Search

Ammonia (NH 3 ) is the most abundant alkaline gas in the atmosphere, mainly emitted by agricultural activities. NH 3 readily reacts with other atmospheric acidic pollutants, such as the oxidation products of sulfur dioxide (SO 2 ) and nitrogen oxides (NOₓ), to create fine particulate matter, which has far-reaching effects on human health and ecosystems. Here, we investigated long-term atmospheric NH 3 trends in South Asia (SA) using satellite observations from the Infrared Atmospheric Sounding Interferometer (IASI). We analyzed 15 years (2008-2022) of IASI-NH 3 retrievals against climate, biophysical, and chemical variables using an ensemble of multivariate statistical methods to identify the major factors driving the observed patterns in the region. Trend analysis of IASI-NH 3 data reveals a significant rise in atmospheric NH 3 over 51 % of SA plains, but a downward trend over 31 % of the region. Spatial correlation analysis reveals that biophysical factors, representing cropland expansion and agriculture intensification, have the highest positive correlation over 56 % of SA plains experiencing positive NH 3 trends. However, our results reveal that the chemical conversion of NH 3 to ammonium compounds, driven by the positive trends in NOₓ and SO 2 pollution, is driving the apparently declining trend of NH 3 in the other regions. Our results provide important insights into the NH 3 trends detected by satellite data and can better inform the policy design aimed at reducing NH 3 emissions and improving air quality for developing regions of the world., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Individuals' coping differs based on sociocultural determinants and the nature of illness. This study developed a coping typology for South Asians with chronic illnesses and differentiated the coping profiles based on sociocultural determinants. Individuals (n = 384) with chronic illness were recruited. The Brief COPE scale was used for data collection and latent profile analysis for typology development. The class differences were examined in terms of age, gender, socioeconomic status, education, type of family, smoking, primary decision maker in the family, type of community, number of years living with chronic illness and type of health care services used. Latent profile analysis supported four class model: Avoider-Emotion (n = 34, 9%), Problem-Emotion (n = 128, 33.9%), Problem-Avoider (n = 55, 14.6%) and Emotion-Avoider (n = 161, 42.6%) copers. Comparison of classes across chronic illness showed that individuals with chronic respiratory disorders were Emotion-Avoider and Avoider-Emotion copers, those with cardiac problems were Problem-Emotional and Problem-Avoiders copers, those with renal problems were Emotional-Avoiders and Problem-Emotions copers, and individuals with mental health issues were mainly Problem-Emotional and Emotion-Avoider copers. These class differences were statistically different (χ 2  = 134, df = 18, p < .001). The findings can be useful for developing coping programmes for South Asian populations in low- and middle-income countries and South Asian immigrants., (© 2024 International Union of Psychological Science.)

The reliance on replacement blood donors in developing countries has led to an increased prevalence of transfusion-transmitted infections (TTIs), including HIV. This systematic review and meta-analysis aimed to assess the seroprevalence of HIV among blood donors in South Asian countries and disseminate the findings in choropleth maps. In addition, gender-specific prevalence or the yearly trend of HIV prevalence among blood donors was also investigated. Following the PRISMA guidelines, we searched PubMed, Scopus, CAB abstracts, CINAHL, and Google Scholar for articles published between January 2000 and December 2022. The DerSimonian-Laird effect model was used due to the high heterogeneity of the data. Data analysis was performed using R Studio version 4.1.0, ArcGIS, and GraphPad Prism 7.0. The pooled seroprevalence of HIV among blood donors in South Asian countries was found to be 0.13%, with the highest prevalence of 0.19% in India and the lowest prevalence of 0.02% in Bangladesh and Bhutan. Female blood donors had a higher seroprevalence than their male counterparts (0.24%, vs. 0.17%). In contrast to voluntary blood donors with an HIV seroprevalence of 0.13%, replacement blood donors have a higher HIV prevalence of 0.26%. The observed high heterogeneity was attributed to variations in country, gender, type of blood donors, and study year. This study demonstrates a significant burden of HIV among blood donors in South Asia, emphasizing the need for enhanced donor screening protocols, targeted interventions and educational campaigns to ensure the safety of blood transfusion services. Future research should explore additional risk factors and focus on expanding screening methods, particularly in resource-limited settings., Competing Interests: Declarations. Conflict of interest: The authors do not have any conflict of interest., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

South Asia is a global hotspot of air pollution gaining attention due to its severe implications, in which atmospheric mercury (Hg) could cause detrimental health effects in metropolitan areas. In this study, first-time year-round (January - December 2019) mean total gaseous mercury (TGM) concentration at Kathmandu, Nepal - a sub-tropical city in South Asia was reported at 9.9 ± 10.0 ng m -3 . Seasonal TGM variation at Kathmandu showed highest concentration in winter (16.8 ± 16.9 ng m -3 ) and lowest in summer (2.9 ± 2.1 ng m -3 ). Generally higher daytime TGM concentration as opposed to night-time TGM indicated Hg build-up within atmospheric boundary layer due to low wind speed and high humidity. Events with high wind speed (> 30 m s -1 ) induced regional pollutant transport from nearby brick kilns and cement factories. Principal component analysis associated a major part of TGM with PM 2.5 and CO and indicated the remarkable influence of fuel combustion and vehicular emissions. Backward trajectory and potential source contribution factor analysis further indicate the impact of regional Hg emissions and transboundary emissions from India towards Nepal, which expands beyond the Himalayas and the Tibetan Plateau. Prominent low-grade coal burning and kilning activities in winter spiked up TGM concentrations, resulting in the highest health quotient (HQ = 0.24) value, which could significantly impact public health. Our study presented the most comprehensive set of continuous annual atmospheric Hg monitoring data from Nepal in the South Asian region. The results serve as a baseline for regional atmospheric Hg levels and offer a critical reference for assessing and addressing air pollution concerns in Nepal as well as throughout South Asia., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier B.V.)

Background: South Asians are known for their increased predisposition for type 2 diabetes (T2D). We describe the most recent prevalence and trends of diabetes, prediabetes, and undiagnosed diabetes in South Asia based on surveys conducted from 2000 to 2024., Methods: A comprehensive search was conducted in PubMed, Web of Science and Scopus databases for population-based studies describing diabetes/prediabetes prevalence. Including STEPS surveys, 7261 records were screened for eligibility, of which 89 were included in this analysis. Prevalences and trends of diabetes, undiagnosed diabetes and prediabetes were analysed by country, making male/female and urban/rural comparisons., Results: Prevalence of diabetes in South Asia has increased from 11.29 % in 2000-2004 to 22.30 % in 2020-2024. Sri Lanka and Pakistan have demonstrated a steep rise in diabetes over the two decades. India and Bangladesh, have also shown a rise in prevalence from 2.5 % (2015-16) to 8.1 % (2019-21) and 5.5 % (2006) to 8.3 % (2018), respectively. Diabetes prevalence among males was higher. Urban prevalence was higher than rural throughout the region, with both sectors showing a rising trend. Prediabetes followed a similar pattern. Despite the high burden, a large proportion remained undiagnosed, being as high as 17.5 % in Delhi, India (2010-11)., Conclusion: Pooled prevalences show a rising burden of diabetes over the past decade, with a considerable proportion being undiagnosed, in South Asia. Urban prevalence is higher than rural prevalence throughout the region. Prediabetes also shows a similar rising trend, with a notable proportion o being undiagnosed, alerting the need for coordinated efforts for early diagnosis, and prevention., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Research Trust of DiabetesIndia (DiabetesIndia) and National Diabetes Obesity and Cholesterol Foundation (N-DOC). Published by Elsevier Ltd. All rights reserved.)

Background: Psychological phenomena such as impostor phenomenon (IP) and low work-related satisfaction increase the risk of burnout among medical professionals. The prevalence of these contributory risk factors among South Asian medical professionals has not been examined thus far. This study aims to assess the prevalence, severity and associations of IP, including self-reported satisfaction with training, in a cohort of postgraduate doctors in Sri Lanka., Methods: This cross-sectional study was conducted among medical and surgical postgraduate trainees enrolled at Post Graduate Institute of Medicine, University of Colombo. A self-administered questionnaire including the Clance Impostor Phenomenon Scale was used for data collection. SPSS version 26 was used for analysis, and associations were analysed using Chi Square and logistic regression., Results: The response rate was 75.3% (n = 201). Of the study population, 9% (n = 18) experienced few impostor characteristics, 51.7% (n = 104) experienced moderate impostor characteristics, 38.8% (n = 78) experienced frequent impostor characteristics and 0.5% (n = 1) experienced intense impostor characteristics. The mean IP value was 55.55 (SD-12.03), in the category of moderate IP. Significant associations were seen between IP and sociodemographic factors of being single, lack of friendships outside medicine and improvement in financial status related to medical profession (p < 0.05); academic factors such as satisfaction with pursuing postgraduate training and satisfaction with academic performance (p < 0.05); work-related factors such as early stages of postgraduate training, lack of confidence in communicating with superiors and other specialties, receiving criticism from the team and sense of guilt regarding patient outcomes (p < 0.05). Self-reported satisfaction with postgraduate training was expressed by 79.1% (n = 159) of trainees, with 59.2% (n = 119) self-reporting poor work-life balance. Self-reported satisfaction with training was associated with satisfaction with chosen specialty, self-reported satisfaction with academic performance, good work-life balance, confidence in interpersonal interactions, financial stability and family support (p < 0.05)., Conclusions: A significant number of Sri Lankan medical and surgical postgraduate trainees experienced IP. This phenomenon is significantly associated with sociodemographic, academic and work-related factors. Self-reported trainee satisfaction with postgraduate training was high and associated with positive psychosocial factors., Competing Interests: Declarations. Ethics approval and consent to participate: Ethics approval was obtained from Faculty of Medicine, University of Colombo (EC-23-057). Consent for publication: Consent for participation was taken from all study participants. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

