Female Community Health Volunteers Research Articles

Role of female community health volunteers in the prevention and early detection of chronic kidney disease in Nepal

Role of female community health volunteers in the prevention and early detection of chronic kidney disease in Nepal

Sustainability of a 12-month lifestyle intervention delivered by community health workers in reducing blood pressure in Nepal: 5-year follow-up of the COBIN open-label, cluster randomised trial

The sustainability and scalability of limited-duration interventions in low-income and middle-income countries remain unclear. We aimed to investigate the sustainability in reduction of blood pressure through a 12-month lifestyle intervention led by community health workers to reduce blood pressure in Nepal, 4 years after the intervention ceased. The Community-Based Intervention for Control of Hypertension in Nepal (COBIN) trial was a non-blinded, cluster-randomised trial done in Kaski, Nepal. Adults aged 25-65 years were eligible. People were excluded if they declined consent, were severely ill, unlikely to be in the community throughout the intervention, or pregnant. During the 12-month intervention, female community health volunteers (FCHVs) visited participants in the intervention groups and provided lifestyle counselling and blood pressure measurement every 4 months. At the end of the 12-month intervention, systolic blood pressure was significantly lower in the intervention group than in the usual care group in all cohorts, ranging from -2·3 mm Hg (95% CI -3·8 to -0·8) lower in those with normal blood pressure to -4·9 mm Hg (-7·8 to -2·0) in the hypertensive cohort. The primary outcome for this follow-up study was a mean change in systolic blood pressure from baseline to follow-up at 60 months. We did an intention-to-treat analysis. Between April 1, 2015, and Dec 31, 2015, 1638 participants were recruited in COBIN (939 [57·3%] assigned to intervention and 699 [42·7%] assigned to usual care). Of the 1468 (89·6%) who completed the 12-month assessments, we followed up 1352 (92·1%) participants at 60 months, between Oct 11, 2020, and May 5, 2022. 964 (71·3%) participants were women and 388 (28·7%) were men. From baseline to 60 months, the mean systolic blood pressure increased by 10·4 mm Hg (95% CI 9·1-11·6) in the intervention group and 6·0 mm Hg (4·6-7·5) in the usual care group (adjusted mean difference 4·1 mm Hg [2·2 to 5·8]). Lifestyle counselling and blood pressure monitoring by community health workers is effective in substantially reducing blood pressure while adults are being monitored in a trial but, following cessation of the intervention, this benefit is not maintained in the long term, with potential for harm. This finding could have important implications for funders and research communities to regularly target participants for education and follow-up at an optimal timepoint to reduce any likelihood of harm. Monash University (Melbourne, VIC, Australia) and the Jayanti Memorial Trust (Kathmandu, Nepal). For the Nepali translation of the abstract see Supplementary Materials section.

Assessment of knowledge of diabetes mellitus among female community health volunteers (FCHV) of Jiri, Nepal

Introduction: Type 2 diabetes mellitus (DM) has become a global epidemic with significant disability and premature death. Identification of the level of knowledge related to diabetes among the health workers is important in strategies for prevention of diabetes mellitus. Method: This study was conducted as a community based study in Jiri Hospital in Dolakha district. All the FCHV working in the Dolakha district were selected for this study. Data was collected using Diabetes Knowledge Questionnaire (DKQ). Data was analysed using SPSS programme version 16.0. Result: A total of 90 participants were included in the study. Average score obtained was 15 out of 24. There was not significant association found between educational background and score (p-value=0.8835) No significant difference between the age groups and scores was found (p-value=0.5485). No FCHV’s had received training on diabetes mellitus. Having a family member with diabetes did not impact the obtained score (p-value= 0.9511). Conclusion: This study did not show any relation on knowledge with age, educational background or having a family member with diabetes.

Exploring the feasibility of integrating health, nutrition and stimulation interventions for children under three years in Nepal's health system: A qualitative study.

