Perceived barriers to accessing Female Community Health Volunteers' (FCHV) services among ethnic minority women in Nepal: A qualitative study

Exploring the motivations of female community health volunteers in primary healthcare provision in rural Nepal: A qualitative study

Motivating Community Health Workers (CHWs)-many of whom are volunteers-is crucial for achieving Universal Healthcare Coverage (UHC) for Primary Healthcare (PHC) in resource-poor areas. In rural Nepal, PHC is mostly delivered by female CHWs, locally known as Female Community Health Volunteers (FCHVs), but little is known about them. This paper explores experiential factors influencing FCHVs' motivations, including how motivation intersects with women's livelihoods and consider what this means for achieving PHC in Nepal and globally. We conducted qualitative research in the hill and the Terai (flatland bordering India) areas of Nepal. Data were purposively collected through 31 semi-structured interviews (20 volunteers, 11 paid local health workers) and three focus group discussions with additional 15 volunteers. All interviews were audio-recorded, transcribed verbatim in Nepali and translated into English. Data were coded using NVivo10, analysed thematically at individual, organisational and community levels. FCHVs' motivations to volunteer was affected in several ways. At the individual level, participants wanted and were committed to voluntary work, yet the opportunity costs of volunteering, out-of-pocket expenditure and inadequate family support strained many of the women who were already overburdened. At the community level, perceived lack of appreciation of volunteer efforts by community members, who saw volunteers as paid health workers, undermined FCHVs motivation to volunteer. Finally, at the organizational level, a bureaucratic emphasis on recording and reporting, and lack of respect from local health workers undermined their motivation at work. Our paper illustrates how FCHVs from some of the poorest backgrounds can be highly motivated to volunteer, yet inadequate social and economic support across individual, organisational and community levels undermined this motivation, the security of their livelihoods, and thus wider efforts to achieve PHC. Financial investments are needed to compensate FCHVs, so that they remain motivated to deliver global health goals for PHC.

An anthropological history of Nepal's Female Community Health Volunteer program: gender, policy, and social change

BACKGROUND

Community health workers (CHWs) are central to Primary Health Care globally. Amidst the current flourishing of work on CHWs, there often is a lack of reference to history-even in studies of programs that have been around for decades. This study examines the 35-year trajectory of Nepal's Female Community Health Volunteers (FCHVs).

METHODS

We conducted a content analysis of an archive of primary and secondary research materials, grey literature and government reports collected during 1977-2019 across several regions in Nepal. Documents were coded in MAXQDA using principles of inductive coding. As questions arose from the materials, data were triangulated with published sources.

RESULTS

Looking across four decades of the program's history illuminates that issues of gender, workload, and pay-hotly debated in the CHW literature now-have been topics of discussion for observers and FCHVs alike since the inception of the program. Following experiments with predominantly male community volunteers during the 1970s, Nepal scaled up the all-female FCHV program in the late 1980s and early 1990s, in part because of programmatic goals focused on maternal and child health. FCHVs gained legitimacy as health workers in part through participation in donor-funded vertical campaigns. FCHVs received a stable yet modest regular stipend during the early years, but since it was stopped in the 1990s, incentives have been a mix of activity-based payments and in-kind support. With increasing outmigration of men from villages and growing work responsibilities for women, the opportunity cost of health volunteering increased. FCHVs started voicing their dissatisfaction with remuneration, which gave rise to labor movements starting in the 2010s. Government officials have not comprehensively responded to demands by FCHVs for decent work, instead questioning the relevance of FCHVs in a modern, medicalized Nepali health system.

CONCLUSIONS

Across public health, an awareness of history is useful in understanding the present and avoiding past mistakes. These histories are often not well-archived, and risk getting lost. Lessons from the history of Nepal's FCHV program have much to offer present-day debates around CHW policies, particularly around gender, workload and payment.

Unsung heroes in Ghana's healthcare system: the case of community health volunteers and community health management committee

BACKGROUND

In Ghana, the community-based health planning and services (CHPS) policy highlights the significance of both community health management committees (CHMCs) and community health volunteers (CHVs) in the Ghanaian health system. However, research into their specific effects on health system improvement is scarce. Some research has focussed on the roles of the CHMCs/CHVs in implementing specific targeted health interventions but not on improving the overall health system. Therefore, this research aims to examine the role of the CHMCs and CHVs in improving the Ghanaian health system.