With a significant proportion of the population facing considerable deficits in access to health care and financial protection, progress toward universal health coverage (UHC) continues to be a challenge in South Asia. The objective of this scoping review is to examine the challenges and opportunities for UHC in South Asia. We used the six-stage Arksey and O'Malley methodological framework for investigation and the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews checklist to structure and report the review. A systematic search retrieved 2776 records from three databases and 13 gray literature sources, of which 27 records were reviewed. Frequently emerging challenges include underfunding of the health system, the nascent stage or inadequate coverage of the social protection or insurance system, fragmentation in the health system, the inability to effectively regulate the private sector, a health system that is unprepared to effectively address non-communicable diseases, and concerns about the quality of and equality of access to health care. While a diversity of challenges, mostly driven by the country-specific context, continue to falter progress toward UHC in the South Asia region, several consistent themes emerge. Considering this as an initial attempt to map the existing literature, we recommend future research to examine how the challenges and priorities evolve over time., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Despite the considerable health and economic burden of disability in the South Asian (SA) region, there is limited evidence of impairments and disabilities prevalence and the need for Assistive Technologies (ATs). This scoping review aims to synthesise the evidence of the impairments and disabilities in SA countries. This review followed Arksey and O'Malley's methodological framework. EBSCOhost, EMBASE, PubMed, and Web of Science databases were searched for original research articles from SA countries. In this study, impairment and disability refer to functional limitations restricting individuals from performing activities, including visual, hearing, speaking, cognitive, mobility, and self-care difficulties. The review included full-text, English-language articles addressing any impairment and disability, without restrictions on publication date. This review identified 105 articles distributed over the six impairment and disability domains: visual, hearing, mobility, self-care, speaking, and cognitive. Most evidence originated from India (50.5%) and focused on visual impairments (53.3%). The review identified that heterogeneity in methodologies, case identification definitions, and study settings contributed to variations in prevalence estimation and restricted the comparability within and across countries. Besides, the uneven distribution of studies across countries suggests varying inclinations of countries toward specific impairment and disability domains. The review identified variations in prevalence due to differences in methodologies, definitions, and contexts. The review also identified the uneven distribution of studies, limited evidence on ATs, reliance on self-reported data, and lack of nationally representative research. Future research should use standardised case identification and evidence-based approaches to enhance comparability and minimise response biases.

Introduction: There are limited data on the prevalence of cardiovascular risk factors/diseases (diabetes, obesity, hypertension, and dyslipidemia) and their composite scores reflecting overall cardiovascular health among young (< 50 years old) married couples., Methods: We have an established longitudinal prospective cohort of postpartum women with a history of hyperglycemia [pre-existing diabetes (PED; n = 101), overt diabetes in pregnancy (ODiP; n = 92), gestational diabetes (GDM; n = 643)], and normoglycemia (n = 183) in pregnancy and their spouses (n = 819). In this study, we report data from baseline cross-sectional evaluation of these 819 young couples regarding the burden of cardiovascular risk factors/diseases, their concordance and associations., Results: The mean (SD) age was 33.5 (4.9) years for women and 36.9 (5.4) years for men, and the evaluation was performed at a median (IQR) postpartum interval of 30 (20-45) months. Diabetes, hypertension, obesity, and dyslipidemia were present in 25.0%, 6.9%, 25.6%, and 4.0% of women and 15.8%, 20.2%, 14.3%, and 8.2% of men, respectively. Among men, dysglycemia (diabetes/prediabetes) and adverse cardiovascular score (average/poor) showed a significant trend in progression according to the antenatal categories of their partner (highest in DIP, intermediate in GDM, and lowest in normoglycemia). The concordance was higher for adverse cardiovascular score (58.5%), overweight/obesity (48.7%), and dysglycemia (42.4%) compared to prehypertension/hypertension (29.2%) and hypercholesterolemia (8.2%). The odds ratios were significant for all associations evaluated, except for elevated blood pressure, being strongest (OR > 2.0) for overweight/obesity and adverse cardiovascular score., Conclusions: Nearly three in five young couples evaluated in the study showed concordance for adverse cardiovascular scores. The cardiovascular risk in men increased in a graded manner across the increasing severity of antenatal glycemic categories of their partners., (© 2024. The Author(s).)

Objectives: Although medication abortion drugs technically require a prescription in India, research suggests that they are often available directly from pharmacies. We conducted a mystery client study in the capital city of Delhi to explore the availability, accessibility, and pharmacy dispensing practices of mifepristone/misoprostol in the absence of a prescription., Study Design: Using two predetermined client profiles - one of an unmarried woman and one of her male partner - we visited community pharmacies in different neighborhoods. Mystery clients began the interaction with a request for "a pill to bring back" a period after a positive pregnancy test. We documented product availability, price, and outcome and assessed the quality of the client-pharmacy worker interaction. We analyzed these encounters using descriptive statistics and for themes., Results: In late 2022, we made 172 visits to 86 pharmacies. Medication abortion pills were available at more than half of the pharmacy visits (n=91, 53%) and our mystery clients purchased the drugs without a prescription during 22% (n=37) of all visits. The woman and man clients purchased mifepristone/misoprostol on a similar number of occasions, but we assessed the pharmacy worker interactions with the man as more positive. Pharmacy workers provided varied information about the regimen and the encounters were brief., Conclusions: Medication abortion drugs appear to be available without a prescription in a sizeable minority of pharmacies in Delhi, India. Our findings suggest that identifying ways to work with pharmacy workers to support their ability to provide medically accurate information about the optimal mifepristone/misoprostol regimen is warranted., Implications: Pharmacy access to mifepristone/misoprostol has the potential to greatly reduce barriers to accessing abortion care in India. Despite technically requiring a prescription, medication abortion drugs are available behind-the-counter at a sub-set of pharmacies in Delhi. Future research on formalizing and supporting pharmacy access and exploring abortion seekers' experiences with pharmacy access is warranted., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: The objective of the current study was to estimate the prevalence and associated factors of overweight/obesity among Bangladeshi adolescents aged 15-19 y and to identify whether wealth-related inequality exists for overweight/obesity among Bangladeshi older adolescents., Methods: We analyzed publicly available national representative secondary data from the 2019-2020 Bangladesh Adolescent Health and Wellbeing Survey. This cross-sectional survey was carried out among 18 249 adolescents aged 15-19 y regardless of their marital status using a two-stage stratified sampling technique (the data of 9128 eligible adolescents were included in this analysis). The WHO reference population for body mass index-for-age (1+Z score) was considered as overweight/obesity., Results: We found that girls had significantly (p<0.05) higher prevalence of overweight/obesity (11.63%) than boys (8.25%); however, their biological sex as well their age were not significantly associated with higher odds of overweight/obesity. Those who were in their higher grade (grade 11 and higher) in the school and had been exposed to media were more likely (1.67 and 1.39 times, respectively) to be overweight/obesity compared with primary grade (0-5) and those who experienced no media exposure, respectively. Inequality analysis revealed that adolescents belonging to wealthy households had significantly higher rates of overweight/obesity than those in poorer households (concentration index=0.093)., Conclusions: The study exhibited the multifaceted nature of overweight/obesity among Bangladeshi older teenagers, revealing that their school grade, exposure to media content and wealth-related inequality emerged as significant contributing factors. The findings underscore the urgent need for targeted interventions and public health strategies to address the escalating burden of overweight and obesity in this age group., (© The Author(s) 2024. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.)

Objective: Individuals with neurodevelopmental and/or neurocognitive disorders (NNDs) have complex, long-term care needs. In Bangladesh, India, and Pakistan, informal carers shoulder the responsibility and strain of providing care for people with NNDs. Intense care demand, societal and cultural care expectations, and lack of support infrastructure often lead to psychosocial strain in this inadequately researched community, particularly during crises such as the COVID-19 pandemic. This study explored and identified specific features of the coping styles exhibited by informal carers of people with NNDs from Bangladesh, India, and Pakistan during the COVID-19 pandemic., Material and Methods: Between June and November 2020, 245 carers in India, Pakistan, and Bangladesh responded to open-ended questions in the CLIC (Coping with Loneliness, Isolation, and COVID-19) survey. A reflexive thematic analysis was conducted to uncover the underlying themes and identify coping strategies and stressors. A frequency analysis was performed to examine the associations between these themes and carer nationality. Significant tests identified coping styles., Results: We identified three coping styles: religiosity (Pakistan), caregiving as a natural life path (Bangladesh), and self-care (India). The religiosity and natural life path styles reside on the fatalism/acceptance continuum and suggest an insight-oriented therapeutic approach. Self-care is a problem-solving strategy that calls for a behaviorally oriented approach. Family overreliance on the carer was a concern across all three groups., Conclusions: The findings underscore the need for accessible support pathways to sustain care standards, ensuring the well-being of carers and care recipients., (© 2024 John Wiley & Sons Ltd.)