Community-based primary care settings are a potential entry point for delivering Early Childhood Development (ECD) interventions in Nepal. Past studies have suggested that integrating stimulation with nutrition interventions is an effective way to deliver multiple benefits for children, but there is limited knowledge of how to do this in Nepal. We conducted a qualitative study in Nepal's Dhanusha district to explore how stimulation interventions for early learning could be integrated into existing health and nutrition programmes within the public health system. Between March and April 2021, we completed semi-structured interviews with caregivers (n = 18), health service providers (n = 4), district (n = 1) and national stakeholders (n = 4), as well as policymakers (n = 3). We also carried out focus group discussions with Female Community Health Volunteers (FCHVs) (n = 2) and health facility operation and management committee members (n = 2). We analysed data using the framework method. Respondents were positive about introducing stimulation interventions into maternal and child health and nutrition services. They thought that using health system structures would help in the implementation of integrated interventions. Respondents also highlighted that local governments play a lead role in decision-making but must be supported by provincial and national governments and external agencies. Key factors impeding the integration of stimulation into national programmes included a lack of intersectoral collaboration, poor health worker competency, increased workload for FCHVs, financial constraints, a lack of prioritisation of ECD and inadequate capacity in local governments. Key barriers influencing the uptake of intervention by community members included lack of knowledge about stimulation, caregivers' limited time, lack of paternal engagement, poverty, religious or caste discrimination, and social restrictions for newlywed women and young mothers. There is an urgent need for an effective coordination mechanism between ministries and within all three tiers of government to support the integration and implementation of scalable ECD interventions in rural Nepal.

Health worker perspectives on access to antenatal care in rural plains Nepal during the COVID-19 pandemic.

The COVID-19 pandemic affected access to antenatal care in low and middle-income countries where anaemia in pregnancy is prevalent. We analyse how health workers provided antenatal care and the factors affecting access to antenatal care during the COVID-19 pandemic in Kapilvastu district in the western plains of Nepal. We used qualitative and quantitative methodologies, conducting eight semi-structured interviews with health workers who provided antenatal care during the pandemic, and a questionnaire containing open and closed questions with 52 female community health volunteers. Antenatal care was severely disrupted during the pandemic. Health workers had to find ways to provide care with insufficient personal protective equipment and guidance whilst facing extreme levels of stigmatisation which prevented them from providing outreach services. Pregnant women were fearful or unable to visit health institutions during the pandemic because of COVID-19 control measures. Pre-pandemic and during the pandemic health workers tried to contact pregnant and postpartum women and families over the phone, but this was challenging because of limited access to phones, and required pregnant women to make at least one antenatal care visit to give their phone number. The pandemic prevented new pregnancies from being registered, and therefore the possibilities to provide services over the phone for these pregnancies were limited. To reach the most marginalised during a pandemic or other health emergency, health volunteers and households need to exchange phone numbers, enabling proactive monitoring and care-seeking. Strengthening procurement and coordination between the municipal, provincial, and federal levels of government is needed to ensure adequacy of antenatal supplies, such as iron folic acid tablets, in health emergencies. Community engagement is important to ensure women and families are aware of the need to access antenatal care and iron folic acid, and to address stigmatisation of health workers.

Management of COVID-19 and vaccination in Nepal: A qualitative study.

The aim of this research is to investigate the perspective of citizens of Nepal on the management COVID-19, the roll-out of the vaccine, and to gain an understanding of attitudes towards the governments' handling of the COVID-19 pandemic. A qualitative methodology was used. In-depth interviews were conducted with 18 males and 23 females aged between 20 and 86 years old from one remote and one urban district of Nepal. Interviews were conducted in November and December 2021. A thematic approach was used to analyse the data, utilising NVivo 12 data management software. Three major themes were identified: (1) Peoples' perspective on the management of COVID-19,(2) people's perception of the management of COVID-19 vaccinationand (3) management and dissemination of information. It was found that most participants had heard of COVID-19 and its mitigation measures, however, the majority had limited understanding and knowledge about the disease. Most participants expressed their disappointment concerning poor testing, quarantine, vaccination campaignsand poor accountability from the government towards the management of COVID-19. Misinformation and stigma were reported as the major factors contributing to the spread of COVID-19. People's knowledge and understanding were mainly shaped by the quality of the information they received from various sources of communication and social media. This heavily influenced their response to the pandemic, the preventive measures they followedand their attitude towards vaccination. Our study concludes that the study participants' perception was that testing, quarantine centres and vaccination campaigns were poorly managed in both urban and rural settings in Nepal. Since people's knowledge and understanding of COVID-19 are heavily influenced by the quality of information they receive, we suggest providing contextualised correct information through a trusted channel regarding the pandemic, its preventive measuresand vaccination. This study recommends that the government proactively involve grassroots-level volunteers like Female Community Health Volunteers to effectively prepare for future pandemics. This study was based on in-depth interviews with 41 people from diverse socioeconomic backgrounds. This study would not have been possible without their participation.

