NCDI Poverty Comission, 2018

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Source:NCDI Povery Comission, 2018

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Health Financing Situation
● Around one-third (36%) of current health expenditure is due to NCDs
● One-fourth (27.4%) of population spend more than 10% of total expenditure on health
● Slightly more than half of total Out of Pocket (OOP) expenditure goes for NCDs
● Approximately 6.4% of the total government expenditure on health goes for NCDs
● Less than 1% of external development assistance for health in Nepal is for NCDs
Source: http://nhrc.gov.np/wp-content/uploads/2019/07/Choices-towards-achieving-
UHC.pdf

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NCD Related Specific Policies in Nepal
Integrated NCD prevention and
control policy in Nepal (2007)
Multisectoral Action Plan
for NCD in Nepal (2014-
2020)
Package of Essential Non-
communicable Diseases (PEN)-2016

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NCD Related Specific Policies in Nepal
National Mental Health
Policy, 2073 - draft
Tobacco Control Act, 2010
Oral Health Policy, 2070

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NCD Related Supplementary Policies in Nepal
National Nutrition Policy
and Strategy, 2004 NHSS 2015-2020 National Health Policy
2019

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Integrated NCD prevention and control policy in Nepal (2007)
Vision
Gain best possible quality of life and longevity by preventing and controlling
NCDs in Nepal
Mission
Promote healthy lifestyles by empowering people, strengthening health
services and creating conducive socio-economic environment
Goal
Reduce morbidity and mortality related to NCDs

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Integrated NCD prevention and control policy in Nepal (2007)
Objectives
• Reduce the major risk factors (tobacco use, alcohol consumption, physical
inactivity and unhealthy diet)
• Strengthen capacity of health personnel, institutions and other
stakeholders for identification of the major risk factors and to use
comprehensive approach for health promotion and primary prevention
• Strengthen capacity of health system to prevent, diagnose and manage
NCDs through standard guidelines and protocol appropriate to various
level of health care
• Develop a national surveillance system for NCDs and their risk factors

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Package of Essential Non-communicable Diseases
(PEN)(2006)
● WHO PEN package was launched as a follow up of the commitment of the 69th session of
the WHO Regional Committee for the South and the Colombo Declaration on
“Strengthening health systems to accelerate delivery of non communicable services at the
primary care level”
● In Nepal, PEN package was launched in Kailali district on 5th October 2016 and was
piloted in two districts (Kailali and Ilam)
● Has been introduced to screen, diagnose, treat and refer Cardiovascular Diseases, COPD,
cancer, diabetes, and mental health at health posts, primary health care centres and
district hospitals for early detection and management of chronic diseases within the
community
https://publichealthupdate.com/package-essential-noncommunicable-pen-disease-interventions-nepal/

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Nepal PEN Protocol
● Protocol is a tool for implementing PEN for primary care in low resource settings
● There are 4 PEN Protocols:
○ Protocol 1- Prevention of heart attack, stroke and kidney disease through integrated
management of diabetes and hypertension
○ Protocol 2- Health education and counseling of healthy behavior
○ Protocol 3- Management of chronic obstructive pulmonary disease (COPD)
○ Protocol 4-Assessment and referral of women with suspected cancer (breast,
cervical)
● The MoHP Nepal endorsed PEN protocols 1 and 2 in July 2016
● Protocol -1 is for Health Post (HP) and protocol-2 is for Primary Health Care
Centre(PHCC)
https://phcrd.gov.np/index.php/pen-protocol
http://www.edcd.gov.np/resources/download/pen-training-trainers-guide-2075

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National Mental Health Policy (Draft 2073)
● The Ministry of Health has drafted a new National Mental Health Policy, which it said
would soon be tabled at the Cabinet for approval
● It has adopted five policies in area of mental health to ensure
○ Availability and accessibility of basic quality mental health services for all citizens
prepare necessary human resources in order to deliver mental health and psycho-
social service,
○ Protect the fundamental human rights of the people with psycho-social disability and
mental illness
○ Enhance public awareness to promote mental health and combat stigma resulting
from mental illness, and
○ Promote and manage health information system and research
18

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Nepal Tobacco Product Act, 2010
● Smoke Free Places- Smoking is prohibited on public transport and in a specified list of
public places, which includes most workplaces and public places
● Tobacco Advertising, Promotion and Sponsorship- The law generally prohibits all
tobacco advertising, promotion and sponsorship.
● Tobacco Packaging and Labeling- Health warnings are composed of both pictures and
text and cover 90 percent of the upper front, upper back, and two sides of smoked tobacco
product packaging and the upper front, upper back, and lids (where appropriate) of
smokeless tobacco product packaging
● Cigarette Contents and Disclosure- requires need for disclosure of information on the
contents and emissions of their products
● Sales Restrictions- sale of tobacco products is prohibited to persons under the age of 18,
cultural facilities, recreational facilities, and within 100 meters of educational facilities,
health facilities, among other places https://www.tobaccocontrollaws.org/legislation/country/nepal/summary

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National Oral Health Policy
● The primary aim of the National Oral Health Policy,2070 is the provision of high quality,
effective, basic oral health care to all of the people of Nepal
○ This includes the emphasis on promotive, preventive, curative and rehabilitative care
● The goal of the National Oral Health Policy is to prevent and control of the determinants of oral
disease and promote oral health amongst the Nepalese people.
NATIONAL STRATEGIC PLAN FOR ORAL HEALTH
● This plan identifies the priority national strategies to improve oral health for the nation and the
action plans needed to implement these strategies.
○ Oral health promotion
○ Affordable fluoridation of the mouth
○ Oral urgent treatment (emergency care)
○ Basic curative treatment using the Atraumatic Restorative Treatment approach
https://www.mohp.gov.np/downloads/National%20Oral%20Health%20Policy.pdf

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National Nutrition Policy and Strategy (2004)
Areas addressed
● 13 strategic nutrition approaches
○ Except for ‘the strategy for monitoring,’ 12 other strategic approaches are categorized
into:
21
Short term objectives Long term objectives
1. Protein-energy Malnutrition (PEM)
2. Iron Deficiency Anemia (IDA)
3. Iodine Deficiency Disorder (IDD)
4. Vitamin A Deficiency (VAD)
5. Intestinal Worm infestation
6. Low Birth Weight (LBW)
7. Infectious Diseases
8. Nutrition in Exceptionally Difficult
Circumstance
1. Household Food Security
2. Dietary Habit
3. Lifestyle Related Diseases
4. School Health and Nutrition

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National Nutrition Policy and Strategy (2004)
Basis for policy making
● Improving the nutritional status of people is,
○ one of the prime duties of the government
○ an essential factor in improving their health status and the quality of life
● Already many nutrition-related programs present in the country
● Important to clarify the strategies and the types of activities really necessary for each
program
● Useful in systematic and efficient implementation of various nutrition programs

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Nepal Health Sector Strategy (2015-2020)
Background
● Primary instrument to guide the health sector for the next five years, under the auspices of
National Health Policy 2014
● Adopts the vision and mission set forth by the National Health Policy
● Carries the ethos of constitutional provisions to guarantee access to basic health services
as a fundamental right of every citizen

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Nepal Health Sector Strategy (2015-2020)
Situation Analysis - Shifting Burden of Diseases and Health Problems
● Global Burden of Diseases Study estimates:
○ Nepal is facing increasing burden of NCDs and injuries
○ NCDs account for “more than 44% of deaths, 80% of outpatient contacts, and 39% of
DALYs lost.
○ Major NCDs in Nepal are cardiovascular diseases, diabetes, cancer, chronic
respiratory diseases, oral diseases, and mental disorders.
○ These burdens are further exacerbated by rising health care costs that have resulted
in high out-of-pocket expenditure (55% in 2008/09) despite of increasing
government expenditure on health.