Purpose of Review: Health data sciences can help mitigate high burden of cardiovascular disease (CVD) management in South Asia by increasing availability and affordability of healthcare services. This review explores the current landscape, challenges, and strategies for leveraging digital health technologies to improve CVD outcomes in the region., Recent Findings: Several South Asian countries are implementing national digital health strategies that aim to provide unique health account numbers for patients, creating longitudinal digital health records while others aim to digitize healthcare services and improve health outcomes. Significant challenges impede progress, including lack of interoperability, inadequate training of healthcare workers, cultural barriers, and data privacy concerns. Leveraging digital health for CVD management involves using big data for early detection, employing artificial intelligence for diagnostics, and integrating multiomics data for health insights. Addressing these challenges through policy frameworks, capacity building, and international cooperation is crucial for improving CVD outcomes in region., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Food adulteration with toxic chemicals is a global public health threat. Lead chromate adulterated spices have been linked with lead poisoning in many countries, from Bangladesh to the United States. This study systematically assessed lead chromate adulteration in turmeric, a spice that is consumed daily across South Asia. Our study focused on four understudied countries that produce >80 % of the world's turmeric and collectively include 1.7 billion people, 22 % of the world's population. Turmeric samples were collected from wholesale and retail bazaars from 23 major cities across India, Pakistan, Sri Lanka, and Nepal between December 2020 and March 2021. Turmeric samples were analyzed for lead and chromium concentrations and maximum child blood lead levels were modeled in regions where samples had detectable lead. A total of 356 turmeric samples were collected, including 180 samples of dried turmeric roots and 176 samples of turmeric powder. In total, 14 % of the samples (n = 51) had detectable lead above 2 μg/g. Turmeric samples with lead levels greater than or equal to 18 μg/g had molar ratios of lead to chromium near 1:1, suggestive of lead chromate adulteration. Turmeric lead levels exceeded 1000 μg/g in Patna (Bihar, India) as well as Karachi and Peshawar (Pakistan), resulting in projected child blood lead levels up to 10 times higher than the CDC's threshold of concern. Given the overwhelmingly elevated lead levels in turmeric from these locations, urgent action is needed to halt the practice of lead chromate addition in the turmeric supply chain., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Genome-wide association studies (GWAS) and polygenic score (PGS) development are typically constrained by the data available in biobank repositories in which European cohorts are vastly overrepresented. Here, we increase the utility of non-European participant data within the UK Biobank (UKB) by characterizing the genetic affinities of UKB participants who self-identify as Bangladeshi, Indian, Pakistani, "White and Asian" (WA), and "Any Other Asian" (AOA), towards creating a more robust South Asian sample size for future genetic analyses. We assess the relationships between genetic structure and self-selected ethnic identities resulting in consistent patterns of clustering used to train a support vector machine (SVM). The SVM model was utilized to reassign n = 1,853 AOA and WA participants at the subcontinental level, and increase the sample size of the UKB South Asian group by 1,381 additional participants. We then leverage these samples to assess GWAS performance and PGS development. We further include environmental covariates in the height GWAS by implementing a rigorous covariate selection procedure, and compare the outputs of two GWAS models: GWAS null and GWAS env . We show that PGS performance derived from environmentally adjusted GWAS yields comparable prediction to PGS models developed with an order of magnitude larger training dataset ( R 2 =0.021 vs 0.026). Models with 7 - 8 environmental covariates double the variance explained by PGS alone. In summary, we demonstrate how GWAS performance can be improved by leveraging ambiguous ethnicity codes, ancestry matched imputation panels, and including environmental covariates.

Background: The prevalence of gestational diabetes mellitus (GDM) is increasing, particularly in low- and middle-income countries (LMICs) like Nepal. GDM self-management, including intensive dietary and lifestyle modifications and blood glucose monitoring, is critical to maintain glycemic control and prevent adverse outcomes. However, in resource-limited settings, several barriers hinder optimal self-management. Mobile health (mHealth) technology holds promise as a strategy to augment GDM treatment by promoting healthy behaviors and supporting self-management, but this approach has not yet been tested in any LMIC., Objective: This report describes the protocol to develop a culturally tailored mHealth app that supports self-management and treatment of GDM (GDM-Dhulikhel Hospital [GDM-DH] app, phase 1) and test its usability and preliminary efficacy (phase 2) among patients with GDM in a periurban hospital setting in Nepal., Methods: The study will be conducted at Dhulikhel Hospital in Dhulikhel, Nepal. In the development phase (phase 1), a prototype of the GDM-DH app will be developed based on expert reviews and a user-centered design approach. To understand facilitators and barriers to GDM self-management and to gather feedback on the prototype, focus groups and in-depth interviews will be conducted with patients with GDM (n=12), health care providers (n=5), and family members (n=3), with plans to recruit further if saturation is not achieved. Feedback will be used to build a minimum viable product, which will undergo user testing with 18 patients with GDM using a think-aloud protocol. The final GDM-DH app will be developed based on user feedback and following an iterative product design and user testing process. In the randomized controlled trial phase (phase 2), newly diagnosed patients with GDM (n=120) will be recruited and randomized to either standard care alone or standard care plus the GDM-DH app from 24-30 weeks gestation until delivery. In this proof-of-concept trial, feasibility outcomes will be app usage, self-monitoring adherence, and app usability and acceptability. Exploratory treatment outcomes will be maternal glycemic control at 6 weeks post partum, birth weight, and rates of labor induction and cesarean delivery. Qualitative data obtained from phase 1 will be analyzed using thematic analysis. In phase 2, independent 2-tailed t tests or chi-square analyses will examine differences in outcomes between the 2 treatment conditions., Results: As of July 2024, we have completed phase 1. Phase 2 is underway. The first participant was enrolled in October 2021, with 99 participants enrolled as of July 2024. We anticipate completing recruitment by December 2024 and disseminating findings by December 2025., Conclusions: App-based lifestyle interventions for GDM management are not common in LMICs, where GDM prevalence is rapidly increasing. This proof-of-concept trial will provide valuable insights into the potential of leveraging mHealth app-based platforms for GDM self-management in LMICs., Trial Registration: ClinicalTrials.gov NCT04198857; https://clinicaltrials.gov/study/NCT04198857., International Registered Report Identifier (irrid): DERR1-10.2196/59423., (©Lauren T Berube, Archana Shrestha, Abha Shrestha, Jean-Francois Daneault, Prabin Raj Shakya, Meghnath Dhimal, Roman Shrestha, Shristi Rawal. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 21.10.2024.)

Asian elephants (Elephas maximus) are the largest extant terrestrial megaherbivores native to Asia, with 60% of their wild population found in India. Despite ecological and cultural importance, their population genetic structure and diversity, demographic history, and ensuing implications for management/conservation remain understudied. We analyzed 34 whole genomes (between 11× and 32×) from most known elephant landscapes in India and identified five management/conservation units corresponding to elephants in Northern (Northwestern/Northeastern), Central, and three in Southern India. Our data reveal signatures of divergence and serial colonization and a potential dilution of genetic diversity from north to south of India. The northern populations diverged from others more than 70,000 years ago, have higher genetic diversity, and have low inbreeding (pi = 0.0016 ± 0.0001; F ROH > 1 MB  = 0.09 ± 0.03). Two of three populations in Southern India have low diversity and are inbred, with very low effective population sizes compared with census sizes (pi = 0.0014 ± 0.00009 and 0.0015 ± 0.0001; F ROH > 1 MB  = 0.25 ± 0.09 and 0.17 ± 0.02). Analyses of genetic load reveal the purging of potentially high-effect insertion/deletion (indel) deleterious alleles in the southern populations and a decreasing number of deleterious alleles from north to south in India. However, despite dilution and purging for the damaging mutation load in Southern India, the load that remains is homozygous. High homozygosity of deleterious alleles, coupled with low neutral genetic diversity, make southernmost populations high priority for conservation attention. Most surprisingly, our study suggests that patterns of genetic diversity and genetic load can correspond to genomic signatures of serial founding events, even in large, highly mobile, endangered mammals., Competing Interests: Declaration of interests The authors declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Despite decades of a call to action to engage men in reproductive health, men are often left out of programs and interventions. In India, where half of pregnancies are reported as unintended, patriarchal gender norms and still dominant patterns of arranged marriages make engaging men in family planning and strengthening couples communication critical in increasing reproductive autonomy and helping young couples meet their reproductive goals. This study explores the feasibility and acceptability from the men's perspective of the pilot of a gender transformative intervention for newly married couples in India., Methods: A pilot study was conducted of TARANG, a 4 month intervention for newly married women, with light touch engagement of husbands (4 sessions). A total of 41 husbands participated in the pilot, and we collected baseline knowledge and endline feasibility and acceptability data from them, along with in depth qualitative interviews with 13 men. The study was conducted in June 2023-January 2024., Results: Men had low levels of knowledge about biology, family planning, with the majority of men reporting that no one had provided them information about these topics. Most men wanted to delay the first birth by at least 2 years, yet less than a quarter had discussed childbearing plans with their partner or engaged in family planning methods. While all men reported high acceptability (satisfaction and usefulness), feasibility (participation) was low, with only 43% attending 2 or more sessions. Main barriers to participation included commitments due to work and migration. Men reported that the intervention led to improvements in their relationships with their wives, gave them a sense of empowerment, and led them to become resources for other men in their community., Conclusions: Men in these rural communities are not receiving the information that they need to meet their reproductive goals, however, they greatly desire this information and ways to improve relationships with their new wives. Such an intervention appears to have the potential to help change norms and spread information in the community and provide men with positive, life affirming feelings. Providing information through technology could address barriers to in-person engagement. TRIAL REGISTRATION CLINICALTRIALS.GOV : 03/13/24.NCT06320964., (© 2024. The Author(s).)