Nutritional status and its associated factors among under five years Muslim children of Kapilvastu district, Nepal.

Malnutrition is a major public health problem throughout the world especially in Southeast Asia. This study aims to find out nutritional status and its associated factors among under five Muslim children of Kapilvastu district Nepal. Community based cross-sectional study was conducted among 336 under five Muslim children in Kapilvastu district Nepal from December 2021 to May 2022. Multistage probability random sampling was used. Among ten local units, three were selected randomly. Then from selected three units, two wards from each unit which covers large proportion of Muslim were selected purposively. After selecting wards, listing of household having children 6 to 59 months was done with the help of Female Community Health Volunteers and 56 children were selected by simple random sampling from each wards. About half of Muslim children were underweight, 0.9% were overweight, 17.3% were wasted and 63.1% were stunted. Children with >4 members in family (AOR = 2.82, CI: 1.25-6.38), joint/extended family (AOR = 0.33, CI: 0.16-0.68), living with other than parents (AOR = 2.68, CI: 1.38-5.21), mother having primary (AOR = 2.59, CI: 1.09-6.10) and fathers having SLC and above education (AOR = 0.41, CI: 0.19-0.89), school going children (AOR = 0.27, CI: 0.15-0.48), no having agricultural land (AOR = 2.68, CI: 1.55-4.65), history of chronic diseases (AOR = 3.01, CI = 1.06-8.54) were significantly associated with underweight. Mothers having secondary (AOR = 0.30, CI: 0.10-0.88) and fathers having primary education (AOR = 3.50, CI: 1.26-9.74), school going children (AOR = 0.16, CI: 0.06-0.41), no having own land (AOR = 4.73, CI: 2.13-10.48), history of child chronic disease (AOR = 3.55, CI = 1.38-9.12) were significantly associated with wasting. Similarly, male children (AOR = 1.70, CI: 1.01-2.85), living in rural area (AOR = 0.17, CI: 0.09-0.31), joint/extended family (AOR = 0.28, CI: 0.13-0.64), living with other than parents (AOR = 3.71, CI: 1.84-7.49), fathers having secondary education (AOR = 0.50, CI: 0.27-0.94) and no having own land (AOR = 1.95, CI: 1.13-3.37) were significantly associated with stunting. Underweight, wasting and stunting in under-five Muslim children were above the cutoff point from the significant level of public health and higher than national data. Hence, this study suggests collaborative and immediate attention from responsible governmental and non-governmental organizations working in nutrition for providing informal learning opportunity, intervention regarding parental support to child, school enrolment at appropriate age, prevention and treatment of children's chronic diseases, intervention for income generating activities and addressing problems of household food insecurity among Muslim communities.

PS-P16-8: DIAGNOSIS AND TREATMENT OF HYPERTENSION BY COMMUNITY HEALTH WORKERS IN RURAL NEPAL: MAIN RESULTS OF THE MUTU TRIAL

Objective: To evaluate the effectiveness and safety of a community health worker intervention for diagnosing and managing hypertension (HTN) in rural Nepal. Design & Methods: We conducted a quasi-experimental study in two rural municipalities in Nepal, assigning one as an active site (7 communities) and the other as a comparison site (8 communities, which received enhanced usual care). The intervention in the active site involved three home visits for blood pressure (BP) monitoring and counseling by trained community-based community health workers (Female Community Health Volunteers) and treatment of HTN by trained community health workers based in government Health Posts under physician supervision using a simplified protocol with amlodipine. The comparison site received one home visit by Female Community Health Volunteers. A total of 1428 adults with untreated HTN (systolic BP of 140–179 and/or diastolic BP of 90–119 mm Hg) were enrolled. The primary outcome was a reduction in systolic BP at 12 months (measured in 94% of enrolled participants), and the secondary outcome was HTN control rate defined as BP < 140/90 mm Hg. Results: The mean baseline systolic BP was 145.4 mm Hg in the active site (n = 576, 46% women) and 146.9 mm Hg in the comparison site (n = 760, 46% women). At 12 months, while BP was lower in both sites, mean SBP fell more in the active site [net mean difference of -11.0 mm Hg, (95% CI: -12.5 to -9.6; P < 0.001)] (Table). The corresponding net difference in DBP was -6.0 mm Hg (95% CI: -6.8 to -5.1; P < 0.001). HTN control and medication treatment were both higher in the active site compared to the comparison site (Table). There were four deaths unrelated to the intervention (2 in the comparison site and 2 in the active site). Conclusion: In rural communities of Nepal, a health system intervention with trained community health workers diagnosing and treating hypertension, supervised by a physician, substantially lowered BP and achieved higher control rates compared to usual care. The success of this intervention provides strong support of enhanced roles for community health workers to diagnose and treat HTN. Scaling up such interventions could potentially address the major workforce gaps that lead to low HTN control rates, particularly in rural communities of low and middle-income countries.