METHODS

The study was conducted in three districts in the Ashanti region of Ghana. A total of 35 participants, mainly health service users and health professionals, participated in the study. Data were collected using semi-structured individual in-depth interviews. Participants were selected according to their patient-public engagement or community health activity roles. Data were transcribed and analysed descriptively using NVIVO 12 Plus.

RESULTS

We found that the effectiveness of CHMCs and CHVs in health systems improvement depends largely on how members are selected. Additionally, working through CHMC and CHVs improves resource availability for community health services, and using them in frontline community health activities improves health outcomes.

CONCLUSIONS

Overall, we recommend that, for countries with limited healthcare resources such as Ghana, leveraging the significant role of the CHMCs and CHVs is key in complementing government's efforts to improve resource availability for healthcare services. Community health management committees and CHVs are key in providing basic support to communities with limited healthcare personnel. Thus, there is a need to strengthen their capacities to improve the overall health system.

Assessing food-based strategies to address anaemia in pregnancy in rural plains Nepal: a mixed methods study

Anaemia in pregnancy is a persistent health problem in Nepal and could be reduced through nutrition counselling and strengthened iron folic acid supplementation programmes. We analysed 24-hour diet recall data from 846 pregnant women in rural plains Nepal, using linear programming to identify the potential for optimised food-based strategies to increase iron adequacy. We then conducted qualitative research to analyse how anaemia was defined and recognised, how families used food-based strategies to address anaemia, and the acceptability of optimised food-based strategies. We did 16 interviews of recently pregnant mothers, three focus group discussions with fathers, three focus group discussions with mothers-in-law and four interviews with key informants. Dietary analyses showed optimised diets did not achieve 100 % of recommended iron intakes, but iron intakes could be doubled by increasing intakes of green leaves, egg and meat. Families sought to address anaemia through food-based strategies but were often unable to because of the perceived expense of providing an 'energy-giving' diet. Some foods were avoided because of religious or cultural taboos, or because they were low status and could evoke social consequences if eaten. There is a need for counselling to offer affordable ways for families to optimise iron adequacy. The participation of communities in tailoring advice to ensure cultural relevance and alignment with local norms is necessary to enable its effectiveness.

Contextual factors affecting the implementation of an anemia focused virtual counseling intervention for pregnant women in plains Nepal: a mixed methods process evaluation

BACKGROUND

Anemia is estimated to cause 115,000 maternal deaths each year. In Nepal, 46% of pregnant women have anemia. As part of an integrated anemia-prevention strategy, family engagement and counseling of pregnant women can increase compliance to iron folic acid tablets, but marginalized women often have lower access to these interventions. We implemented the VALID (Virtual antenatal intervention for improved diet and iron intake) randomized controlled trial to test a family-focused virtual counseling mHealth intervention designed to inclusively increase iron folic acid compliance in rural Nepal; here we report findings from our process evaluation research.

METHODS

We conducted semi structured interviews with 20 pregnant women who had received the intervention, eight husbands, seven mothers-in-laws and four health workers. We did four focus groups discussions with intervention implementers, 39 observations of counseling, and used routine monitoring data in our evaluation. We used inductive and deductive analysis of qualitative data, and descriptive statistics of monitoring data.

RESULTS

We were able to implement the intervention largely as planned and all participants liked the dialogical counseling approach and use of story-telling to trigger conversation. However, an unreliable and inaccessible mobile network impeded training families about how to use the mobile device, arrange the counseling time, and conduct the counseling. Women were not equally confident using mobile devices, and the need to frequently visit households to troubleshoot negated the virtual nature of the intervention for some. Women's lack of agency restricted both their ability to speak freely and their mobility, which meant that some women were unable to move to areas with better mobile reception. It was difficult for some women to schedule the counseling, as there were competing demands on their time. Family members were difficult to engage because they were often working outside the home; the small screen made it difficult to interact, and some women were uncomfortable speaking in front of family members.