Background: Newly married young women face increased susceptibility to adverse health outcomes, social isolation, and disempowerment, yet interventions targeting this vulnerable group remain limited. We examined the feasibility and acceptability of TARANG, a life skills and reproductive health empowerment intervention, developed for and with young newly married women., Methods: We recruited 42 newly married women as participants in our study. We conducted a convergent mixed-methods, single-group cluster pilot study to the intervention in which 41 participants (retention rate=97.6%) completed both baseline and endline surveys in July 2023 and January 2024, respectively. We assessed three primary outcomes--feasibility using proportion of participants who completed at least 50% sessions, acceptability using proportion completely satisfied/somewhat satisfied with TARANG and usefulness using proportion who found TARANG useful/somewhat useful. We conducted in-depth interviews with a purposive sample of 12 participants to understand intervention acceptance and usefulness of the intervention and 6 program staff and moderators to understand barriers to implementing the intervention. We analyzed the quantitative data with descriptive statistics and qualitative data using thematic analysis. We triangulated data from monitoring data filled by moderators, quantitative surveys with participants, and qualitative data., Results: In the pilot study, 35/42 participants had completed at least one session. Overall, 82% participants attended at least 50% of the sessions. Among those who attended at least 1 session,97% were satisfied/somewhat satisfied with the intervention and 100% of participants found the intervention to be useful/somewhat useful. Qualitative findings reveal participants' appreciation for open discussions on sensitive topics, such as family planning, and highlight the intervention's role in filling knowledge gaps and fostering social connections, better sense of agency and improved relationships with mothers-in-law and husbands. While barriers to consistent participation were identified, feedback informed refinements to the intervention for the main trial, including session modifications, increased engagement strategies, and integration of educational videos., Conclusion: Our community-based participatory approach, developed with input from end users, demonstrated not only high acceptability and feasibility but also had many benefits for newly married women in rural/tribal Rajasthan. Our findings also led to adaptations that may enhance delivery of, and satisfaction with TARANG intervention, which will be tested with a larger sample in a rigorous cluster randomized controlled trial in Rajasthan, India., Clinicaltrialsgov: The study is registered at ClinicalTrials.gov (NCT06320964). Registered retrospectively on 13 March 2024, https://clinicaltrials.gov/study/NCT06320964., Competing Interests: Competing interests The authors declare that they have no competing interests.

Background: South Asia and Southeast Asia account for more than 40% of the global stroke burden, with differences in stroke risk factors, mortality, and outcomes compared to high-income countries. Sociocultural norms compound the preexisting biological risk differences, resulting in a disproportionate burden of stroke in women in this region. This review summarizes the sex and gender differences across the stroke care continuum in South Asia and Southeast Asia over the past 20 years., Summary: Despite a higher incidence of stroke in men than women in South and Southeast Asia, women have greater stroke severity and poorer outcomes after stroke. Higher levels of premorbid disability and poor physical health at baseline may be contributory. There is a high prevalence of vascular risk factors such as hypertension, dyslipidemia, cardiac sources of embolism, as well as metabolic syndrome and insulin resistance, among the women in this region. Smoking is uncommon among women; however, other forms of smokeless tobacco, such as tobacco leaf and betel nut chewing, are more prevalent, especially in the rural areas in these countries. Women are more likely to have delayed presentations to the hospital due to untimely recognition of stroke symptoms; however, with regards to door-to-needle times or intravenous thrombolysis (IVT) rates, we found equivocal data. Wide gaps exist in stroke awareness and healthcare-seeking behaviors, with women more commonly opting for public hospitals and low-cost wards, more likely to discontinue treatment, and less likely to adhere to poststroke rehabilitation., Key Findings: This review exposes the gender lacunae in stroke service provision across South Asia and Southeast Asia while acknowledging the many knowledge gaps in our understanding. Although the biological risk differences are non-modifiable, educational, policy, and economic measures to mitigate sociocultural barriers are much needed in the region. Sound epidemiological data are needed from more countries to better understand these differences and bridge this gap. It is imperative to advocate and implement policies and programs for stroke care viable for women, cognizant of the gender and cost bias, as well as the interplay of social and cultural structures specific to the regions., (© 2024 S. Karger AG, Basel.)

Background: Tuberculosis (TB) is a major public health issue in South Asia and accounts for a large share of the global TB burden. Despite global efforts to curb TB incidence and mortality, progress in South Asia has been uneven, necessitating focused regional analysis to guide effective interventions. This study aims to analyse the trends in the TB burden in South Asia from 1990 to 2021 and project future TB incidence rates up to 2031., Methods: This study utilized data from the Global Burden of Disease (GBD) 2021 results to analyse trends in age-standardized incidence (ASIR), prevalence (ASPR), mortality (ASMR), and disability-adjusted life years (DALYs) rates (ASDR) associated with TB in South Asia from 1990 to 2021. Joinpoint regression analysis was employed to identify significant trends, whereas ARIMA models were used to project future TB incidence rates up to 2031., Results: This study revealed significant declines in the ASIR, ASPR, ASDR, and ASMR related to TB in South Asia over the past three decades. Prominent reductions were found in Bangladesh and Bhutan, whereas India, Pakistan, and Nepal continue to bear the highest TB burdens. The ARIMA model projections indicate a continued decline in TB incidence across the region, although the extent of the decline varies by country, with less favourable trends observed in Nepal and Pakistan. The analysis also highlights tobacco use, high fasting plasma glucose, and high body mass index as significant risk factors contributing to the TB burden., Conclusions: Substantial progress has been made in reducing the TB burden in South Asia; however, sustained and intensified efforts are needed, particularly in countries with inconsistent progress. These findings emphasize the need for targeted interventions to meet the WHO End TB Strategy (WETS) targets by 2035. Continuous monitoring and adaptive strategies will be crucial in maintaining and accelerating progress toward TB elimination in South Asia., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Output generation processes across South Asia are deemed unclean (highly emission-intensive) due to excessive reliance on fossil fuels. Thus, decarbonizing the growth processes of countries within this region has critical emphasis among policymakers. However, since the South Asian countries are not yet ready to undergo the renewable energy transition in full form, it is unlikely that their annual carbon discharge levels will subside anytime soon. Under such constraining circumstances, these countries need to limit the rate at which their respective carbon emission levels rise each year. Therefore, the impacts of digitalization on annual carbon emission growth rates in selected South Asian countries are assessed in this study. Overall, considering internet penetration rate as a proxy of digital technology adoption, the results confirm that policies aimed at digitalizing the concerned South Asian economies not only exert emission growth rate-reducing impacts via a direct channel, but also indirectly reduce emission growth rates by making natural resource-based industries more productive, expediting the energy sector greening processes, greening the financial sectors, making corruption controlling measures within institutions more effective, and limiting urbanization-induced environmental quality-worsening effects. Therefore, it is relevant for the South Asian governments to emphasize on digitalization while simultaneously ensuring that green digital technologies are adopted within the major macroeconomic sectors across this region., Competing Interests: The authors declare no known competing interests.The author declares that there is no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Author(s).)

Urbanization induces homogenization and changes the behavioural patterns of various bird species, thereby facilitating coexistence and prompting adaptations to disturbances in urban environments. However, there is limited research on the influence of how urbanization affects bird tolerance towards humans, especially in developing sub-tropical regions such as Nepal, which is undergoing rapid unplanned urbanization. This study identified the flight initiation distance (FID) as a proxy for assessing bird tolerance. We focused on evaluating the human tolerance levels of 33 bird species using their FIDs in urban and rural habitats within Kathmandu Valley, a rapidly urbanizing city in South Asia. We found higher tolerance in urban birds than in their rural conspecifics, which varies mainly with dietary guild and season. The positive impact on FID was associated with time of the day and body size, while a negative association was observed with flock size, mean population density of humans and interaction between body size and elevation. Our study highlights the increased tolerance level of birds in urban areas, probably owing to habituation, and emphasizes the imperative need to investigate the potential adverse effect on urban bird population owing to this increased tolerance level., Competing Interests: We declare we have no competing interests., (© 2024 The Author(s).)

NEED: Cervical cancer is a major global public health issue, particularly affecting low and middle-income countries, distinctly in the South Asian region. This geographical region lacks a well-organized routine cervical screening program. Consequently, this scoping review aimed to investigate the evidence on factors influencing the adoption and implementation of routine cervical cancer screening in South Asia., Methods: Adopting the "Arksey and O'Malley and Levac et al." methodology, databases such as PubMed, CINAHL, Web of Science, and Scopus were scrutinized in the pursuit of relevant studies. Subsequently, the collected data were synthesized by adopting the Consolidated Framework for Implementation Research (CFIR) model., Results: A total of 837 records were initially identified and screened for eligibility, including 55 studies. The successful adoption and implementation of cervical cancer screening in South Asia encounter numerous obstacles within the health system, including the absence of a comprehensive program protocol for screening, inadequate health infrastructure, and the presence of multiple sociocultural factors, such as social stigma, low levels of education, and concerns related to modesty., Conclusion: To optimize adoption and implementation, it is imperative to construct a customized policy framework that incorporates a risk communication strategy tailored to the specific contexts of these nations. Drawing insights from the experiences of South Asian countries in executing cervical cancer screening programs can inform the formulation of policies for similar healthcare initiatives aimed at facilitating the expansion of HPV vaccination efforts., (© 2024. The Author(s).)