PS-P12-9: PERCEPTIONS AND PERSEPECTIVES OF THE COMMUNITY AND HEALTHCARE PROVIDERS ON HYPERTENSION HEALTHCARE-SEEKING BEHAVIOR AND TREATMENT ADHERENCE IN RURAL NEPAL

Objective: The aim of this study was to identify factors influencing healthcare-seeking behavior and treatment adherence of people living with hypertension in the rural municipalities of Sindhupalchok District, Nepal. In the context of patient-provider relationships and power dynamics, this qualitative study explored and described the perceptions and perspectives of hypertensive patients, formally diagnosed within the past six months, and of their healthcare providers on the encountered challenges, barriers and facilitators in seeking healthcare and adhering to their prescribed treatment regimen for hypertension. Design and method: Semi-structured in-depth interviews were conducted with 20 patients living with hypertension, five healthcare providers and four political leaders in Sindhupalchok District, Nepal. Additionally, two focus group discussions were carried out with ten female community health volunteers who conduct outreach work. Participants were recruited through purposive sampling via snowball and opportunistic sampling techniques from government-run health facilities. The socio-ecological model developed by Mcleroy et al. (1988) was applied. The data collected were transcribed verbatim and translated into English language, and thematically analyzed using NVivo software. Results: Several factors influenced the healthcare-seeking behavior and treatment adherence of hypertensive patients living in the rural municipalities of Sindhupalchok District, Nepal. They consisted of intrapersonal or individual factors (health literacy, knowledge, awareness and perception of disease risk factors, perceived sovereignty and autonomy over ones biological body, symptoms, manifestations and complications), interpersonal factors (family and peer support as well as interactions with the healthcare provider and their perceived authority over the patient), community factors (misconceptions about modern treatments, ayurvedic medicine, community health workers motivations to serve the community), and organizational and governmental factors (misinformation about service provision, accessibility and affordability of healthcare, trust in government authorities). Conclusions: Findings from this study indicate the importance of considering the four major layers and components of the socio-ecological model to understand the healthcare-seeking behavior and treatment adherence of people living with hypertension in the rural communities of Sindhupalchok District, and to design culturally appropriate, low-cost community-based interventions that can improve health service uptake. Taking actions to address the challenges faced by the formal healthcare system in educating patients about health literacy, raising awareness about hypertension risk factors, causes and prevention strategies, building loyalty within the community, conducting routine at-home screening, referrals to primary health facilities and door-to-door distribution of medicines by trusted members of the community are urgently needed to improve acceptance of care and treatment adherence of this chronic non-communicable disease.

Knowledge and Practice of Breast Self-Examination among Female Community Health Volunteers in Dharan Sub-Metropolitan City, Province No. 1, Nepal

Background: Regular breast self-examination is the most cost-effective method for the early detection of breast cancer. Female community health volunteers (FCHVs) could play an important role in teaching the community about breast self-examination (BSE). We aimed to assess the knowledge and practice of breast self-examination among FCHVs. Methods: Descriptive cross-sectional study was conducted using the census sampling method to select FCHVs from all 20 wards of Dharan sub-metropolitan city. Face-to-face interview was conducted using a semi-structured questionnaire to collect information related to the knowledge of BSE from consenting participants. The practice of BSE was assessed through direct observation of BSE by using a checklist. Descriptive and inferential statistical analysis was done using SPSS version 10.0. The level of significance was set at 0.05. Results: A total of 95 FCHVs (out of 107) were enrolled in the survey. The mean age (SD) of the study participants was 42.45 (8.97) years; 85.3% were married and majority (64.2%) had completed secondary level of education. The majority of the FCHVs, 65 (68.4%), earned monetary income less than NPR.7000.00 per month. The majority, 82 (86.3%), of the FCHVs had adequate knowledge but only 21 (22.2%) respondents had ever practiced BSE. No significant association was found between the knowledge and practice of BSE with the selected demographic variables such as age, marital status, educational level, age at menarche, and menopause. Conclusion: The FCHVs had adequate knowledge but poor practice regarding BSE. Training should be emphasized to improve their practice of BSE.