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National Health Policy ( 2019 )
● The NHP 2019 has been formulated on the basis of the lists of:
○ Exclusive and concurrent powers and functions of federal, state and
local levels as per the constitution
○ Policies and programmes of the Government of Nepal
○ International commitments made by Nepal at different times
○ Problems, challenges, available resources and evidences in the health sector
● Problems in promoting and availing quality health services at all levels include:
○ Prevalence of health problems related to communicable and non-communicable diseases,
malnutrition, accidents and disasters
○ Increase in the burden of NCD and mental health problems generated from globalisation and
changes in food habits and lifestyles

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National Health Policy (2019)
● The new health policy has six objectives, 25 policies and 146 strategies to improve the
health sector of the country
● Policies related to NCD and its determinants

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Strategies for the Policy - 12:

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Strategies for the Policy -12

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Strategies for the Policy - 13:

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MSAP for Prevention and Control of NCD’s
(2021-2025)
Vision
Non-communicable disease free healthy and
productive citizen.
Mission
Raising the living standard of Nepalese by reducing
death from NCDs through the prevention and
control of non-communicable diseases
The evidences presented is linked with this policy in particular**

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Multi-sectoral Action Plan for the Prevention and Control
of NCD (2014 - 2020)
Vision
All people of Nepal enjoy the highest attainable status of health, well-being and quality of life at
every age, free of preventable NCDs, avoidable disability and premature death
Goal
The goal of the multisectoral action plan is to reduce preventable morbidity, avoidable
disability and premature mortality due to NCDs in Nepal
Targets
Inline with the SEAR NCD targets, Nepal has adopted 10 targets to be achieved by 2025

Reducing Tobacco
Consumption
(2021-2025)
01

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Tobacco Use
Basis for Policy Making
Source: Steps Survey 2019

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Trend in Tobacco Use
Tobacco use did not change
much between 2013 and 2019
either for smoked or smokeless
tobacco or among women or
men

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Tobacco
Evidence 1
Published Date: 2014
Journal: Pharmaceutical, Biological
and Chemical Science
Method Cross-sectional study conducted in Central Development Region to assess the
tobacco behavior and its association with blood pressure
Results Out of total respondents, 42.1% Male and 18.4% female respondents were currently
using tobacco. There was no significant relation between tobacco using habit and
systolic blood pressure but the relation observed between diastolic blood pressure
and tobacco habit. (p=<0.05).
Appraisal Higher prevalence of tobacco smoking and its relationship with diastolic BP can be
taken as a basis for policy making.
Adhikari K, Gupta N. Tobacco use: A Major Risk Factor for Non-Communicable Diseases in Central Nepal2014.

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Tobacco
Evidence 2 Published Date: 2019
Journal: Toxicology Research
Method A hospital-based age- and sex-matched case–control study was carried out with a
total of 612 respondents.
Results Current smokers and ex-smoker had an increased risk of CAD (OR: 6.64, 95% CI: 3.64
– 12.12; OR:1.89, 95% CI: 1.08 – 3.31) in comparison to never smokers
Appraisal The evidence suggests the need of taking actions for prevention and control of
tobacco use.
Basnet TB, Xu C, Mallah MA, Indayati W, Shi C, Xu J, et al. Association of smoking with coronary artery
disease in Nepalese populations: a case control study. Toxicology Research. 2019;8(5):677-85.

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Tobacco
Journal: International Journal
of Cancer
Method A case-control study was conducted in Nepal with 549 incident HNC cases and 601
controls.
Results Individuals who smoked tobacco, chewed products and drank alcohol had a 13-fold
increase in HNC risk (OR: 12.83; 95% CI: 6.91, 23.81) compared to individuals who
did not have any of these habits.
Appraisal Suggests preventive strategies against starting these habits and support for quitting
these habits are necessary.
Chang CP, Siwakoti B, Sapkota A, Gautam DK, Lee YA, Monroe M, Hashibe M. Tobacco smoking, chewing
habits, alcohol drinking and the risk of head and neck cancer in Nepal. Int J Cancer. 2020 Aug 1;147(3):866-875.
doi: 10.1002/ijc.32823.

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Tobacco
Intervention: Increase in taxation every year for all kind of tobacco products
Journal: BMJ
Method Review Study: Voluminous literature on tobacco taxes is assessed, drawing heavily
from seminal and recent publications
Results Significant increases in tobacco taxes that increase tobacco product prices encourage
current tobacco users to stop using, prevent potential users from taking up tobacco
use, and reduce consumption among those that continue to use, with the greatest
impact on the young and the poor.
Appraisal Policy is in alignment with the particular evidence
Chaloupka FJ, Yurekli A, Fong GT. Tobacco taxes as a tobacco control strategy. Tobacco control. 2012 Mar 1;21(2):172-80.

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Tobacco
Intervention: Increase in taxation every year for all kind of tobacco products
Evidence 2 Published Date: May 2020
Authors: Nepal Development Research
Institute, Government of Nepal
Method Review the cigarette taxation systems in six country case studies and, drawing
on these international experiences, make the case for a significant increase in
tobacco tax
Results Problem of tobacco taxes in Nepal is that taxes are very low to begin with
The taxation of tobacco products in Nepal is significantly below the WHO
standard of 70% of retail price.
An opportunity to increase taxes on cigarettes which will both decrease
consumption and increase government revenues
https://www.ndri.org.np/wpcontent/uploads/2020/11/Tobacco-Taxation-in-Nepal-What-can-be-done.pdf

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Tobacco
Intervention: Tobacco packaging with graphic warnings to 90% of the pack
Evidence 1
Journal: Tobacco Induced Diseases
Method Included studies that used an experimental protocol to assess PWLs. Studies had
to report findings for youth or young adult samples (aged <30 years).
Results PWLs led to higher attention, stronger cognitive and affective reactions, more
negative pack attitudes and smoking attitudes, and increased intentions not to
use tobacco products compared to text warnings. PWLs were perceived to be
more effective than text warnings for both cigarette packs and smokeless tobacco
packs.
Appraisal Policy is in alignment with the evidence
Francis DB, Mason N, Ross JC, Noar SM. Impact of tobacco-pack pictorial warnings on youth and young adults: a systematic review of
experimental studies. Tobacco Induced Diseases. 2019;17.

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Tobacco
Intervention: Tobacco packaging with graphic warnings to 90% of the pack
Evidence 2
Journal of Health and Allied Sciences
Method Community-based cross-sectional analytical with the quantitative method,
interviewed 389 adults (111 Quitters and 278 Smokers) of Kaski district
Results Nearly one-third of the participants (32.7%) had bought a single piece of tobacco
product, which is not allowed in Nepal. Only twelve percent of participants
wanted to quit or already quitted as s/he saw the PHWLs.
Appraisal The study doesn’t provide a compelling evidence for the policy action
Budha KB, Adhikari C, Gahatraj NR. Perceived Effectiveness of Pictorial Health Warning Labels of Tobacco Products and Associated Factors
among Smokers and Quitters in Kaski District, Nepal. Journal of Health and Allied Sciences. 2019 Dec 31;9(2):29-37.

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Tobacco
Intervention: Simple plain packaging in all tobacco products
Evidence 1
Journal: Frontiers in Public Health
Method Twelve focus group discussions (n = 124), stakeholder analysis with 24 officials and an
opinion poll with 346 participants were conducted between December 2011 and May
2012, Delhi.
Results The majority of participants perceived that plain packaging would reduce the appeal and
promotional value of the tobacco pack (>80%), prevent initiation of tobacco use among
children and youth (>60%), motivate tobacco users to quit (>80%), increase notice ability,
and effectiveness of pictorial health warnings on tobacco packs (>90%).
Arora M, Tewari A, Grills N, Nazar GP, Sonrexa J, Gupta VK, et al. Exploring perception of Indians about plain packaging of tobacco products: a
mixed method research. Frontiers in public health. 2013;1:35.

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Tobacco
Intervention: Banning Tobacco related Advertisement
Evidence 1 Published Date: May 2000
Journal of Health Economics
Method Prior studies examined more closely with several important insights
emerging from this analysis
Results The primary conclusion of this research is that a comprehensive set of
tobacco advertising bans can reduce tobacco consumption and that a
limited set of advertising bans will have little or no effect
Appraisal Evidence suggests comprehensive set of tobacco advertising bans for policy
action
Saffer H, Chaloupka F. The effect of tobacco advertising bans on tobacco consumption. Journal of health
economics. 2000 Nov 1;19(6):1117-37.