Background: Esophageal cancer (EC) remains a significant health challenge in South Asia, with poor prognosis despite advancements in diagnostics and treatment. Identifying and validating prognostic factors is essential for improving patient outcomes. Methods: A prospective study was conducted with 146 biopsy-confirmed EC patients at the Dr. Ruth K.M. Pfau Civil Hospital, Karachi, Pakistan. Clinical and laboratory data were collected and analyzed using descriptive statistics, receiver operating characteristic (ROC) analysis, and the Chi-square test. Survival outcomes were assessed using Kaplan-Meier curves, log-rank tests, and Cox proportional hazard models for univariate and multivariate regression analyses, with statistical significance set at p ≤ 0.05. Results: Bivariate analysis showed significant associations of the neutrophil lymphocyte ratio (NLR) ( p = 0.017), C-reactive protein to albumin ratio (CAR) ( p = 0.033), red cell distribution width to platelet ratio (RPR) ( p = 0.020), and systemic immune-Inflammation index (SII) ( p = 0.009) with patient survival. Univariate analysis identified tumor length >10 cm ( p = 0.016), T4 stage ( p = 0.015), metastasis ( p < 0.001), surgery not performed ( p < 0.001), and SII ( p = 0.022) as significant factors for survival, with higher SII linked to poorer overall survival ( p = 0.020). Interestingly, in the multivariate model, only metastasis ( p < 0.001) and surgery not performed ( p = 0.011) remained significant. Conclusions: Immuno-inflammatory markers may be less pertinent prognostic factors for EC in the South Asian population.

This study investigates the burden of COPD attributable to air pollution in South Asia using data from the Global Burden of Disease Study from 1990 to 2019. Method Data for this study were obtained from the Global Burden of Disease Study 2019. The burden was measured in terms of death, disability-adjusted life years (DALYs), and Years of life lost (YLLs). Results Since 1990, several countries in South Asia registered substantial declines in mortality rates attributed to COPD, ranging from -37.47% in Pakistan to -66.25% in Bangladesh. Similar trends were observed for DALYs and YLLs as well, which have potentially contributed to a considerable decrease in mortality rates at the regional level (-43.13%) compared to a 32.59% decline in Low SDI and 56.87% decline globally. Conclusion Despite significant declines since 1990, the burden of COPD attributable to air pollution reductions in the South Asian region's rates remains alarmingly high.

Objective: This quasi-experimental study aimed to describe the outcome of a social skills intervention for adolescents with depression followed up at an outpatient Child and Adolescent Psychiatry Unit. Twenty adolescents with depression attending a tertiary care facility in Colombo, Sri Lanka were recruited, who participated in two social skills training programmes (6 months apart), in addition to pharmacological treatment. Outcome of the programme was measured by a self-administered questionnaire that assessed perceived changes in social skills, before and after the intervention. Wilcoxon Signed Rank test was used to determine the statistical significance of improvement in social skills., Results: The sample consisted of 80% (n = 16) female adolescents. Median scores (inter-quartile range) for social skills before and after the first social skills programme were 31.5 (21.0-36.0) and 33.0 (28.25-40.25) respectively, indicating a significant improvement in social skills following intervention (p = 0.011, r = 0.57). A similar improvement was observed after the second programme (n = 10), reporting higher median scores for social skills after intervention (29.5 vs. 37.5, p = 0.005, r = 0.89). A significant improvement was also observed in perceived ability to cope with depressive thoughts after intervention (p = 0.032), indicating that social skills training can be a useful adjunct to pharmacological interventions, in the management of depression in adolescents., (© 2024. The Author(s).)

This research investigates the intricate relationships between economic variables and how they affect South Asian nation's ability to develop sustainably. Given the growing concerns about climate change and global warming brought on by emissions of greenhouse gases, this study looks into the connection between emissions of CO 2 , green energy, industrialization, foreign direct investment, economic globalization, and financial development from 1995 to 2022. Second-generation panel techniques were employed in this study to look at the relationship between variables because of the potential of residual cross-sectional dependency and heterogeneity. The empirical outcomes display that green energy, economic globalization, and financial development reduce CO 2 emissions by 1.839%, 1.223%, and 3.902% respectively. Industrialization and foreign direct investment degrade the environment by 4.302% and 1.893% respectively. A bidirectional causality link between green energy, industrialization, economic globalization, and CO 2 emissions was found by Dumitrescu and Hurlin (D-H). Based on our findings, we recommend legislative support for renewable energy, cleaner technologies, and strict environmental regulations, aligning with the Sustainable Development Goals (SDGs). Encouraging FDI, sustainable practices, and financial development can drive economic growth while preserving the environment. As we approach COP28, this holistic approach to sustainable development becomes increasingly vital for South Asian countries to achieve their SDG targets and combat climate change., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Limited information on the co-prevalence of undernutrition, micronutrient deficiencies, overnutrition, and abnormal levels of noncommunicable disease biomarkers at the same time in children and adolescents in India hinders efforts to comprehensively address their health., Objectives: This study aimed to examine the prevalence and correlates of double burden of malnutrition (DBM) and triple burden of malnutrition (TBM) among children and adolescents (5-19 y) to inform policies and programs., Methods: A total of 17,599 children (5-9 y) and 16,184 adolescents (10-19 y) with available biomarker data from the Comprehensive National Nutrition Survey were included. Malnutrition was defined based on either undernutrition based on anthropometry, overnutrition/abnormal metabolic markers, and anemia/micronutrient deficiency. DBM was defined as the coexistence of any 2 forms of malnutrition. DBM+ was defined as the coexistence of undernutrition and/or micronutrient deficiency along with overnutrition. TBM was defined as having the coexistence of all 3 forms of malnutrition. The prevalence of DBM, DBM+, and TBM was estimated accounting for probabilistic selection. We used mixed-effect binomial regression to determine correlates of DBM/TBM in children and adolescents separately., Results: The prevalence of DBM, DBM+, and TBM was 50.8%, 37.2%, and 14.4%, respectively, in children and 53.4%, 36.1%, and 12.7%, respectively, in adolescents. The prevalence of DBM+ was significantly higher in girls compared to in boys in the 5-9 y age group. In children, being in a disadvantaged caste group, having a lower wealth index, having inadequate diet diversity, having no maternal schooling, and having a recent history of acute illness were associated with DBM. In adolescents, being in a disadvantaged caste group, maternal occupation, and lower paternal age were correlated with DBM. A similar set of variables was associated with TBM in both age groups., Conclusions: The prevalence of DBM and TBM is substantial in children and adolescents in India and varies across states. Socioeconomic factors and acute illness were the main correlates for DBM and TBM., (Copyright © 2024 American Society for Nutrition. Published by Elsevier Inc. All rights reserved.)

Objective: In Pakistan, a predominantly Muslim country, information on the patterning of suicidal thoughts and behaviors, as well as associated public perceptions and opinions, is limited. We sought to advance knowledge on suicide and self-harm in Pakistan with a large, online survey., Method: Leveraging results from a twelve-item online survey ( N  = 5,157) circulated by the largest English language newspaper in Pakistan, we assessed personal experiences, opinions, and attitudes toward help-seeking in the context of suicide. We calculated proportions with 95% confidence intervals for endorsed responses and implemented binomial generalized linear models with odds ratios to assess differing response tendencies by age, gender, and urban/rural residence., Results: Personal experiences related to suicide and self-harm as well as encounters in social circles were common. Mental illness tended to be recognized as a high likelihood contributor to suicide death over and above nonviolent interpersonal problems. Most considered suicide a way to escape pain, and few considered suicide to be immoral. Barriers to help-seeking included social deterrents, inaccessibility, and unaffordability. Women and youth emerged as higher risk groups, though the status of rural Pakistanis remained unclear., Conclusion: The survey provides a preliminary basis for considering the unique experiences and perspectives of the public in shaping suicide prevention and intervention efforts in Pakistan.

Background: Pregnancy loss that includes both miscarriage and stillbirth cause significant psychological distress for women including anxiety, depression, and grief that persist long after physical recovery. This study focuses on the experiences of women in Pakistan, where pregnancy loss rates are high., Objective: To explore how pregnant women with anxiety symptoms and a history of pregnancy loss perceive their past experiences with the loss and how it affects overall well-being in their current pregnancy., Design: Qualitative methods were used to explore the impact of previous pregnancy loss on the well-being of pregnant women., Setting: This qualitative research was embedded within a randomized control trial conducted in a tertiary care facility in Rawalpindi, Pakistan., Participants: Data were collected through in-depth interviews with 18 pregnant women who had experienced pregnancy loss. Data was analyzed using Framework Analysis., Findings: The findings revealed several factors influencing participants' well-being during pregnancies that resulted in a loss, such as unsupportive and abusive environments, unintended pregnancies, certain superstitious beliefs, poor health, and lack of access to quality healthcare. The study also highlighted the adverse impact of previous pregnancy loss on the ongoing pregnancy, including deterioration of physical and mental health and aversion of healthcare services. However, some participants reported positive changes in medical and self-care practices and an enhanced faith and reliance on destiny in their subsequent pregnancies., Conclusion: Our study highlights the lasting impact of past pregnancy loss on subsequent pregnancies, affecting overall wellbeing and leading to healthcare avoidance. We identified persistent anxiety along with positive outcomes like enhanced medical practices and strengthened faith. Results suggest the need for culturally responsive interventions to support the overall well-being of anxious pregnant women with a history of pregnancy loss in resource-constrained settings., Competing Interests: Declaration of competing interest The work is original. None of the content is included in another manuscript, has been published previously, or is currently under consideration for publication elsewhere. The study followed ethical guidelines and received human subjects’ approval both at the Johns Hopkins Bloomberg School of Public Health Institutional Review Board (Baltimore, MD), the Human Development Research Foundation Ethics Committee (Islamabad, Pakistan), the Rawalpindi Medical University Institutional Research Forum (Rawalpindi, Pakistan), and the National Institute of Mental Health Global Mental Health Data Safety and Monitoring Board, prior to the initiation of the study. All authors participated substantively to the paper and have approved the final version of the manuscript. Finally, the authors of this manuscript have no conflicts of interest to declare., (Copyright © 2024. Published by Elsevier Ltd.)