Anxiety, Depression, and Stress among Female Community Health Volunteers during COVID-19 Pandemic in Province 1, Nepal

Introduction Female Community Health Volunteers (FCHVs) are an integral part of various community-based health programs visiting households and communities to screen for diseases, risk factors and educate on basic health issues. A profound and wide range of psychological health issues (anxiety, stress, and depression) at the individual, community, and international levels has been reported during the COVID-19 outbreaks. Methods An analytical cross-sectional study design was used to assess the anxiety, depression, and stress level among rural and urban FCHVs during the COVID-19 in Province 1. A multistage random sampling technique was be used the select the sample. The total sample size was 384. Semi-structured structured valid Depression, Anxiety and Stress Scale (DASS-21) was used for measuring the Depression, Anxiety, and Stress level of FCHVs. Descriptive analysis i.e. frequency, percentage, mean, median, and standard deviation was used to assess the level of anxiety, depression, and stress among adults. Inferential analysis i.e. logistic regression was used to find the association between dependent and selected demographic variables. Findings The study revealed that the prevalence of extremely severe levels of anxiety was 35.5 % of the Female Community Health Volunteers (FCHVs) 23.4% of moderate level of stress and 21.6% of respondents were a severe level of depression respectively. There is significant association between level anxiety and ethnicity (p=0.040; OR=1.562; CI=1.021-2.390), occupation (p=0.013; OR=3.861; CI=1.325-11.249) and place of residence (p≤ 0.001; OR=1.959; CI=1.470-3.413). There is significant association between level stress and occupation (p=0.037; OR=3.363; CI=1.074-10.531) place of residence (p=0. 005; OR=1.817; CI=1.193-2.767). There is significant association between level depression and ethnicity, occupation (p≤0.001; OR=2.117; OR=1.391-3.222) and place of residence (p=0. 026; OR=3.371; CI=1.158-9.812). The study concluded that the female community Health Volunteers was mild, moderate, severe and extremely severe level of anxiety, stress and depression level so prompt psychiatric intervention to enhance the mental wellbeing of FCHVs.

Training program for female community volunteers to combat COVID 19 in rural Nepal

ABSTRACT Female Community Health Volunteers (FCHV) in Nepal have identified lack of appropriate training as a barrier to involvement in the COVID 19 response. With more than 50,000 FCHVs serving rural areas of Nepal, they are instrumental in healthcare and are a major source of information delivery to those with the most limited health-care access in Nepal. This communication describes an innovative training programme to rapidly equip FCHVs with knowledge on COVID 19 response. The ongoing programme leverages partnerships between local municipalities and a local community-based organisation and has rapidly trained more than 300 FCHVs across four districts with a population of 1,000,000, and has plans to expand the training across the country. This training programme is a key example of how local partnerships can be utilised for digital training of FCHVs in remote parts of Nepal and leveraged to strengthen response capacity during the pandemic.

Critical success factors for high routine immunization performance: A case study of Nepal

IntroductionThe essential components of a vaccine delivery system are well-documented, but robust evidence on how and why the related processes and implementation strategies drive catalytic improvements in vaccination coverage are not well established. To address this gap, we identified critical success factors that may have led to substantial improvements in routine childhood immunization coverage in Nepal from 2000 through 2019. MethodsWe identified Nepal as an exemplar in the delivery of early childhood immunization through analysis of DTP1 and DTP3 coverage data. Through interviews and focus group discussions at the national, regional, district, health post, and community level, we investigated factors that contributed to high and sustained vaccine coverage. We conducted a thematic analysis through application of implementation science frameworks to determine critical success factors. We triangulated these findings with quantitative analyses using publicly available data. ResultsThe following success factors emerged: 1) Codification of health as a human right, - along with other vaccine-specific legislation - ensured the stability of vaccination programming; 2) National and multi-national partnerships supported information sharing, division of labor, and mutual capacity building; 3) Pro-vaccine messaging through various mediums, which was tailored to local needs, generated public awareness; 4) Female Community Health Volunteers educated community members as trusted and compassionate neighbors; and 5) Cultural values fostered collective responsibility and community ownership of vaccine coverage. ConclusionThis case study of Nepal suggests that the success of its national immunization program relied on the engagement and understanding of the beneficiaries. The immunization program was supported by consistent and reliable commitment, collaboration, awareness, and collective responsibility between the government, community, and partners. These networks are strengthened through a collective dedication to vaccination programming and a universal belief in health as a human right.