CONCLUSIONS

It is important to understand gender norms, mobile access, and mobile literacy before implementing an mHealth intervention. The contextual barriers to implementation meant that we were not able to engage family members as much as we had hoped, and we were not able to minimize in-person contact with families. We recommend a flexible approach to mHealth interventions which can be responsive to local context and the situation of participants. Home visits may be more effective for those women who are most marginalized, lack confidence in using a mobile device, and where internet access is poor.

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.

The experiences and challenges of community health volunteers as agents for behaviour change programming in Africa: a scoping review

Community health volunteers are considered a vital part of the community health structure in Africa. Despite this vital role in African health systems, very little is known about the community health volunteers’ day-to-day lived experiences providing services in communities and supporting other health workers. This scoping review aims to advance understanding of the day-to-day experiences of community health volunteers in Africa. In doing so, this review draws attention to these under-considered actors in African health systems and identifies critical factors and conditions that represent challenges to community health volunteers’ work in this context. Ultimately, our goal is to provide a synthesis of key challenges and considerations that can inform efforts to reduce attrition and improve the sustainability of community health volunteers in Africa. This scoping review was conducted using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews checklist to achieve the objectives. A comprehensive search of six databases returned 2140 sources. After screening, 31 peer-reviewed studies were selected for final review. Analytical themes were generated based on the reviewers’ extraction of article data into descriptive themes using an inductive approach. In reviewing community health volunteers’ accounts of providing health services, five key challenges become apparent. These are: (1) challenges balancing work responsibilities with family obligations; (2) resource limitations; (3) exposure to stigma and harassment; (4) gendered benefits and risks; and (5) health-system level challenges. This scoping review highlights the extent of challenges community health volunteers must navigate to provide services in communities. Sustained commitment at the national and international level to understand the lived experiences of community health volunteers and mitigate common stressors these health actors face could improve their performance and inform future programs.

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

BACKGROUND

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.

OBJECTIVE

To examine variables explaining active engagement of VMFs, at least 4 years post-training, in an HFP program in Nepal.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

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

Background

In 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.

Methods

We 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).

Results

Facilitators 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.

Conclusions

To 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.

Respectful Maternity Care in South Asia: What Does the Evidence Say? Experiences of Care and Neglect, Associated Vulnerabilities and Social Complexities

Background

Respectful maternity care encompasses the right to continuity of care and dignified support for women during the reproductive period, enabling informed choice. However, the evidence is limited in the context of South Asia region where maternal, perinatal and newborn mortality is still a critical challenge to health systems. Evidence is required to better understand the context of respectful maternity care to inform directions for appropriate policy and practice.

Objective

The objective of this scoping review was to explore facilitators and barriers of respectful maternity care practice in South Asia.

Design

CINAHL, EMBASE, PubMed, Medline, SCOPUS and Cochrane databases were used to identify related studies. Data were systematically synthesized and analysed thematically.

Findings

There was considerable heterogeneity in the 61 included studies from seven South Asian countries, with most of the research conducted in Nepal and India. While the experience of abuse and neglect was common, 10 critical themes emerged related to neglected choices and compromised quality of care (particularly where there were health inequities) in the context of institutional care experiences; and the imperative for improved investment in training and significant policy and legislative change to enforce equitable and respectful maternity care practice.

Conclusions and Implications for Practice

Evidence about respectful maternity care in South Asia indicates that women accessing professional and facility-based services experienced high levels of disrespect, abuse and maltreatment. Women from vulnerable, socially disadvantaged and economically poor backgrounds were more likely to experience higher level abuse and receive poor quality of care. There is an urgent need for a well-resourced, sustained commitment to mandate and support the provision of respectful and equitable maternity care practice in South Asia.

Gender and Antimicrobial Resistance: What Can We Learn From Applying a Gendered Lens to Data Analysis Using a Participatory Arts Case Study?

Antimicrobial resistance (AMR), the natural process by which bacteria become resistant to the medicines used to kill them, is becoming one of the greatest threats to health globally. AMR is accelerating at alarming rates due to behaviors across human, animal, and environmental health sectors as well as governance and policy shortfalls across each sector. Antimicrobial resistant infections occur through the same channels as other infectious diseases and are most common in countries/areas where there is limited access to improved sanitation facilities, reliable healthcare and health education. At the community level, much remains to be understood about the drivers of antimicrobial resistance and how to generate community-led, acceptable solutions. Gender can influence every part of an individual's health experiences; access to knowledge, healthcare facilities, financial resources and paid employment are all heavily gendered and influence behaviors relating to the procurement of antimicrobial and antibiotic agents. This analysis uses data gathered during a participatory video study designed to work with two communities in Nepal to understand drivers of antibiotic mis and over use from the perspective of the communities themselves. Findings reveal that gender impacts upon many aspects of AMR-driving behaviors within this community and stimulate essential discussion as to the importance of gender in future AMR research. This paper places a spotlight on gender in the wider AMR conversation, an area that is currently neglected, and improve our collective knowledge on the drivers of AMR from a gendered perspective.