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Tobacco
Intervention: Enforcement of Law in Smoke free public places
Evidence 1 Published Date:2022
Journal: PLOS ONE
Method Cross-sectional study conducted in the Biratnagar metropolitan city, a total of
725 public places within the metropolitan city were surveyed
Results The overall compliance with smoke-free legislation was 56.4%. The highest
compliance (75.0%) was observed in Government office buildings. The lowest
compliance was observed in eateries, entertainment, and shopping venues
(26.3%).
Appraisal Evidence suggests enforcement of laws to increase compliance
Basnet LB, Budhathoki SS, Adhikari B, Thapa J, Neupane B, Moses T, Dhimal M, Pokharel PK, Ghimire A, Belbase D, Khatri S.
Compliance with the smoke-free public places legislation in Nepal: A cross-sectional study from Biratnagar Metropolitan City. Plos one.
2022 Mar 9;17(3):e0264895.

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Tobacco
Intervention: Enforcement of Mobile Health, National Toll Free Line and Helpline
Evidence 1
Journal: Cochrane
Method Systematic Review, included 26 randomised controlled studies (involving
over 33,000 people) that compared smoking quit rates in people who
received text messages or smartphone apps to help them quit, with people
who did not receive these programmes.
Results Found that text messaging programmes may be effective in supporting
people to quit, increasing quit rates by 50% to 60%.
Whittaker R, McRobbie H, Bullen C, Rodgers A, Gu Y, Dobson R. Mobile phone text messaging and
app-based interventions for smoking cessation. Cochrane Database of Systematic Reviews 2019, Issue
10. Art. No.: CD006611. DOI: 10.1002/14651858.CD006611.pub5

Alcohol Consumption
(2021-2025)
02

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Alcohol
Alcohol
consumption
Prevalence of current alcohol consumption(people who consumed alcohol
in the past 12 month) amongst all the adults was 23.9%. 20.8% of all
adults were current drinkers(consumed alcohol in past 30 days)
Pattern Province 2 and 5 had lowest prevalence of current alcohol consumption(11.5%
and 20.7%) compared to the national average of 23.9%. Province 3 had the
highest prevalence of current alcohol consumption, 33.2 %
The highest prevalence of current drinkers were in lowest wealth
quintiles(30%) and adults with no or less than primary education
Type Raksi(traditional home-brewed spirit) was the most consumed alcohol (50.9%),
followed by jaad (24.5%)and beer(16.8%)

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Alcohol
Heavy
episodic
drinking
Prevalence of HED increased with increasing age both in total population and
amongst current drinkers. 32.9% of adult in the age group 15-24 years indulged
in HED increasing to 38.6% among 55-69 year group.
Unrecorded
Alcohol use
76.3% of current drinkers in rural municipality consumed unrecorded alcohol
compared to 57.2% in metropolitan region.
In total population 14.3% of adults consumed unrecorded alcohol and amongst
the current drinkers 68.5% consumed unrecorded alcohol.
Alcohol
dependence
13.6% reported they were not able to stop drinking once started, 6.3% needed a
drink first thing in the morning and 8% adult failed to perform task that were
expected from them. The proportion of current drinkers that showed the three
signs of alcohol dependence generally increased with age was significantly
higher among men than women

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Alcohol
Harm to
others
In the total population 10.3% of adults reported being harmed due to someone
else’s drinking.
13.1% women reported facing family problems and problems with a partner
compared to 7.7% of the men.
Higher proportion of adults reported facing some harm due to someone else’s
drinking in rural municipality as compared to metropolitan/sub-metropolitan
area.
Alcohol
accessibility
Among adults who ever consumed alcoholic drink 88.2% found it easy or very
easy to obtain alcohol
Only 27.9% adults who ever consumed alcohol perceived that alcohol has
become less affordable than before.
None of the underage participants(15-18 years) who tried to buy alcohol
reported they were refused for alcohol due to their age.

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Alcohol
Exposure to
advertising
and
marketing of
alcohol
18.7% of adults reported seeing advertisements promoting alcohol on some
media platform.
More than 1 in 5 participants who attended social events as sports events,
concerts saw alcohol advertisement.
Exposure to
anti-alcohol
message
Nearly 1 in 2 (47.9%) adults reported seeing or hearing any message on one or
more media platforms, that discouraged consumption of alcohol.
50.2% of adults in age group 15-24 saw or heard messages, while only 41.5%
adult in the age group 55-69 years noticed these.

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Alcohol
Drink Driving Amongst the adults who drove vehicle in past 12 months, 3.9% reported being
checked by traffic police for drunk driving.
Proportion of adults driving under influence of alcohol decreases with
increasing age.
More adults from rural municipality drove under influence of alcohol and rode
with a driver who had consumed 2 or more drinks in the past 30 days as
compared to metropolitan/sub metropolitan region. (20.5% and 13.2% versus
9.9% and 8.6%)

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Alcohol
Intervention: Expansion of Anti Drink and Drive Campaign to 7 provinces
Journal: Frontiers in
sustainable cities
Method “Never Drink and Drive” campaign ran on media. Data collected from two
representative household surveys conducted among sample of adult drivers aged
18-55. n=751
Results After campaign participants demonstrated improved knowledge and attitudes
around drink driving laws and enforcement(OR=1.51, p<0.05), they were
significantly more likely to agree that would be caught by police for drink
driving(OR=12.66, p<0.1). Behavior also improved-post campaign participants
reported significantly lower rates of driving soon after drinking alcohol, compared
with pre-campaign participants.
Appraisal The policy of anti drink and drive campaign is aligned with the particular evidence.
https://www.frontiersin.org/articles/10.3389/frsc.2020.563350/full?journalName=Frontiers_in_Sustainable_Cities&id=563350

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Alcohol
Journal: BMC Public Health
Method 19 studies were included. Studies that evaluated the effect of mass media
campaigns for reducing alcohol impaired driving and alcohol related
crashes. Studies published between jan 1, 2002 to December 31, 2013 were
included
Results Studies that evaluated the impact of mass media independently showed
reduction more consistently, whereas results of studies that had concomitant
enforcement activities were more variable. Summary effects calculated from 7
studies showed no evidence of media campaigns reducing the risk of alcohol-
related injuries or fatalities(RR 1.00, 95% CI=0.94 to 1.06)
https://link.springer.com/content/pdf/10.1186/s12889-015-2088-4.pdf

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Alcohol
Evidence 3
https://www.unescap.org/sites/default/files/6.Do%20not%20drink%20
%26%20Drive-Nepal.pdf

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Alcohol
Intervention: Complete Ban on alcohol advertisement, promotion and
sponsorship
Evidence 1
Journal: Applied Economics
Method Economic model is used to examine the pooled time series data from
20 countries over 26 years.
Results Primary conclusion of this study was alcohol advertising bans decrease
alcohol consumption.
Appraisal Policy is in alignment with the evidence.
https://www.tandfonline.com/doi/abs/10.1080/00036840110102743

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Alcohol
Intervention: Complete Ban on alcohol advertisement, promotion and sponsorship
Evidence 1
Method Studies identified in 2006 with no date restriction. 7 Cohort studies (more than 13.000
young people aged 10-26 yrs)that evaluated exposure to advertising or marketing or
alcohol portrayals and drinking at baseline and assessed drinking behavior at follow-up in
yound people were selected reviewed.
Results Data from prospective cohort studies suggest there is an association between exposure to
alcohol advertising or promotional activity and subsequent alcohol consumption in young
people
Appraisal Bans should be endorsed and continued. However this intervention does not cover for the
unrecorded alcohol consumption in Nepal which has the highest proportion. So this
intervention should incorporate discouragement in use of unrecorded alcohol too.
https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-9-
51#:~:text=Conclusion,of%20residual%20or%20unmeasured%20confounding