Facilitators and barriers to participation in health mothers’ groups in improving maternal and child health and nutrition in Nepal : A mixed-methods study

BackgroundIn Nepal, Health Mother’s Groups (HMG) are women’s group-based programmes for improving maternal and child health. However, they remain underutilised with only 27% of reproductive-aged women participating in an HMG meeting in 2016. This study aimed to understand the facilitators and barriers to HMG meeting participation.MethodsWe conducted a convergent mixed-methods study using cross-sectional quantitative data from the 2016 Nepal Demographic and Health Survey and primary data collected via 35 in-depth interviews and eight focus group discussions with 1000-day women and their family members, female community health volunteers (FCHVs) and health facility staff in two geographies of Nepal, Kaligandaki and Chapakot. Quantitative data were analysed using logistic regression and qualitative data using deductive coding. The results were triangulated and thematically organised according to the socio-ecological model (SEM).ResultsFacilitators and barriers emerged across individual, interpersonal and community levels of the SEM. In the survey, women with more children under five years of age, living in a male-headed household, or in rural areas had increased odds of HMG participation (p < 0.05) while belonging to the Janajati caste was associated with lower odds of participation (p < 0.05). Qualitative data helped to explain the findings. For instance, the quantitative analysis found women’s education level associated with HMG participation (p < 0.05) while the qualitative analysis showed different ways women’s education level could facilitate or hinder participation. Qualitative interviews further revealed that participation was facilitated by women’s interest in acquiring new knowledge, having advanced awareness of the meeting schedule and venue, and engagement with health workers or non-government organisation staff. Participation was hindered by the lack of meeting structure and work obligations during the agricultural season.ConclusionsTo improve women’s participation in HMGs in Nepal, it is necessary to address factors at the SEM’s individual, interpersonal, and community levels, such as enhancing FCHV literacy, providing advance notice of the meeting schedule, upgrading the meeting venues and reducing women’s workload through family support, particularly during agricultural season. These improvements are essential for strengthening effective implementation of HMG meetings and similar women’s group-based platforms, and for ultimately improving maternal and child health in Nepal.

Effect of a female community health volunteer-delivered intervention to increase cervical cancer screening uptake in Nepal: a cluster randomized controlled trial

This study aimed to assess the effect of Female Community Health Volunteer (FCHV)-delivered intervention to increase cervical cancer screening uptake among Nepalese women. A community-based, open-label, 2-group, cluster randomized controlled trial (CRCT) was conducted in a semi-urban setting in Western Nepal. Fourteen clusters (1:1) were randomly assigned to the intervention group, which received a 12-month intervention delivered by FCHVs or the control group (usual care). Between April and June 2019, 690 women aged 30–60 years were recruited for CRCT during the baseline survey. A follow-up assessment was conducted after the completion of the 12 months intervention. The primary outcome was the change in cervical cancer screening from baseline to 12-month follow-up. Of 690 women, 646 women completed the trial. 254 women in the intervention group and 385 women in the control group were included in the primary outcome analysis. There was a significant increase in cervical cancer screening uptake in the intervention group [relative risk (RR), 1.48; 95 % confidence interval (CI) 1.32, 1.66; P < 0.01)], compared to the control group. The secondary outcome was the change in median knowledge score among women that increased from 2 [interquartile range (IQR) 1–4] (baseline) to 6 [IQR 3–9] (follow-up) in the intervention group. However, the median knowledge score remained almost the same among women in the control group 2 [IQR 1–5] to 3 [IQR 2–5]. Our study findings reported that an FCHV-delivered intervention significantly increased cervical cancer screening uptake among women living in a semi-urban setting in Nepal.Trial registration: ClinicalTrials.gov NCT03808064.