Background: Craniopharyngiomas are rare benign tumors located in the sellar and suprasellar region, with an incidence of 0.5-2 cases per million as reported in Western studies. Post-treatment, including surgery and/or radiotherapy, many patients develop significant obesity, primarily due to hypothalamic damage and associated complications such as hypopituitarism. In the South Asian population, genetic predisposition to obesity at lower BMIs, coupled with a carbohydrate-rich diet, may exacerbate obesity in craniopharyngioma patients, presenting a unique challenge., Methods: This submission is a commentary based on a comprehensive literature review. The authors conducted the review using PubMed to focus on English-language articles covering hypothalamic obesity, craniopharyngioma and obesity in the South Asian population from 1939 to the present., Results: The literature review revealed that 50-60 % of patients treated for craniopharyngioma develop obesity, predominantly linked to hypothalamic damage, although these data are mainly derived from Western studies. Hypopituitarism was frequently observed, further contributing to the obesity. Despite a caloric intake appropriate for the age and gender, these patients exhibited reduced physical activity as measured by wrist accelerometers. Patients with hypothalamic obesity due to craniopharyngioma are at risk for metabolic syndrome and cardiovascular morbidity. Additionally, visual impairment was common, leading to a decreased quality of life. The South Asian population, genetically predisposed to visceral obesity and a carbohydrate-rich diet, may display a distinct phenotype. Although multiple treatment modalities have been tried, there is no definite treatment modality available to counteract this condition at present., Conclusion: South Asian phenotype of craniopharyngioma-related obesity is characterized by significant metabolic and hormonal dysregulation, influenced by both dietary and genetic factors. Nevertheless, there may be a lot to be still understood about this devastating, rapid, relentless hypothalamic obesity syndrome. Also, a higher morbidity rate within this population, underscores the need for further research to develop targeted interventions., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests. As permitted for guest editor, this would be the only publication submitted to this special issue from the guest editor's desk. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Author(s).)

Background: Immunomodulators are important for management of autoimmune diseases and hematological malignancies. Significant inter-individual variation in drug response/reactions exists due to genetic polymorphisms. We describe frequency of identified genetic polymorphisms among Sri Lankans., Methods: Sri Lankan data were obtained from an anonymized database of 670 participants. Data on variants and global distribution of Minor Allele frequency (MAF) of other populations (South Asian, Ashkenazi-Jewish, East-Asian, European-Finnish, European-non-Finnish, Latino-American, African/African-American) were obtained from pharmGKB online database., Results: SLC19A1 (rs1051266) variant had a MAF (95% CI) of 63.3% (60.7-65.9). Other common variants included FCGR3A (rs396991), MTHFR (rs1801133), ITPA (rs1127354), CYP2C9*3 (rs1057910) and NUD15*3 (rs116855232), with MAFs of 35.3% (32.7-37.9), 12.2% (10.4-13.9), 10.9% (9.2-12.6), 9.8% (8.2-11.4), 8.3% (6.8-9.8) respectively. Less commonly present variants included CYP2C9*2 (rs1799853) (2.5%[1.7-3.4]), TPMT*3C (rs1142345) (1.9%[1.1-2.6]), TPMT*3B (rs1800460) (0.2%[0-0.5]), CYP3A5*6 (rs10264272) (0.2%[0-0.4]) and CYP3A4*18 (rs28371759) (0.1%[0-0.2]). The SLC19A1 (rs1051266), NUD15*3 (rs116855232), CYP2C9*3 (rs1057910), FCGR3A (rs396991), and ITPA (rs1127354) showed significantly higher frequencies in Sri Lankans compared to many other populations, exceptions include FCGR3A in Ashkenazi-Jewish and ITPA in East-Asians. Conversely, MTHFR (rs1801133), TPMT*3B (rs1800460), and CYP2C9*2 (rs1799853) were significantly less prevalent among Sri Lankans than in  many other populations. Sri Lankans exhibited lower prevalence of TPMT*3C (rs1142345) compared to European-non-Finnish, Latino-Americans, and African/African-Americans; CYP3A4*18 (rs28371759) compared to East-Asians; and CYP3A5*6 (rs10264272) compared to African/African-Americans and Latino-Americans., Conclusion: Sri Lankans exhibit higher frequencies in variants reducing methotrexate efficacy (SLC19A1), increasing azathioprine myelotoxicity (NUDT15), and lower frequencies in variants linked to increased azathioprine toxicity (TPMT*3B, TPMT*3C), reduced tacrolimus efficacy (CYP3A4*18), and methotrexate toxicity risk (MTHFR). Beneficial variants enhancing rituximab efficacy (FCGR3A) are more prevalent, while those reducing tacrolimus dosage (CYP3A5*6) are less common. This highlights need for targeted medication strategies to improve treatment outcomes., (© 2024. The Author(s).)

Background and Context: Providing care to the elderly is an emerging area of interest due to the increase in elderly population not only in the developed world but also in low and middle income countries. In Pakistan a country with an overall population of over 200 million, the elderly population amounts to 11.3 million. Caregiving of the elderly tends to occur within the kinship motivated by sociocultural norms as well as absence of government support facilities. While quantitative literature exists in Pakistan describing the "caregiver's burden," an in-depth analysis into the experiences of familial caregivers is missing., Methods: The research used qualitative methods with the aim to explore the lived experiences of 7 daughters and 3 daughters-in-law, living in Karachi, Pakistan providing care to the elderly requiring assistance in at least two tasks of daily living., Results: Five themes were developed inductively through the phenomenological method. All participants were Muslim and belonged to the upper economic strata of the society. Findings reveal that obligations to care are dominant in kinship circles particularly among women. Participants highlighted the importance of elderly in the Pakistani society, especially due to the religious lens that considers them as blessings. Daughter caregivers spoke about caregiving of their parents as a form of role reversal, emphasizing also upon the life-long emotional bond that served as a strong motivator. On the other hand, for daughter-in-law caregivers, motivations to care also stemmed from social expectations and kinship obligations. All participants reported multiple difficulties during the caregiving experience, despite existence of paid formal help, with respect to balancing multiple role demands and the nature of caregiving that requires constant effort. Results also illustrate that despite the desire to care for the elderly within a collectivist and patrilocal society, participants experienced multiple physical and emotional effects. However, a few also reported an increase in self-mastery and self-worth., Conclusion: This study reveals that despite increasing urbanization and more women working outside the home, providing care to the elderly appears to be centered within the kinship circle. The research makes important contributions to the ageing literature in Pakistan with relevance to other South Asian contexts., (© 2024. The Author(s).)

Background: Mental disorders remain the most significant contributor to years lived with disability in South Asia, yet governmental health expenditure on mental health in South Asia remains very low with limited strategic policy development. To strengthen the case for action it is important to better understand the profound economic costs associated with poor mental health., Methods: We conducted a systematic review on the costs of all mental disorders, as well as intentional self-harm and suicide, in the World Bank South Asia Region. Ten global and South Asian databases as well as grey literature sources were searched., Results: 72 studies were identified, including 38 meeting high quality criteria for good reporting of costs. Of these, 27 covered India, five Pakistan, four Nepal and three Bangladesh and Sri Lanka. Most studies focused on depressive disorders (15), psychoses (14) and harmful alcohol use (7); knowledge of economic impacts for other conditions was limited. Profound economic impacts within and beyond health care systems were found. In 15 of 18 studies which included productivity losses to individuals and/or carers, these costs more than outweighed costs of health care., Conclusion: Mental disorders represent a considerable economic burden, but existing estimates are conservative as they do not consider long-term impacts or the full range of conditions. Modelling studies could be employed covering longer time periods and more conditions. Clear distinctions should be reported between out-of-pocket and health system costs, as well as between mental health service-specific and physical health-related costs., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflicts of interest., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Context: Recent data from the South Asian subregion have raised concern about the dramatic increase in the prevalence of metabolic diseases, which are influenced by genetic and lifestyle factors., Objective: The aim of this systematic review was to summarize the contemporary evidence for the effect of gene-lifestyle interactions on metabolic outcomes in this population., Data Sources: PubMed, Web of Science, and SCOPUS databases were searched up until March 2023 for observational and intervention studies investigating the interaction between genetic variants and lifestyle factors such as diet and physical activity on obesity and type 2 diabetes traits., Data Extraction: Of the 14 783 publications extracted, 15 were deemed eligible for inclusion in this study. Data extraction was carried out independently by 3 investigators. The quality of the included studies was assessed using the Appraisal Tool for Cross-Sectional Studies (AXIS), the Risk Of Bias In Non-randomized Studies-of Interventions (ROBINS-I), and the methodological quality score for nutrigenetics studies., Data Analysis: Using a narrative synthesis approach, the findings were presented in textual and tabular format. Together, studies from India (n = 8), Pakistan (n = 3), Sri Lanka (n = 1), and the South Asian diaspora in Singapore and Canada (n = 3) reported 543 gene-lifestyle interactions, of which 132 (∼24%) were statistically significant. These results were related to the effects of the interaction of genetic factors with physical inactivity, poor sleep habits, smoking, and dietary intake of carbohydrates, protein, and fat on the risk of metabolic disease in this population., Conclusions: The findings of this systematic review provide evidence of gene-lifestyle interactions impacting metabolic traits within the South Asian population. However, the lack of replication and correction for multiple testing and the small sample size of the included studies may limit the conclusiveness of the evidence. Note, this paper is part of the Nutrition Reviews Special Collection on Precision Nutrition., Systematic Review Registration: PROSPERO registration No. CRD42023402408., (© The Author(s) 2024. Published by Oxford University Press on behalf of the International Life Sciences Institute.)

