The role of female community health volunteers in maternal health service provision in Nepal: A qualitative study

Nepal achieved the Millennium Development Goal 5 by reducing its maternal mortality by more than two thirds. This achievement has been credited to Female Community Health Volunteers (FCHVs) delivering basic Maternal Health Service (MHS) to pregnant women and mothers in their communities. This thesis explores the role of FCHVs in MHS provision in two regions (the hill and Terai ), from the perspectives of health workers, service users, and FCHVs themselves. Data were collected between May 2014 and September 2014 using qualitative methods. Semi-structured interviews were conducted with 20 FCHVs, 11 health workers and 26 women in villages. In addition, four focus group discussions were held with 19 FCHVs and field notes were taken throughout the data collection. Data were analysed using thematic analysis. The study found that most participants viewed FCHVs as a valuable resource in improving MHSs. In both regions, the FCHVs raised health awareness among pregnant women or mothers and referred them for check-ups. They shared health messages through mothers' group meetings and the meetings were also used for discussions around budgeting and finance, which sometimes left little time for discussion on health topics. Such activities, combined with the FCHVs’ lack of education, often proved to be counterproductive to their service provision. The roles of FCHVs were crucial in the hill region where there was limited access to professional healthcare. An important area of FCHVs’ work involved accompanying and assisting women during delivery. In addition, they distributed medicines, administered pregnancy tests and informed women about emergency contraception and availability of abortion services. The FCHVs used novel methods to share maternal health information: for example, they sang folk songs which contained health messages or visited new mothers with food hampers. Such services were invaluable for women in the remote hill villages, who otherwise would not have received any healthcare. In terms of their motivations to volunteer, this study found that FCHVs viewed their work as a form of basic human and social responsibility. In addition, they reported feeling empowered as a result of training and socio-economic opportunities. However, a lack of financial and non-financial incentives was the key hindrance for them in delivering their services, followed by their perception of community misunderstanding about their services. In addition, health system factors such as lack of medical supplies and irregular supervision hindered them in carrying out their role effectively. In general, volunteers in the Terai received less support than those in the hill region. Furthermore, FCHVs perceived a lack of respect by some health workers towards them. A lack of coordination between government health centres and non-governmental organisations was also noted. The thesis concludes with several recommendations for policy makers, practitioners and researchers in order to improve the services by FCHVs. These include providing the FCHVs with context specific support - financial and non-financial incentives, access to supplies, educational training, and supportive supervision - to enable them to deliver services more productively. Recommendations are also made for ensuring that FCHVs are recognised and respected for their contribution to MHSs by local health workers and their communities, as well as coordinating activities among local organisations that mobilise FCHVs to ensure that their services flourish in the future

The effectiveness of community engagement and participation approaches in low and middle income countries: contextualisation of review findings to South Asia and Nepal

Community engagement and participation approaches in South Asia and Nepal could be successful in the area of maternal and child health. Policy options should focus on appropriate incentives for volunteers; and local geographical, social, and cultural norms should be taken into account when engaging government, NGOs and the public

The effectiveness of community engagement and participation approaches in low and middle income countries: a review of systematic reviews with particular reference to the countries of South Asia

Community engagement and participation approaches continue to be viewed as important, particularly in low resource settings. Drawing on the general trend in the evidence identified, community engagement and participation approaches have played a role in successful intervention delivery across health system domains and areas of health

Should our academic approach towards researching South asia change due to COVID-19?

As COVID-19 disrupts established research norms, many methodological and ethical questions have come to the forefront of the debate on how we study South Asia. Here Nabeela Ahmed, Sally Cawood, Sarita Panday, Megnaa Mehtta, Glyn Williams, Jiban Kumar Karki and Ankit Kumar (Research collective, University of Sheffield) reflect on their recent discussions on whether researchers should consider changing the way they conduct their work in the wake of the pandemic

Neighbourhood walkability as a moderator of the associations between older adults’ information technology use and social activity: A cross-sectional study with sensitivity analyses

Background Research to date suggests that information technology use by older adults can be positively associated with social activity, but whether neighbourhood walkability can play a role in this relationship has not been investigated. Aim To assess the associations between information technology use and social activity as well as the moderating influences of walkability in these associations. Methods This study adopted a cross-sectional design with sensitivity analyses as well as techniques against common methods bias. The study population was community-dwelling older residents of Accra aged 60 years or higher. A total of 890 older adults participated in this study. The hierarchical linear regression analysis was used to analyse the data. Results Information technology use was found to be positively associated with social activity. Among the three domains of information technology use, only packaged software use assessment was positively associated with social activity. Walkability was found to positively moderate the associations between social activity and information technology use as well as packaged software use assessment. Walkability strengthened the negative association between innovativeness attitude (another domain of information technology use) and social activity. Conclusions Information technology use can facilitate social activity, but experimentation with new information technologies can discourage social engagement, even in higher walkability. Packaged software use assessment, which measures the ability to use packaged software such as WhatsApp, can more significantly support social activity in higher walkability

The Health Consequences of Urbanization in Nepal: Perspectives from a Participatory Photo Project with Recent Rural-Urban Migrants