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Alcohol
Intervention: Implementation of SAFER initiatives with necessary modification
Evidence 1
Method Systematic review of the literature to assess the effectiveness of
alcohol tax policy interventions for reducing excessive alcohol
consumption. 72 papers published prior to 2005 were included.
Results Nearly all studies including those with different study designs found that
there was an inverse relationship between the tax or price of alcohol and
indices of excessive drinking or alcohol-related health outcomes.
Appraisal This policy has link with the evidence.
Journal: American journal of
Preventive Medicine
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3735171/

Diet
(2021-2025)
03

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Diet
Intervention: Banning of advertisement of un healthy diet targeted to children
Evidence 1 Published Date: 2 July 2016
Journal: Springer(Current
Nutrition report)
Method Evidence review against Bradford Hill’s causality framework
Results The exposure to food marketing and children’s food behaviours, when
examined together, satisfies all key criteria commonly used to evaluate
causal relationships in epidemiology.
Appraisal Policy is in alignment with epidemiological evidence
10.1007/s13668-016-0166-6

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Diet
Intervention: Development of National low salt consumption strategy
Journal: CNS Neuroscience &
Therapeutics
Method Systematic review and meta-analysis of prospective or case–control
study published from 1966 to 2012.
Results High salt intake was associated with risk of stroke event (pooled odd ratio
[OR], 1.34; 95% confidence interval [CI], 1.19–1.51), stroke death (1.40;
1.21–1.63)
doi: 10.1111/j.1755-5949.2012.00355.x

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Diet
Intervention: Development of National low salt consumption strategy
Evidence 1 Published Date: 22 Jan 2020
Journal: The Journal Of Clinical
Hypertension
Method Cross-sectional study,
500 out of the 2815 total participants enrolled in the COBIN cohort using
systematic random sampling technique
Results In a multivariate analysis adjusting for all the available confounding
variables, for each 1 g increase in salt intake, systolic blood pressure was
predicted to increase by 0.3 mm Hg
https://doi.org/10.1111/jch.13813

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Diet
Intervention:Remove trans fat by using REPLACE package
Journal: Diabetes & Metabolic
Syndrome: Clinical Research &
Reviews
Method Review Articles
Results A 2% absolute increase in energy intake from trans-fat has been associated
with a 23% increase in cardiovascular risk
https://doi.org/10.1016/j.dsx.2019.03.033

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Diet
Intervention:Remove trans fat by using REPLACE package
Source: American Nutrition Association, The Heart Foundation
Source: STEPS Survey 2019

2/25/2024 64
Diet
Intervention: Awareness regarding adverse effect of Pesticides/Insecticides and
reduction in their use
Evidence 1
Journal:Research Journal of
Agriculture and Forestry Sciences
Method Reviews of articles
Results Increasing trend of pesticide consumption for agricultural purposes.
Fungicides are the major form of pesticide used in the country
http://heri.org.np/documents/A%20Review%20on%20Status%20of%20Pesticides%20Use
%20in%20Nepal.pdf

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Diet
Intervention: Awareness regarding adverse effect of Pesticides/Insecticides and
reduction in their use
Book: Comprehensive-Insights-in-
Vegetables Nepal(NAST)
Conclusion High frequency and cocktail spray of different pesticides were evident
while using pesticides, which are still exist. Poor safety measures and lack
of proper gears during pesticide application are one of the great concerns
that pose the pesticide applicators at great health risk
https://nast.gov.np/documentfile/Comprehensive-Insights-in-Vegetables-Book.pdf

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Diet
Evidence 1
Method
Results
Appraisal
https://nast.gov.np/documentfile/Comprehensive-Insights-in-Vegetables-Book.pdf

2/25/2024 67
Diet
Intervention: Promotion of consumption of fruits and vegetables tax and
trust policy development
Consumption of
Fruits and Vegetables
Average servings of fruits and vegetables consumed per day: 2(0.5
servings of fruits and 1.5 servings of vegetables per day)
Prevalence of in sufficient fruits and vegetables in take:: (<5 servings ~
400gms a day) 96.7% in adults (96.3% women,97% men)
Knowledge on
recommended intake
for fruits and
vegetables
Only 10.1% of adults reported the correct servings for recommended
fruits and vegetables in take per day(10.4% women,9.8%men)
Source: STEPS Survey 2019

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Diet
Intervention: Policy - Mother's Milk Substitutes (Control of Sale and Distribution) Act, 2049 (1992)
Evidence 1 Published Date: 01 February 2012
Journal: The American Journal of
Clinical Nutrition
Method Systematic Review(15 studies for inclusion in the systematic review and 11
studies for inclusion in the meta-analysis)
Results In formula- fed infants, fat-free mass was higher at 3–4 mo Compared with
breastfeeding, formula feeding is associated that at 12 mo, fat mass was
higher in formula-fed infants [0.29 kg (−0.03, 0.61 kg)] than in breastfed
infants
https://doi.org/10.3945/ajcn.111.027284

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Diet
Journal: The Journal of Childhood
Obesity(peer revied and open assess)
Method U.S. longitudinal data collected from 1234 children were analyzed using
logistic regression models and generalized estimating equation (GEE).
Results Regarding breastfeeding duration, more than 6 months (vs. never) was
associated with a decreased risk for childhood obesity by 42% (OR: 0.58,
95% CI: 0.36–0.94).
DOI: 10.1089/chi.2016.0210
Intervention: Policy - Mother's Milk Substitutes (Control of Sale and Distribution) Act, 2049 (1992)

Physical Activity
(2021-2025)
04

2/25/2024 71
Physical Activity
Intervention: yoga and physical activity in school curriculum
Evidence : Impact of Aerobic Physical Exercise on
Cardiovascular Health of In-school Adolescents of
Nepalgunj, Nepal
Manita Pyakurel et al
Published Date:.2013
Journal:Texila International
Journal of Public Health
Method:- This was an eight-week quasi-experimental design conducted by systematic
random selection of consenting 8 th and 9 th graders assigned into intervention
and control groups by odd and even number randomization, respectively
Results Impact of physical exercise on CVH-related parameters was significant for three
CVH related parameters of resting -HR (ES=0.56; p<0.001), BMI (ES=0.474;
p<0.05), DBP (ES=0.355; p<0.05). The study recommends that physical exercise
should be made part of school curriculum activities
Appraisal Recommends physical activity in school curriculum.
10.21522/TIJPH.2013.08.02.Art032

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Physical Activity
Intervention: Yoga and physical activity in school curriculum
Evidence” Physical activity and its correlates among higher
secondary school students in an urban district of Nepal
Kiran Thapa et al
Method:- Cross-sectional study, used Global Physical Activity Questionnaire (GPAQ), Data
from 945 high school students from 23 randomly selected schools were analyzed
Results The prevalence of low physical activity was 8% for males and 31% for females.
About 31% of the adolescents and 14% of young adults did not meet the WHO
recommendations of physical activity. Forty-seven percent of the total physical
activity was borne by recreational activities. Correlates of low physical activity
included school type and mode of transport among females, family support and
drinking among males, and playground/park around home among both
Appraisal Need to address other factors before implementation in school curriculum.
https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-019-7230-2

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Physical Activity
Evidence Results from Nepal’s 2018 Report Card on
Physical Activity for Children and Youth
Narayan Subedi et al
Published Date:2020
Journal: Journal of Exercise Science
& Fitness
Method:- Published scientific papers on physical activity of Nepalese children and youth (5-17
years) were searched systematically in four databases (Medline, Embase, PsycINFO,
and PubMed Central) while some survey reports were manually searched
Results Among the ten indicators, five indicators were successfully graded based on available
data. Overall Physical Activity was graded as D+. Active Transportation and Family
and Peers were assigned as A- and A, respectively. Community and Environment was
graded as C-.
Appraisal Need to promote physical activity in school.
https://doi.org/10.1016/j.jesf.2020.02.001