Mercury (Hg) is a globally distributed heavy metal. Here, we study Hg concentration and isotopic composition to understand the status of Hg pollution and its sources in Pakistan's paddy soil. The collected paddy soils (n = 500) across the country have an average THg concentration of 22.30 ± 21.74 ng/g. This low mean concentration suggests Hg pollution in Pakistan was not as severe as previously thought. Meanwhile, samples collected near brick kilns and industrial areas were significantly higher in THg than others, suggesting the influence of Hg emitted from point sources in certain areas. Soil physicochemical properties showed typical characteristic of mineral soils due to the study area's arid to semi-arid climate. Hg stable isotopes analysis, depicted mean Δ 199 Hg of -0.05 ± 0.12‰ and mean δ 202 Hg -0.45 ± 0.35‰, respectively, for contaminated sites, depicting Hg was primarily sourced from coal combustion by local anthropogenic sources. While uncontaminated sites show mean Δ 199 Hg of 0.15 ± 0.08‰, mean Δ 200 Hg of 0.06 ± 0.07‰ and mean δ 202 Hg of -0.32 ± 0.28‰, implying long-range transboundry Hg transport through wet Hg(II) deposition as a dominant Hg source. This study fills a significant knowledge gap regarding the Hg pollution status in Pakistan and suggests that the Hg risk in Pakistan paddies is generally low., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: The relevance of anthropometric indices in predicting cardiovascular disease (CVD) or CVD risk factors is established across different countries, particularly in the high-income countries. However, past studies severely lacked representation from the south and southeast Asian countries. The main aim of this study was to determine the performance of conventional and new anthropometric indices to best predict 10-year cardiovascular disease (CVD) risk in south Asian and southeast Asian populations., Methods: The present study examined data from 14,532 participants in three south Asian and 13,846 participants (all aged between 40 and 74 years) in six southeast Asian countries, drawn from twelve cross-sectional studies (WHO STEPwise approaches to NCD risk factor surveillance [STEPS] survey data from 2008 to 2019). A Predictive performance of ten anthropometric indices were examined for predicting 10-year CVD risk ≥ 10% (CVD-R ≥ 10%). The 10-year CVD-R ≥ 10% was calculated by utilising the WHO CVD risk non-laboratory-based charts. Receiver operating characteristic (ROC) curve analysis was used to identify the optimal anthropometric index., Findings: Among the ten anthropometric indices, a body shape index (ABSI), body adiposity index (BAI), body roundness index (BRI), hip index (HI), and waist-height ratio (WHtR) performed best in predicting 10-year CVD risk among south Asian males and females. Improved performances were found for ABSI, BRI, conicity index (CI), WHtR, and waist-hip ratio (WHR) for 10-year CVD-R ≥ 10% predictions among southeast Asian males. Contrastingly, among southeast Asian females, ABSI and CI demonstrated optimal performance in predicting 10-year CVD-R ≥ 10%., Interpretation: The performance of anthropometric indices in predicting CVD risk varies across countries. ABSI, BAI, BRI, HI, and WHtR showed better predictions in south Asians, whereas ABSI, BRI, CI, WHtR, and WHR displayed enhanced predictions in southeast Asians., Funding: None., Competing Interests: There was no funding source for this study. The article processing charge is supported by The Department of Women's and Children's Health, Uppsala University, Sweden, provided to SMR. MTI is a PhD student at Murdoch University, supported by the Murdoch University International Postgraduate Research Scholarship. All authors declare no other competing interests., (© 2024 The Author(s).)

South Asia contributes the most to stroke mortality worldwide. This study aimed to determine the long-term trends in stroke mortality across four South Asian countries and its associations with age, period, and birth cohort. In 2019, nearly one million stroke deaths occurred across South Asia, and the associated age-standardized mortality rate (ASMR) was 80.2 per 100,000. Between 1990 and 2019, India had the largest decrease in the ASMR (-35.8%) across the four South Asian countries. While Pakistan had the smallest decrease in the ASMR (-7.6%), an increase was detected among males aged 15 to 34 years and females aged 15 to 19 years. Despite a 22.8% decrease in the ASMR, Bangladesh had the highest ASMR across the four South Asian countries. Nepal reported a witness increase in the stroke ASMR after 2006. Improved period and cohort effects on stroke mortality were generally indicated across the analyzed countries, except for recent-period effects in males from Nepal and cohort effects from those born after the 1970s in Pakistan. Stroke mortality has decreased in the four South Asian countries over the past 30 years, but potentially unfavorable period and cohort effects have emerged in males in Nepal and both sexes in Pakistan. Governmental and societal efforts are needed to maintain decreasing trends in stroke mortality.

Background: Non-communicable diseases (NCDs) are a global epidemic challenging global public health authorities while imposing a heavy burden on healthcare systems and economies., Aim: To explore and compare the prevalence of NCDs in South Asia, the Caribbean, and non-sub-Saharan Africa, aiming to identify both commonalities and differences contributing to the NCD epidemic in these areas while investigating potential recommendations addressing the NCD epidemic., Method: A comprehensive search of relevant literature was carried out to identify and appraise published articles systematically using the Cochrane Library, Ovid, Google Scholar, PubMed, Science Direct, and Web of Science search engines between 2010 and 2023. A total of 50 articles fell within the inclusion criteria., Results: Numerous geographical variables, such as lifestyle factors, socio-economic issues, social awareness, and the calibre of the local healthcare system, influence both the prevalence and treatment of NCDs. The NCDs contributors in the Caribbean include physical inactivity, poor fruit and vegetable intake, a sedentary lifestyle, and smoking, among others. While for South Asia, these were: insufficient societal awareness of NCDs, poverty, urbanization, industrialization, and inadequate regulation implementation in South Asia. Malnutrition, inactivity, alcohol misuse, lack of medical care, and low budgets are responsible for increasing NCD cases in Africa., Conclusion: Premature mortality from NCDs can be avoided using efficient treatments that reduce risk factor exposure for individuals and populations. Proper planning, implementation, monitoring, training, and research on risk factors and challenges of NCDs would significantly combat the situation in these regions., (© 2024. The Author(s).)

Objective: Assess longer-term changes in food habits and anthropometry among Grades 1-2 primary school students from four public schools in Colombo, Sri Lanka, following a 3-week programme including a classroom-based motivational storybook discussion and self-monitoring food diary (FD)., Methods: This follow-up study assessed changes from baseline (pre-intervention) BMI z-scores and food habits (increased healthy food-item consumption/decreased unhealthy food-item consumption reflected by an increase in FD score) and parental perceptions (anonymous questionnaires) among 863 students (aged 6-8 years), between 9 and 12 months after completing the programme (November 2019-February 2020)., Results: Food habits showed sustained improvement from baseline mean FD score (baseline vs. follow-up: 51 ± 23% vs. 67 ± 22%, p < 0.001), with children from all BMI subgroups (underweight [UW], normal weight [NW], overweight [OW] and obesity [OB]) showing a significant increase in FD scores (ranging from 14.1% to 17.2%, p < 0.001). BMI z-scores increased in children living with UW (-2.85 to -2.21, p < 0.00) and NW (-0.70 to -0.57, p < 0.001), but did not change in children with OW (+1.5 to +1.49, p = 0.83) and OB (+2.85 to +2.21, p = 0.19). Most parents (n = 497, 97.8%) reported satisfaction with programme outcomes., Conclusion: This programme led to sustained improvement in food habits among young primary school children from all BMI categories, increase in BMI towards the median among children living with UW and NW, and stabilization of BMI in children with OW and OB, suggesting it as a useful tool for improving nutritional status of young children in low- and middle-income countries (LMIC) facing the double burden of under- and overnutrition., (© 2024 World Obesity Federation.)