Using mobile health to strengthen the communication skills for effective delivery of health information in Nepal: A qualitative study of the perspectives of Female Community Health Volunteers

Background Female Community Health Volunteers (FCHVs) play an important role in linking community members-particularly marginalised and vulnerable women and health facilities in Nepal. There has been increased use of mobile phones amongst FCHVs and their support to improve the quality of health services FCHVs provide, with positive results. Under the leadership of Ministry of Health and Population (MoHP), Department of Health Services (DoHS), and investment by the UK Department for International Development (DFID) via Nepal Health Sector Support Programme 3 (NHSSP 3), BBC Media Action designed and tested an innovative mobile phone-based solution that can best support FCHVs in their work as health promoters in local communities. This study aimed to examine the changes in the FCHVs-beneficiary interaction and communication since the introduction of a mobile-based intervention (Mobile Chautari). Methods A qualitative study was conducted in three districts of Nepal: Tehrathum, Darchula and Rautahat using in-depth interviews, focus group discussions with FCHVs, pregnant women and mothers with children less than 5 years old, mothers-in-law, and health facility staff. In addition, observation of Health Mothers Group (HMG) meeting was also conducted. Data analysis was conducted using thematic analysis. Results The mHealth intervention was acceptable to the FCHVs and the use of Mobile Chautari helped FCHVs recognise the value of communication aids and facilitate effective discussions in HMG meeting. FCHVs felt more confident when talking about health issues and communicated more effectively with diverse beneficiaries. FCHVs felt that Mobile Chautari improved their status in the communities, which also helped enhance trust between FCHVs and communities. Conclusions Mobile Chautari has the potential to strengthen the communication skills of FCHVs and bridge the gap between the FCHVs and their beneficiaries. Mobile Chautari appears to be a promising way to communicate health related information and communicate with diverse clients. In the short period the study has been able to show the potential of Mobile Chautari and how it could support positive behaviour change.

Sustaining Agriculture and Nutrition Interventions: Continued Engagement of Village Model Farmers in Nepal.

In homestead food production (HFP) programs, village model farmers (VMFs), after training, implement agriculture and nutrition activities to improve household knowledge and practices. Little evidence exists on what enables VMFs to remain actively engaged and for impacts to be sustained. To examine variables explaining active engagement of VMFs, at least 4 years post-training, in an HFP program in Nepal. We used cross-sectional data, collected from 2018 to 2019, among 4750 VMFs of Suaahara, a multisectoral nutrition program. We assessed whether respondents registered their HFP group with the local government, conducted regular group meetings, discussed vegetable growing and chicken rearing practices with group members, or engaged in saving and credit activities in their HFP group. Outcome variable was a count of these 4 activities in which the VMF engaged. Socioeconomic, demographic, and programmatic explanatory variables were identified a priori and by bivariate analysis and were adjusted in ordinal regression models accounting for clusters. On average, VMFs engaged in 1.4 activities. Having attended primary or secondary school (adjusted odds ratios [AOR] = 1.39), being a female community health volunteer (AOR = 1.27), being from an advantaged caste/ethnic group (AOR = 1.34), receiving additional trainings (AOR = 1.56) and inputs (AOR = 1.31) were associated with more active engagement of VMFs. Village model farmers receiving more training and inputs were more likely to remain actively engaged. Female community health workers, people from higher caste/ethnic groups, and those with primary or secondary education were more likely to remain active VMFs and could be targeted for this role in HFP programs leading to sustained impact.

A Quality Improvement Initiative to Enhance the Treatment of Children With Severe Acute Malnutrition in Nepal

ObjectivesDespite being implemented for decades, Nepal’s Integrated Management of Acute Malnutrition program has experienced several implementation challenges such as low coverage, stock outs of ready-to-use therapeutic food supplies, poor reporting, loss to follow up and sub-optimal counselling. To address these and build a culture of continuous service delivery improvement, the Suaahara-II program adopted and assessed a quality improvement (QI) approach. MethodsChange ideas, including increasing case identification through various platforms, developing QA standards to measure service quality, and providing incentives for female community health volunteers, were implemented as part of the QI initiative in four pilot municipalities. To assess changes in outcomes such as cure rate and number of cases identified and lost to follow-up, baseline information was collected over six months pre-implementation and performance was monitored throughout the QI implementation cycle of 17 months (February 2019—June 2021). We also analyzed secondary data from the government health management information system and established a monitoring mechanism to ensure data quality for outcome measures. For the outcome measure of service quality score, we developed a quality assurance (QA) checklist to score services while treating children with severe acute malnutrition (SAM). ResultsOur findings suggest that the QI effort was effective. The SAM cure rate increased from 67.4% pre-implementation to 80% post-implementation and the loss-to-follow-up rate declined from 26% to 8%. The number of new SAM cases fluctuated between 0–20 cases per month likely due to restrictions to mobility caused by the COVID-19 pandemic. Although there is no comparison to facilities that did not participate in the QI pilot, those that did had an average quality assurance score of 82.4%–above the 80% benchmark. ConclusionsWe found that the QI approach helped improve SAM cure rate, limited loss-to-follow-up and improved quality of case management for children with SAM. To successfully and sustainably implement QI to improve service delivery, leadership and local government accountability, regular coaching support and collaborative team efforts are key. Funding SourcesUnited States Agency for International Development (USAID).