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Physical Activity
Evidence Role of Yoga Practices for Mental Health and
Learning Habits of Management Students
Lal Prasad Aryal
Published Date
Journal: The Harvest
Method:- The study was undertaken to the management students of five colleges in the mix
of Tribhuvan University (TU) and Pokhara University (PU), who were learning and
studying at Bachelor level at Kathmandu valley
Results Improving memorization, concentration, commitments and confidence that
ultimately helps in securing good marks in their up-coming examinations. Yoga can
help foster motivation, cultivate internal locus of control, improve sleep, and
generally encourage healthy and balanced living. counteract negative social and
cultural influences,
Appraisal Promotion of yoga in school is beneficial.
https://www.nepjol.info/index.php/harvest/article/download/44337/33450/130389

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Physical Activity
Intervention: Yoga and physical activity , open gym centres in community
Evidence Yoga for hypertensive patients: a study on barriers and
facilitators of its implementation in primary care
Raja Ram Dhungana et al
Journal: GLOBAL HEALTH
ACTION
Method The study was conducted using focus group discussions, in-depth interviews, key
informant interviews, and telephone interview
Results While there is a good potential that a yoga intervention can be implemented in
primary care, capacity development for health workers and the involvement of
community yoga centres in the delivery of the interventions may be required to
facilitate this implementation
Appraisal Suggests involvement of community yoga centres.
https://doi.org/10.1080/16549716.2021.1952753

2/25/2024 76
Physical Activity
Evidence Moving Bodies: Open Gyms and Physical Activity in
Santiago ,RODRIGO MORA
Journal: Journal of Urban Design
Method This paper analyzes the functioning of four recently installed open gyms—
gyms installed on squares and green spaces that can be used free of charge
by anyone—located in Providencia, a residential and commercial district of
Santiago, Chile
Results The results showed that the gyms were very successful in prompting people
to embrace physical activity, even those who were not regular exercisers.
Moreover, the exercise facilities are contributing to the revitalization of the
public spaces in which they are located.
Appraisal Open gyms promote physical activity in the community.
https://doi.org/10.1080/16549716.2021.1952753

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Physical Activity
Evidence Barriers and facilitators to physical activity among urban
residents with diabetes in Nepal
Shanti Kadariya et al
Published Date:2018
Journal: PLOS ONE
Method A descriptive cross-sectional design was adopted using a simple random
sampling of type 2 diabetic patients from two diabetes clinics at Lalitpur
and Kaski districts of Nepal.
Results High prevalence of physical activity among the urban Nepali diabetic
patients; 52% were moderately active and 28% highly active.Physical
fitness, strength and flexibility, better sleep at night, social interaction and
longevity, were identified as the major facilitators. Family responsibilities,
busy schedule and family discouragement were identified as barriers
against being physically active
Appraisal Focus on leisure time physical activities. https://doi.org/10.1371/journal.pone.0199329

2/25/2024 78
Physical Activity
Evidence Prevalence, patterns, and correlates of physical activity in
Nepal: findings from a nationally representative study using the
Global Physical Activity Questionnaire (GPAQ) Zeljko Pedisic et al
Method The data were collected using self-administered questionnaires in a nationally
representative sample of 4143 adults (66.5% females), comprised of both rural and
urban populations in Nepal. PA levels were assessed using the Global Physical
Activity Questionnaire (GPAQ).
Results Around 97% (95% confidence interval [CI]: 96-98%) of men and 98% (95% CI: 98-
99%) of women were found to meet the recommended levels of PA. A multiple
regression analysis showed that less self-reported total PA was associated with older
age, higher level of education, urban place of residence, never been married, being
underweight, and smoking in both sexes and with overweight and obesity in males
(p < 0.05 for all).
Appraisal Focus on occupational and leisure time physical activity.
https://doi.org/10.1186/s12889-019-7215-1

2/25/2024 79
Physical Activity
Intervention: Cycling promotion
Evidence Cycling Promotion and Non-Communicable Disease
Prevention: Health Impact Assessment and Economic Evaluation of
Cycling to Work or School in Florence ,Cristina Taddei et al
Published Date: , 2015
Journal: PLOS ONE
Method Health impact assessment and economic evaluation using a dynamic model over
a ten year period, Cycling to work or school in Florence, Italy
Results Increasing cycling modal share in Florence from 7.5% to about 17% (Scenario 1)
or 27% (Scenario 2) could decrease the incidence of type 2 diabetes by 1.2% or
2.5%, and the incidence of acute myocardial infarction (AMI) and stroke by 0.6%
or 1.2%. Within 10 years, the number of cases that can be prevented is 280 or
549 for type 2 diabetes, 51 or 100 for AMI, and 51 or 99 for stroke in Scenario 1
or Scenario 2, respectively. Average annual discounted savings for the SST are
estimated to amount to €400,804 or €771,201 in Scenario 1 or Scenario 2,
respectively.
Appraisal Cycling contributes in NCD burden. 10.1371/journal.pone.0125491

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Physical Activity
Intervention: Modern and traditional ways of physical activity programme
Evidence Effects of a health worker-led 3-month yoga intervention
on blood pressure of hypertensive patients: a randomised
controlled multicentre trial in the primary care setting
Raja Ram Dhungana et al
Method :Multicentric, two-arm, randomised trial conducted among hypertensive
patients in seven Ayurveda Health Centres in Nepal between March 2017 and
June 2018
Results Included all 121 study participants (intervention/control = 61/60) in the
primary analysis (52.1% males; mean ± SD age = 47.8 ± 10.8 years). The
difference in systolic blood pressure between the intervention group and the
control group was - 7.66 mmHg (95% CI: - 10.4, - 4.93). For diastolic blood
pressure, the difference was - 3.86 mmHg (95% CI: - 6.65, - 1.06). No adverse
events were reported by the participants.
Appraisal Yoga intervention effective in lowering high BP. https://doi.org/10.1186/s12889-021-10528-y

2/25/2024 81
Physical Activity
Intervention: Modern and traditional ways of physical activity programme
Evidence A STUDY ON THE IMPACT OF YOGA ON DAILY
YOGA PRACTITIONERS Mr Naranath Pandey
Journal: The Journal of Madhyabindu
Multiple Campus
Method Researcher went to various yoga centers and met the people who practice daily
yoga, and inquired about the causes and impact of yoga. significance of this
research is to study the physical and mental impacts of yoga on daily yoga
practitioners at yoga centers in Kawasoti Nawalpur.
Results The yoga impact on yoga practitioners is: Problems with thyroid or other throat
problems and anxiety, deconcentrating, fear and stress are cured cent percent,
headache or migraine problems are cured 70.59 percent. Of those with obesity,
54.16 percent found significant improvement, sleep apnea 66.66 percent found
improvement, muscle, joint, neck, and back pain are cured 29.16 percent.
Appraisal Positive effects of yoga on chronic illness. http://www.ijbnpa.org/content/11/1/39

Health Promotion
(2021-2025)
05

2/25/2024 83
Health Promotion
Intervention: Nationwide campaign on NCDs and its risk factors
Journal: BMJ Open
Method In-home interviews using a questionnaire based on the WHO STEPS. Recorded
blood pressure and took anthropometric measurements.
Results 20.1% were current smokers, 43.3% exhibited low physical activity.
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.
Appraisal Health promotion actitivites are apt against practice and knowledge
https://doi.org/10.1136%2Fbmjopen-2013-002976

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Health Promotion
Intervention: Nationwide campaign on NCDs and its risk factors
Evidence 1 Published Date: Oct 2010
Journal: Lancet
Method Reviewed the outcomes of mass media campaigns in the context of various
health-risk behaviours (eg, use of tobacco, alcohol, and other drugs, heart
disease risk factors, sex-related behaviours, road safety, cancer screening
and prevention, child survival, and organ or blood donation). Assessed what
contributes these outcomes, like concurrent availability of required services
and products.
Results Mass media campaigns can produce positive changes or prevent negative
changes in health-related behaviours across large populations.
Appraisal The proposed intervention is aligned with the evidence.
https://doi.org/10.1016/S0140-6736(10)60809-4