Exotic animal practice is at its infancy in South Asia. We lack the formal education for this subject. However, new policies and improvements in the veterinary education system and a positive shift in demographics of exotic animals as pets have led to an upsurge of knowledge about this subject. Earlier people were forced to treat exotic animals, however, now there are many veterinarians who make it a choice to treat these species. This shift in trend will help exotic animal practice grow in South Asia., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The rising burden of cancer significantly influences the global economy and healthcare systems. While local and contextual cancer research is crucial, it is often limited by the availability of funds. In South Asia, with 1.7 million new cancer cases and 1.1 million deaths due to cancer in 2020, understanding cancer research funding trends is pivotal., Methods: We reviewed funded cancer studies conducted between January 1, 2003, and Dec 31, 2022, using ClinicalTrials.gov, International Cancer Research Partnership (ICRP) Database, NIH World RePORT, and WHO International Clinical Trials Registry Platform (ICTRP). We included funded studies related to all cancer types, conducted in South Asian countries, namely Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka., Results: We identified 6561 funded cancer studies from South Asia between 2003 and 2022, increasing from 400 studies in 2003-2007 to 3909 studies in 2018-2022. India had the highest number of funded cancer studies, while Afghanistan, Bhutan, and the Maldives had minimal or no funded cancer research output. Interventional studies (67.3%) were the most common study type funded. The most common cancer sites funded were breast (17.8%), lung (9.9%), oropharyngeal (6.2%), and cervical (5.0%) cancers. On the WHO ICTRP, international funding agencies contributed to a majority of studies (57.5%), except in India where local funding agencies (58.2%) funded more studies., Conclusion: This study identified gaps in research funding distribution across cancer types and geographic areas in South Asia. This data can be used to optimize the distribution of cancer research funding in South Asia, fostering equitable advancement in cancer research., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

During the COVID-19 pandemic, healthcare professionals around the world were driven by universal values of solidarity and duty to provide care. However, local societal norms and existing healthcare systems influenced interactions among physicians, and with patients and their families. An exploratory qualitative study design using in-depth interviews was undertaken with physicians working at two public sector hospitals in Karachi, Pakistan. Using the constant comparison method of data analysis, several key themes were identified highlighting norms of kinship and interdependencies characteristic of collectivistic societies that influenced professional interactions. The role of seniors in the hierarchical society of Pakistan played a major role in provision of care. Physicians reported numerous challenges in dealing with patients and their families amidst public denial fueled due to ill-formed government policies. This included interruption of funeral rites which undermined public trust. The study provides insights into the local moral world of two healthcare institutions in Pakistan., (© 2023 John Wiley & Sons Ltd.)

Background: This study updates our findings from the COVID-19 pandemic surveillance we first conducted in South Asia in 2020 with 2 additional years of data for the region. We assess whether COVID-19 had transitioned from pandemic to endemic at the point the World Health Organization (WHO) ended the public health emergency status for COVID-19 on May 5, 2023., Objective: First, we aim to measure whether there was an expansion or contraction in the pandemic in South Asia around the WHO declaration. Second, we use dynamic and genomic surveillance methods to describe the history of the pandemic in the region and situate the window of the WHO declaration within the broader history. Third, we aim to provide historical context for the course of the pandemic in South Asia., Methods: In addition to updating the traditional surveillance data and dynamic panel estimates from our original study, this study used data on sequenced SARS-CoV-2 variants from the Global Initiative on Sharing All Influenza Data (GISAID) to identify the appearance and duration of variants of concern. We used Nextclade nomenclature to collect clade designations from sequences and Pangolin nomenclature for lineage designations of SARS-CoV-2. Finally, we conducted a 1-sided t test to determine whether regional weekly speed or transmission rate per 100,000 population was greater than an outbreak threshold of 10. We ran the test iteratively with 6 months of data across the sample period., Results: Speed for the region had remained below the outbreak threshold for over a year by the time of the WHO declaration. Acceleration and jerk were also low and stable. While the 1-day persistence coefficients remained statistically significant and positive (1.168), the 7-day persistence coefficient was negative (-0.185), suggesting limited cluster effects in which cases on a given day predict cases 7 days forward. Furthermore, the shift parameters for either of the 2 most recent weeks around May 5, 2023, did not indicate any overall change in the persistence measure around the time of the WHO declaration. From December of 2021 onward, Omicron was the predominant variant of concern in sequenced viral samples. The rolling t test of speed equal to 10 was statistically insignificant across the entire pandemic., Conclusions: While COVID-19 continued to circulate in South Asia, the rate of transmission had remained below the outbreak threshold for well over a year ahead of the WHO declaration. COVID-19 is endemic in the region and no longer reaches the threshold of the pandemic definition. Both standard and enhanced surveillance metrics confirm that the pandemic had ended by the time of the WHO declaration. Prevention policies should be a focus ahead of future pandemics. On that point, policy should emphasize an epidemiological task force with widespread testing and a contact-tracing system., (©Lori A Post, Alan G Soetikno, Scott A Wu, Claudia Hawkins, Maryann Mason, Egon A Ozer, Robert L Murphy, Sarah B Welch, Yingxuan Liu, Robert J Havey, Charles B Moss, Chad J Achenbach, Alexander L Lundberg. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 26.08.2024.)

Background: The burden of childhood trauma (violence, injury/illness, loss) in low-resource settings is high, although the effect of trauma on children's mental and cognitive health is under-researched. Child gender may moderate the association between trauma and outcomes; boys are more likely to experience trauma, but girls are more likely to show distress following trauma., Methods: We draw on data from the Bachpan cohort (n = 888), a sample of mother-child dyads in rural Pakistan, to investigate these associations among 6-year-old children in a South Asian, low-resource setting. Mothers reported on children's lifetime exposure to 15 possible traumas and their current mental health. In addition, children were assessed for their verbal skills, working memory, and inhibitory control. We estimated trauma prevalence and used generalized estimating equations to test the association between number of traumatic events and child mental health and cognitive skills in the overall sample and by gender., Results: 90.5% of children experienced at least one trauma. The most common traumas were death of a loved one (47%) and hearing about war/terrorism on the TV/radio (48%). On average, boys experienced more traumas (M = 3.00) than girls (M = 2.67). Specifically, boys were more likely than girls to experience an injury or hospitalization (30% vs. 21%, p < .05) and to hear about war/terrorism on the TV/radio (52% vs. 43%, p < .05). Trauma was associated with increased mental health difficulties and increased anxiety scores. There was little evidence that trauma exposure was associated with child cognitive skills. The strength of association between trauma and outcomes was similar for boys and girls., Conclusions: Findings show that childhood trauma exposure is common in this setting and associated with worse mental health problems among young boys and girls. Results suggest that trauma-informed interventions are important for supporting child mental health in South Asia., (© 2024. The Author(s).)

Stroke causes around 730,000 deaths in South Asia, nearly half of stroke-related deaths in developing countries. This highlights the need to address health system responses, considering poverty, service quality, and availability. The article identifies four key challenges in stroke management and rehabilitation in South Asia, emphasizing long-term monitoring, risk factor control, and community surveillance, drawing on experiences from Nepal., Competing Interests: Shiva Raj Mishra serves as a deputy editor in Global Heart. The authors have no competing interests to declare., (Copyright: © 2024 The Author(s).)

The growing health challenges in South Asia require further adaptations of community health worker (CHW) programs as a key element of primary health care (PHC). This paper provides a comparative analysis of CHW programs in five countries (Bangladesh, India, Nepal, Pakistan, and Sri Lanka), examines successes and challenges, and suggests reforms to better ensure highly performing CHW programs. To examine CHW programs in the region, we conducted a narrative review of the peer-reviewed and grey literatures, as well as eliciting opinions from experts. Common roles of CHWs include health education, community mobilization, and community-based services, particularly related to reproductive, maternal, neonatal, and child health. Some countries utilize CHWs for non-communicable diseases and other emerging health issues. To maximize the potential contribution of CHWs to achieving Universal Health Coverage, we recommend future research and policy focus on strengthening existing health systems to support the expansion of CHWs roles and better integrating of CHWs into national PHC systems. This is Paper 4 in the Series on Primary Health Care in South Asia, addressing areas that have the potential to revitalize health systems in South Asian countries., Funding: The authors received financial support from the Department of Health Systems Development, WHO South-East Asia Regional Office (WHO SEAR)., Competing Interests: The authors declare no conflict of interest in writing this manuscript., (© 2024 The Authors.)

This series, "Primary health care in South Asia", is an effort to provide region-specific, evidence-based insights for reorienting health systems towards PHC. Led by regional thinkers, this series draws lessons from five countries in South Asia: Bangladesh, India, Nepal, Pakistan, and Sri Lanka. This is the last paper in the series that outlines points for future action. We call for action in three areas. First, the changing context in the region, with respect to epidemiological shifts, urbanisation, and privatisation, presents an important opportunity to appraise existing policies on PHC and reformulate them to meet the evolving needs of communities. Second, reorienting health systems towards PHC requires concrete efforts on three pillars-integrated services, multi-sectoral collaboration, and community empowerment. This paper collates nine action points that cut across these three pillars. These action points encompass contextualising policies on PHC, scaling up innovations, allocating adequate financial resources, strengthening the governance function of health ministries, establishing meaningful public-private engagements, using digital health tools, reorganising service delivery, enabling effective change-management processes, and encouraging practice-oriented research. Finally, we call for more research-policy-practice networks on PHC in South Asia that can generate evidence, bolster advocacy, and provide spaces for cross-learning., Funding: WHO SEARO funded this paper. This source did not play any role in the design, analysis or preparation of the manuscript., Competing Interests: We declare no conflict of interest., (© 2024 The Authors.)