What new challenges to health do recent rural-to-urban migrants in Nepal face? How do newly urbanized individuals navigate and seek healthcare in the city? This photo essay offers a glimpse of the answers to these questions from the perspective of newly urbanized people living in Kirtipur and Pokhara, two rapidly growing urban areas in Nepal. It draws on a nine-month participatory study which used participatory photography, amongst other methods, to better understand the health opportunities and risks faced by new rural-urban migrants. All photographs presented in this essay were taken and selected by research participants and are accompanied by their narrations of what these images represent to them. Consequently, this essay provides insights into how the newly urbanized themselves understand threats to their health, and how they understand the urban health system they are confronted with as service users

Selection of study sites and participants for research into Nepal’s federal health system

Introduction: This article offers insights into the process of selecting representative study sites and participants in a longitudinal study in Nepal. As part of the research design process, the selection of representative areas in a large-scale study requires both intellectual and practical considerations. Methods: We briefly introduce our study into the impact of federalization on Nepal’s health system before outlining the criteria considered for the identification of fieldwork sites and the most appropriate study participants for the qualitative interviews and participatory components of this research. Findings: The selected areas are presented with an overview of the areas selected and their justification. The study sites and participants should consider a broader coverage with diverse participants’ backgrounds. Several factors can influence the identification and recruitment of the right participants, including the use of appropriate gatekeepers, gaining access to recruit participants, logistical challenges, and participant follow-up. Conclusion: We conclude that longitudinal qualitative research requires a carefully selected diverse set of study sites and participants to assess the complexities and dynamics of the health system and service provision to ensure that longitudinal research is representative and effective in addressing the research question(s) being investigated

Health System Strengthening: The Role of Public Health in Federal Nepal

This article addresses some of the key Public Health approaches around the ongoing federalisation of the state of Nepal and the associated decentralisation processes in its health system. We start by outlining the main roles of the discipline of Public Health and the contribution it can make to the reform process. Then the next section introduces our on-going study into the effects of the establishment of the Federal Republic of Nepal on the organisation and running of the country’s health system. To capture the Public Health benefits of decentralisation, the process should not be only ‘top-down’, directed by policy elites. Although in theory Nepal’s health system has undergone a process of decentralisation, in practice policy and planning is often still being led by the Federal government, despite the clear roles and responsibilities of the three tiers of government in health service delivery. To improve policy and planning in the newly decentralised health system structure, there needs to be meaningful incorporation of the views of stakeholders at all levels (even the very lowest levels). Our project aims to play a part in addressing this by capturing a wide variety of experiences of the decentralisation process

Selection of study sites and participants for research into Nepal’s Federal Health System

Introduction: This article offers insights into the process of selecting representative study sites and participants in a longitudinal study in Nepal. As part of the research design process, the selection of representative areas in a large-scale study requires both intellectual and practical considerations. Methods: We briefly introduce our study into the impact of federalization on Nepal’s health system before outlining the criteria considered for the identification of fieldwork sites and the most appropriate study participants for the qualitative interviews and participatory components of this research. Findings: The selected areas are presented with an overview of the areas selected and their justification. The study sites and participants should consider a broader coverage with diverse participants’ backgrounds. Several factors can influence the identification and recruitment of the right participants, including the use of appropriate gatekeepers, gaining access to recruit participants, logistical challenges, and participant follow-up. Conclusion: We conclude that longitudinal qualitative research requires a carefully selected diverse set of study sites and participants to assess the complexities and dynamics of the health system and service provision to ensure that longitudinal research is representative and effective in addressing the research question(s) being investigated

Participatory policy analysis in health policy and systems research: reflections from a study in Nepal

Background Participatory policy analysis (PPA) as a method in health policy and system research remains underexplored. Using our experiences of conducting PPA workshops in Nepal to explore the impact of the country’s move to federalism on its health system, we reflect on the method’s strengths and challenges. We provide an account of the study context, the design and implementation of the workshops, and our reflections on the approach’s strengths and challenges. Findings on the impact of federalism on the health system are beyond the scope of this manuscript. Main body We conducted PPA workshops with a wide range of health system stakeholders (political, administrative and service-level workforce) at the local and provincial levels in Nepal. The workshops consisted of three activities: river of life, brainstorming and prioritization, and problem-tree analysis. Our experiences show that PPA workshops can be a valuable approach to explore health policy and system issues – especially in a context of widespread systemic change which impacts all stakeholders within the health system. Effective engagement of stakeholders and activities that encourage both individual- and system-level reflections and discussions not only help in generating rich qualitative data, but can also address gaps in participants’ understanding of practical, technical and political aspects of the health system, aid policy dissemination of research findings, and assist in identifying short- and long-term practice and policy issues that need to be addressed for better health system performance and outcomes. Conducting PPA workshops is, however, challenging for a number of reasons, including the influence of gatekeepers and power dynamics between stakeholders/participants. The role and skills of researchers/facilitators in navigating such challenges are vital for success. Although the long-term impact of such workshops needs further research, our study shows the usefulness of PPA workshops for researchers, for participants and for the wider health system. Conclusions PPA workshops can effectively generate and synthesize health policy and system evidence through collaborative engagement of health system stakeholders with varied roles. When designed with careful consideration for context and stakeholders’ needs, it has great potential as a method in health policy and systems research