2/25/2024 85
Health Promotion
Intervention: Include NCDs and its risk factors in the curriculum
Evidence 1 Published Date: June 2019
Journal: Front. Public Health
Method Analysis of NCD risk reduction–related teaching content within the extant
curricula of undergraduate medical (MBBS) syllabus in India.
Results The new curriculum pays attention to the need for addressing NCD risk
factors and designing strategies for their prevention.
Appraisal The article does not says if the inclusion of NCDs in the MBBS curricula will
have any effect on reduction of NCDs and its risk factors.
https://doi.org/10.3389/fpubh.2019.00133

2/25/2024 86
Health Promotion
Intervention: Implement Health Promotional School Policy and Standards
Journal: IJ Env Res & PH
Method A series of cross-sectional online studies including five federal states and
5006 school principals (40.2% males, 50.8% females) from primary and
secondary public schools was conducted from 2013 to 2018.
Results Based on the results of this study, there is a need to support schools in their
capacity building for health (e.g., regular teacher training, cooperation with
local health services).
Appraisal The article talks more of support for schools but not of NCDs related
outcomes due to health propoting schools.
https://doi.org/10.1093/heapro/daw096

2/25/2024 87
Health Promotion
Evidence 2 Published Date: July 2015
Journal: Nursing & Midwifery
Research Journal
Method 25 high and senior secondary schools (13 gov and 12 pvt) were selected by
stratified random sampling from the list of schools. Observation rating scale
used through interviews and observations.
Results The most promising facilities which were available were student’s health
checkups in schools, health cards being maintained in schools, inter sectoral
coordination, health education and regular co-curricular activities in
schools and areas which need addressing were insufficient toilet facilities,
lack of drinking water facilities and not well maintained first aid kits and
poor transportation facilities.
Appraisal Health promoting schools are promosing. https://doi.org/10.1177%2F0974150X20150303

2/25/2024 88
Health Promotion
Journal: European Journal of
Pharm & Med Research
Method A cross sectional survey was conducted with school headmasters of all
public and private CBSE Schools in Maharashtra State (n =156). Data
analysis included descriptive statistics and Chi-square test.
Results Action plan of HPS was present in 57.9% (70) schools and oral health
education was 100% (121). Statistically significant (P value ≤ 0.05)
difference noted among public and private schools for family income, school
health policies for substance abuse, healthy tuck shop and food availability.
Appraisal The intervention proposed is aligned with the evidence.
https://www.academia.edu/32535327/ASSESSING_HEALTH_PROMOTION_ACTIVITIES_THROUGH_SCHOOL_HEAD_
MASTERS_PERSPECTIVES_CROSS_SECTIONAL_DESCRIPTIVE_STUDY_OF_CBSE_SCHOOLS_IN_INDIA

2/25/2024 89
Health Promotion
Intervention: Empower FCHVs to support community based NCDs activities
Journal: JAMA Netw Open
Method Community-based, open-label, 2-group, cluster randomized clinical trial
with a 12-month delayed control group design was conducted in 14
clusters of a semiurban setting in Western Nepal. Seven clusters were
randomized to the FCHV-delivered intervention in which 20 FCHVs
provided home visits 3 times a year (once every 4 months) for health
promotion counseling and blood glucose monitoring.
Results At 12-month follow-up, the mean fasting blood glucose decreased by 22.86
mg/dL in the intervention group, whereas it increased by 7.38 mg/dL in
the control group.
10.1001/jamanetworkopen.2020.35799

2/25/2024 90
Health Promotion
Intervention: Empower FCHVs to support community based NCDs activities
Journal: PLOS Global PH
Method The training program was part of a cluster-randomized trial of a 12-month
intervention to improve COPD outcomes in a semi-urban area of Western
Nepal
Results The findings of the pre- and post- test assessments showed a significant
improvement in FCHVs’ COPD-related knowledge from a median
(interquartile range) score of 12 (3–16) before to 21 (21–22) (p<0.001)
after the training program. The qualitative assessment revealed the
feasibility of FCHVs’ training on COPD and their acceptability to deliver the
intervention package within the community.
Appraisal The proposed intervention is aligned with the evidence. https://doi.org/10.1371/journal.pgph.0000253

2/25/2024 91
Health Promotion
Intervention: Prevent RHDs and initiate screening for Diabetes and CKDs
Journal: JNMA
Method A community-based screening on, 3218 people >= 20 years were assessed
by door-to-door survey in Dharan, Nepal.
Results Overweight, obesity, hypertension, diabetes and proteinuria were found in
20%, 5.0%, 38.6%, 7.5%, and 5.1% respectively. In the subset group,
Chronic Kidney Disease was detected in 10.6%. Multivariate analysis
indicated age (P < 0.0001) and diabetes (P = 0.027) as statistically
significant predictors for Chronic Kidney Disease.
Appraisal The proposed intervention is aligned with the evidence and
recommendation.
https://air.unimi.it/handle/2434/328261

2/25/2024 92
Health Promotion
Intervention: Establish MaPaSe centred Traffic and Safety Unit in Province
Journal: Science & Justice
Method A comparative study of drug and alcohol findings in various victim groups
(drivers of cars, vans or lorries, car passengers, motorcyclists, motorcycle
passengers, cyclists and pedestrians) between 2000 and 2006.
Results The results of 1047 cases indicated 54% of all victims were positive for drugs
and/or alcohol, with the highest percentage of positive findings occurring in
pedestrians (63%). Males between the ages of 17–24 were most likely to be
involved in a road traffic accident, ... alcohol and cannabinoids were the most
frequent substances across the victim groups.
https://doi.org/10.1016/j.scijus.2008.06.001

2/25/2024 93
Health Promotion
Intervention: Establish MaPaSe centred Traffic and Safety Unit in Province
Journal: Accident Analysis &
Prevention
Method A cross-sectional study was performed using a questionnaire and passive
breath test data to study the prevalence of drinking and driving and the
association of drinking and driving with background characteristics and
drinking patterns on two separate occasions.
Results ... after the passage of the new traffic law, there was a 45% decrease in
driver behavior with positive breathalyzer results.
https://doi.org/10.1016/j.aap.2012.06.011

2/25/2024 94
Health Promotion
Intervention: Strengthen the provision of 5 major risks of road safety
Journal: Traffic Injury
Prevention
Method A review and analyses of data in the literature, including from the World
Health Organization (WHO) and World Bank, and a review of lessons
learned from best practices in high-income countries.
Results The total number of deaths due to road accidents in the 24 Asian countries,
encompassing 56% of the total world population, is 750,000 per year
(statistics 2010). The loss to the economy in the 24 Asian countries is
estimated to around US$800 billion or 3.6% of the gross domestic product
(GDP).
Appraisal The intervention is aligned with the evidence. https://doi.org/10.1080/15389588.2015.1066498

Indoor Air Pollution
(2021-2025)
06

2/25/2024 96
Evidence 1
Journal: International Journal of
Environmental research and public
health
Method case-control study at the National Taiwan University Hospital from April 2018 to June 2019.
Results When we excluded the current smokers and adjusted for age, the adjusted odds ratios (ORs) were
2.22 for habitual cooking at home and 3.05 for indoor incense burning. In females, the adjusted
ORs were 5.39 for habitual cooking at home and 6.01 indoor incense burning. In pleural fluid, the
most important exposure biomarkers for lung cancer were naphthalene, ethylbenzene, and o-
xylene. Habitual cooking and indoor incense burning increased the risk of lung adenocarcinoma.
Appraisal It can be said that indoor air pollution can lead to severe diseases including cancer, and hence the
above activity is in line to evidence doi: 10.3390/ijerph19031164

