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

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