Health Mothers’ Groups in Nepal: Barriers, Facilitators, and Recommendations

BackgroundNepal’s female community health volunteers (FCHVs) each lead a monthly health mothers’ group (HMG) to share health-related information and engage communities in the health system. Suaahara II (SII), a US Agency for International Development–funded multisectoral nutrition program, uses social and behavior change interventions to promote HMG participation and uses its health systems interventions to strengthen HMG quality. ObjectivesThis study aimed to explore HMG functionality and variation across Nepal, including barriers and facilitators to attending HMG meetings. MethodsSII’s cross-sectional annual survey data from 16 districts (n = 192 FCHVs and 1850 mothers with children <2 y) were used. Descriptive and logistic regression analyses were conducted where the outcome variable was whether mothers were active HMG members or not, with FCHV and maternal characteristics as explanatory variables. Qualitative data were obtained from 3 of 16 survey districts (n = 30 observations, n = 30 in-depth interviews with mothers, and n = 16 focus group discussions with mothers, family members, FCHVs, health workers, and SII staff). ResultsAmong FCHVs, 90% reported facilitating HMG meetings, whereas 64% of mothers reported HMG availability, and only 25% reported participating actively in meetings. Household head sex, maternal age, maternal education, maternal self-efficacy, and engagement with an FCHV and SII were associated with whether mothers were active participants in HMG meetings. Qualitative findings highlighted systems-level barriers, including lack of FCHV skills, demotivation, and heavy workload. Mothers noted time as the major constraint and family support, the HMG’s savings component, and active FCHVs as facilitators to participation. ConclusionsFindings suggest that both supply- and demand-side solutions are needed to improve HMG performance and uptake in Nepal. These solutions need to include improving FCHV skills and motivating them to provide high-quality HMG services, as well as encouraging family members to support women so that they have time to participate in the HMGs.

Community-based management of chronic obstructive pulmonary disease in Nepal-Designing and implementing a training program for Female Community Health Volunteers.

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality in Nepal. Female community health volunteers (FCHVs) have proven effective in the delivery of reproductive, maternal, and child health services in Nepal and recently in the prevention and management of hypertension and type 2 diabetes. Evidence on their roles in COPD management is not yet available. The aim of this study was to develop, implement, and evaluate a training program for FCHVs regarding COPD prevention and management. The training program was part of a cluster-randomized trial of a 12-month intervention to improve COPD outcomes in a semi-urban area of Western Nepal. A six-day workshop consisting of thirty hours of training was developed for FCHVs. Training materials incorporated introduction to COPD, risk factors and symptoms, COPD status assessment guide for FCHVs, guidance on breathing techniques, and exercises for people living with COPD. Pre- and post-test questionnaires were administered to assess the change in knowledge of FCHVs, post training skills assessment followed by semi-structured interviews assessed FCHVs' satisfaction with the training program. The findings of the pre- and post- test assessments showed a significant improvement in FCHVs' COPD-related knowledge from a median (interquartile range) score of 12 (3-16) before to 21 (21-22) (p<0.001) after the training program. The qualitative assessment revealed the feasibility of FCHVs' training on COPD and their acceptability to deliver the intervention package within the community. It also indicated that implementing future training with an extended period and a few days break in-between could enhance the effectiveness. Training of FCHVs in COPD management is feasible and leads to improvement in knowledge. The motivation shown by FCHVs to deliver the intervention could inform and guide community programs and policies for COPD prevention and management in Nepal and similar settings.