2/25/2024 97
Journal: Nepal Health Research council
Method It was a cross sectional comparative study. In the study, the researchers compared the
health status of participants’ using cleaner fuel versus biomass fuel and ICS vs traditional
stoves.
Results Decrease in lung function capacity was found with increase in exposure to indoor air pollution, but
need to confirm in a prospective study. Furthermore, Lung function, hypertension, asthma like
symptoms were significantly associated with smoking habit, time of exposure to indoor air
pollution of participants (p value <0.01).
Appraisal It can be said that the activities that can prevent the indoor pollution have to be launched. And
hence this above activity is in line with the evidence.
http://nhrc.gov.np/wp-content/uploads/2017/06/Indoor-air-pollution.pdf

2/25/2024 98
Intervention: Initiate to ban activities for burning HC & solid waste at open
places
Evidence 1 Published Date: April 2014
Journal: Family and Community
Medicine
Method The study was conducted in Saudi Arabia, in selected locations of the hospital,
indicators measured for the period from 2011-2012 AD.
Results It was found that the out door air pollution (SO2, O3) emitted due to hospital waste
burning are affecting the indoor air spaces.
Appraisal The only way this intervention in national policy can be justified is that outdoor
pollutants also effect indoor spaces.
doi: 10.4103/2230-8229.128778

2/25/2024 99
Intervention: Helping for the promotion and use of clean energy like hydro
and other renewable energy (piloting and scaling up)
Evidence 1
Journal: Environmental health
perspective
Method Data are from India’s second National Family Health Survey (NFHS-2) conducted in 1998–1999. NFHS-
2 collected demographic, socioeconomic, and health information from a nationally representative
probability sample of 92,486 households
Results Results from a study among elderly men and women (age ≥ 60 years) showed higher prevalence of
asthma in households using biomass fuels than those using cleaner fuels. As compared to men, the effect
of cooking smoke on asthma was greater among women after adjustment.
Appraisal This evidence suggests that there is need of preventing the indoor air pollution through the production
and consumption of clean energy at home level. Hence, this study supports our activity.
doi: 10.1289/ehp.5559

2/25/2024 100
Intervention: Helping for the promotion and use of clean energy like hydro
and other renewable energy (piloting and scaling up)
Journal: Global Health action
Method This cross-sectional study was conducted among 900 non-smoking women aged
above 30 years, from 45 rural villages of Tiruvallur district of Tamilnadu in Southern
India in the period between January and May 2007.
Results Higher prevalence of COPD among biomass fuel user than clean fuel users. It also
found that the prevalence was two times higher in women spending more than 2 hr a
day in cooking.
Appraisal This evidence suggests that there is need of preventing the indoor air pollution
through the production and consumption of clean energy at home level. Hence, this
study supports our activity.
DOI: 10.3402/gha.v4i0.7226

Health System
Strengthening
(2021-2025)
07

2/25/2024 102
Health system strengthening
Intervention: Reviewing the present PEN package program and updating
Journal: Health Systems &
Reform, Vol. 2 (2016), No. 1
Method A hybrid model, with a decision tree and Markov models, was constructed to reflect the
current service provision for the PEN interventions, focusing on diabetes and hypertension
screening and treatment
Results PEN policy yields the highest health benefit. Study done in Indonesia demonstrates that
with the budget currently invested in the program, the changes proposed will result in
improvements on the current low uptake and poor coverage, thus yielding cost savings for
the government and a possibility to reallocate resources to the country’s priority health
concerns, consequently leading to better health outcomes.
Appraisal The activity set here in the document is in line with the evidence
https://doi.org/10.1080/23288604.2015.1124168

2/25/2024 103
Evidence 2
Author: WHO
Method This study is the retrospective evaluation of the implementation of the PEN protocols
during 12 months in FMCs in Bishkek, using existing sources of data that are routinely
collected. The evaluation included two periods (one year before PEN implementation
and one year after it) and two randomly selected groups of FMCs (PEN and non-PEN).
Results The study concludes that either the implementation of the PEN protocols in
Kyrgyzstan is effective and the design of the pilot and evaluation quality of data were
unable to detect it, or that the current implementation model is ineffective.
Appraisal The intervention in the policy is not in alignment with the particular evidence.
https://www.euro.who.int/__data/assets/pdf_file/0007/337498/PEN-report-2017-
Kyrgyzstan-FINAL-ENG.pdf

2/25/2024 104
Evidence 2
Published Date: April–June 2014 | 3 (2)
Journal: WHO South-East Asia Journal of Public Health
Method All health institutions of Paro (one district hospital and three basic health units [BHUs]) and
Bumthang districts (one district hospital and four BHUs), were included in the PEN pilot
assessment study. All patients who had presented to the clinics in the pilot districts from 1 June
to 31 August 2012 constituted the study population.
Results Among 444 who had three follow-up visits, had declined from 13% to 7.3%. Among 400 persons
with hypertension, use of medication increased and high blood pressure declined from 42.3% to
21.5%. Among 115 persons with diabetes, use of anti-diabetes medication increased and high
blood sugar declined from 68/100 to 51/100. Implementation of the PEN intervention in the
primary health-care setting of Bhutan led to improvement in blood pressure and diabetes
control, and reduction in CVD risk.
Appraisal As the study shows positive effect of PEN package interventions in primary health care settings,
incorporating PEN program effective implementation in the national context seems relevant

2/25/2024 105
Intervention: Initiating the HPV vaccine in Nepal and scaling up through the sustainable
financing
Journal: The Lancet Oncology
Method A multicentre, cluster-randomised trial designed to compare the efficacy of two versus
three doses of quadrivalent HPV vaccine among unmarried girls aged 10–18 years in
India initiated recruitment on Sept 1, 2009.
Results Vaccine efficacy against persistent HPV 16 and 18 infection among participants
evaluable for the endpoint was 95·4% in the single-dose default cohort (2135 women
assessed), 93·1% in the two-dose cohort (1452 women assessed), and 93·3% in three-
dose recipients (1460 women assessed).
Appraisal This finding suggests that the vaccine efficacy for HPV is nearly 95.%. So, initiative HPV
vaccine in Nepal is well justified by this study.
https://doi.org/10.1016/S1470-2045(21)00453-8

2/25/2024 106
Intervention: Initiating the HPV vaccine in Nepal and scaling up through the sustainable financing
Evidence 2
Journal: Vaccines
Method Review Article
Result The notable decrease of HPV 6/11/16/18 among vaccinated women compared with
unvaccinated women shows the vaccine to be highly effective. Moreover, the direct effect of
the vaccine with the cross-protection of bivalent and quadrivalent vaccines results in the
reduction of HPV 6/11/16/18/31/33/45/52/58. HPV vaccination has been shown to
provide herd protection as well.
Appraisal This finding of review article shows that the vaccine its sustained use has good amount of
evidence to apply it at community level.
Kamolratanakul, S.; Pitisuttithum, P. Human Papillomavirus Vaccine Efficacy and Effectiveness
against Cancer. Vaccines 2021, 9, 1413. https://doi.org/ 10.3390/vaccines9121413

2/25/2024
10
7
Intervention: Initiating the HPV vaccine in Nepal and scaling up through the sustainable
financing
Journal:Journal of Vaccines &
Vaccination
Method A systematic review of cost-effectiveness studies including only countries with high CC(Cervical cancer)
incidence (>14.5) and GDP per capita below the high income group
Results The current vaccines protecting against HPV-16 and HPV-18 may prevent up to 70% of new cervical
cancers. Vaccine cross-reactivity for HPV-31, -33, -45, and -52 suggest that an even higher percentage of
cervical cancers might be prevented with its use.
After excluding outliers, six studies showed a range of incremental cost-effectiveness ratios between
$16,600 and $27,231, with a median value of $25,400 or $25,903. These ICERs included only the benefit
from preventing HPV genotypes 16 and 18.
Appraisal So, initiative HPV vaccine in Nepal can be well justified by this study. DOI: 10.4172/2157-7560.1000172

Mental Health
(2021-2025)
08

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Different types of stress
Source: STEPS Survey, 2019

2/25/2024 110
Mental Disorders
• Among the adult participants, 10% had any mental disorder in their
lifetime and 4.3% currently had any mental disorder.
• Lifetime and Current Mood disorders among adult participants were
found to be 3% and 1.4% respectively.
• Prevalence of suicidality was found to be 7.2%.
• Current suicidal thoughts and lifetime suicidal attempts were found to
be 6.5% and 1.1% respectively.
Source: National Mental Health Survey Nepal 2020

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Mental Health
Journal: Drug and Alcohol
Dependence
Method A three-stage cluster sampling design was used to randomly select 513
adults from three of the most heavily earthquake-affected districts in Nepal.
Results Among only those who reported ever drinking (36.1% of the sample),
56.6% drank at hazardous levels. Among those who met criteria for
hazardous alcohol use, 37.8% met criteria for depression, 35.3% for
anxiety, and 3.2% for PTSD
Appraisal The evidence suggest that interventions that address both alcohol and
mental health problems are warranted.

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11
2
Mental Health in STP for BHSP 2078

Oral Health
(2021-2025)
09

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Oral Health
● The primary aim of the National Oral Health
Policy,2070 is the provision of high quality,
effective, basic oral health care to all of the
people of Nepal
● The goal of the National Oral Health Policy is to
prevent and control of the determinants of oral
disease and promote oral health amongst the
Nepalese people.
114

2/25/2024 115
Oral Health
Evidence 1
Journal: JNMA
Method The study was conducted from December 2007 to May 2008. The age of the
school children of the study was divided into two group: 5 - 6 years and 12 - 13
years. A stratified cluster sampling with proportional allocation was used while
grouping the subjects.
Results The caries status was found higher in the age group of 5 - 6 years than in the 12 -
13 years and it was found to be statistically significant (p < 0.001). The dmfs and
caries percentage of the age group 5 - 6 years and the DMFS and caries percent of
the 12 - 13 years was found to be 3.79, 69 % and 1.6, 53.23 % respectively.
Appraisal The caries percentage was found to be above the recommended level of the World
Health Organization. There is burden of dental caries in context of Nepal which
suggests the need of policy actions to address it.
https://pubmed.ncbi.nlm.nih.gov/22922897/

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Oral Health
Evidence 1
Journal: Nepal Med Coll J
Method Data was collected using a pretested questionnaire on 131 schoolchildren aged
8-16-year- olds attending Grade 3-5. Clinical examination was conducted on 361
school children aged 5-16 -year-olds attending grade 1-5.
Results Caries prevalence for 5-6 -year-old was above the goals recommended by WHO
and Federation of Dentistry international (FDI) of less than 50% caries free
children. Caries prevalence in 5-6-year-olds was 52% and 12-13-year-olds was
41%. The mean dmft/DMFT score of 5-6 -year-olds and 12 -13-year -olds was
1.59, 0.31 and 0.52, 0.84 respectively.
Appraisal Caries prevalence of 5-6 -year- old Chepang school children is above the
recommended target set by FDI/WHO. There is burden of dental caries in context
of Nepal which suggests the need of policy actions to address it.
https://pubmed.ncbi.nlm.nih.gov/23672487/

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Oral Health
Evidence 1
Journal: BMC Oral Health
Method Cross-sectional house to house survey was conducted on 310 randomly selected
participants. The participants were stratified into five age groups as per WHO
Basic Oral Health Survey Methods 1997 and further categorized by gender.
Results Most of the participants were from low socioeconomic background (71.3%).
About 40% of the participants deferred dental visit due to financial burden.
Although 99% of the participants brushed their teeth, there was high caries
experience (DMFT: 3.18 ± 5.85; dft: 2.40 ± 2.65). Mean sextant score for bleeding
was 5.58 in 35–44 years age group and 5.61 in 65–74 years age group.
Appraisal The prevalence of dental caries, periodontal diseases, and prosthetic needs were
more compared to national data. There is a need for oral health promotion which
suggests the need of policy actions to address it.

Other NCD of
concern
Not addressed by MSAP for Prevention and
Control of NCD’s (2021-2025)
09

2/25/2024 119
Rheumatic heart disease
Journal: ResearchGate
Method Clinical survey conducted by examining team in selected school and
answering the standard questionnaire. 9420 students(4466 male and
4954 female) included.
Results Prevalence of Rheumatic heart disease and congenital heart disease was
found to be 1.2/1000 and 1.3/1000.
Appraisal There is burden of RHD in context of Nepal which suggests the need of
policy actions to address it.
https://www.researchgate.net/profile/Man-Bahadur
Kc/publication/7540958_Prevalence_of_Rheumatic_and_Congenital_Heart_Disease_in_Schoolchildren_of_Kathma
ndu_Valley_in_Nepal/links/5f3536f6458515b7291c1787/Prevalence-of-Rheumatic-and-Congenital-Heart-Disease-in-
Schoolchildren-of-Kathmandu-Valley-in-Nepal.pdf

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Rheumatic heart disease
Evidence 1
Journal: Nepalese Heart Journal
Method Cardiac screening of 34,876 school children from 115 randomly selected public schools
from two cities of Kathmandu Valley (Kathmandu and Lalitpur) was done. Cases with
abnormal findings in auscultation underwent echocardiography and the diagnosis was
confirmed.
Results The prevalence of Congenital Heart Disease was noted to be 1 per thousand and
prevalence of Rheumatic Heart Disease was found to be 0.90 per thousand (in the age
group 5-16 years) with the most common lesion being
Mitral Regurgitation.
Appraisal Primary and secondary prevention programs of RF/RHD have been effective in Nepal
and are needed to be strengthened and expanded to further reduce the burden of these
diseases.
https://www.nepjol.info/index.php/NHJ/article/view/9738

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Musculoskeletal disorders
Evidence 1
Journal: International journal
of surgery
Method Country wide survey using SOSAS(surgeons overseas assessment of surgical needs)
in May-June 2014. 1350 household surveyed with 2695 respondent(1434 Males and
1261 females).
Results Musculoskeletal disease prevalence was found to be 14.8%. Estimated prevalence of
traumatic MSD was 8.7% and non-traumatic MSD was 6.2%. Based on this study
there are approximately 2.35 million people living with MSDs in Nepal.
Appraisal There is burden of Musculoskeletal disorders which suggests the need to address
this issue in the national NCD
Chawla SS, Khanal S, Ghimire P, Nagarajan N, Gupta S, Varadaraj V, Nwomeh BC, Kushner AL. Musculoskeletal disease in Nepal:
a countrywide cross-sectional survey on burden and surgical access. International journal of surgery. 2016 Oct 1;34:122-6.

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Critical Analysis of NCD Action Plan
• Guiding document to implement all the NCD related activities by multi-stakeholders and
contains broad strategic actions and key milestones to be achieved within a specified time
frame
• Inclusion of three additional disease/condition (road safety, oral health and mental health)
and one additional risk factors (indoor air pollution) to make plan some what contextual.
• Large proportion of NCDI burden bear by factors unattributed to GBD risk factors, but
inadequate program emphasis on dealing with such factors
• Most interventions have been focused on behavioral and metabolic risk factors, however
without addressing the underlying drivers of NCD improvement in NCD status cannot be
achieved

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Critical Analysis of NCD Action Plan
• NCD Action Plan incorporates component of mental health and oral health. However specific
action plans as in reducing tobacco, alcohol consumption and unhealthy diet are not given.
• Interventions related to indoor air pollution seems to be vague and mostly includes
dimensions of overall air pollution. It would have been better if action plans specific to
reducing indoor air pollution were also mentioned.
• Since, NCD intervention outcomes are not achieved at short run, difficult to obtain sustained
political commitment

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Conclusion
• Linking evidence to policy is a continuous ongoing process as further
research develops and new innovation comes through. Thus, evidences can
be linked with policy before, during or even after policy formulation.
• Most interventions and policy actions are in alignment with evidences
from international studies and research
• However, there are limited epidemiological evidences in context of Nepal
• Community-based studies of NCDs in Nepal are limited to a few risk
factors, have small sample size, are mostly cross-sectional in design, and
often lack laboratory investigation
• Increasing calls for epidemiological study combined with implementation
study to address NCDs in context of Nepal

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