Community health workers and health equity in low- and middle-income countries: systematic review and recommendations for policy and practice

Background

The deployment of Community Health Workers (CHWs) is widely promoted as a strategy for reducing health inequities in low- and middle-income countries (LMIC). Yet there is limited evidence on whether and how CHW programmes achieve this. This systematic review aimed to synthesise research findings on the following questions: (1) How effective are CHW interventions at reaching the most disadvantaged groups in LMIC contexts? and (2) What evidence exists on whether and how these programmes reduce health inequities in the populations they serve?

Methods

We searched six academic databases for recent (2014–2020) studies reporting on CHW programme access, utilisation, quality, and effects on health outcomes/behaviours in relation to potential stratifiers of health opportunities and outcomes (e.g., gender, socioeconomic status, place of residence). Quantitative data were extracted, tabulated, and subjected to meta-analysis where appropriate. Qualitative findings were synthesised using thematic analysis.

Results

One hundred sixty-seven studies met the search criteria, reporting on CHW interventions in 33 LMIC. Quantitative synthesis showed that CHW programmes successfully reach many (although not all) marginalized groups, but that health inequalities often persist in the populations they serve. Qualitative findings suggest that disadvantaged groups experienced barriers to taking up CHW health advice and referrals and point to a range of strategies for improving the reach and impact of CHW programmes in these groups. Ensuring fair working conditions for CHWs and expanding opportunities for advocacy were also revealed as being important for bridging health equity gaps.

Conclusion

In order to optimise the equity impacts of CHW programmes, we need to move beyond seeing CHWs as a temporary sticking plaster, and instead build meaningful partnerships between CHWs, communities and policy-makers to confront and address the underlying structures of inequity.

Trial registration

PROSPERO registration number CRD42020177333.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-021-01615-y.

Application of primary healthcare principles in national community health worker programmes in low-income and middle-income countries: a scoping review

OBJECTIVE

To identify which primary healthcare (PHC) principles are reflected in the implementation of national community health worker (CHW) programmes and how they may contribute to the outcomes of these programmes in the context of low-income and middle-income countries (LMICs).

DESIGN

Scoping review.

DATA SOURCES

A systematic search was conducted through PubMed, CINAHL, EMBASE and Scopus databases.

ELIGIBILITY CRITERIA

The review considered published primary studies on national programmes, projects or initiatives using the services of CHWs in LMICs focused on maternal and child health. We included only English language studies. Excluded were programmes operated by non-government organisations, study protocols, reviews, commentaries, opinion papers, editorials and conference proceedings.

DATA EXTRACTION AND SYNTHESIS

We reviewed the application of four PHC principles (universal health coverage, community participation, intersectoral coordination and appropriateness) in the CHW programme's objectives, implementation and stated outcomes. Data extraction was undertaken systematically in an excel spreadsheet while the findings were synthesised in a narrative manner. The quality appraisal of the selected studies was not performed in this scoping review.

RESULTS

From 1280 papers published between 1983 and 2019, 26 met the inclusion criteria. These 26 papers included 14 CHW programmes from 13 LMICs. Universal health coverage and community participation were the two commonly reported PHC principles, while intersectoral coordination was generally missing. Similarly, the cultural acceptability aspect of the principle of appropriateness was present in all programmes as these programmes select CHWs from within the communities. Other aspects, particularly effectiveness, were not evident.

CONCLUSION

The implementation of PHC principles across national CHW programmes in LMICs is patchy. For comprehensiveness and improved health outcomes, programmes need to incorporate all attributes of PHC principles. Future research may focus on how to incorporate more attributes of PHC principles while implementing national CHW programmes in LMICs. Better documentation and publications of CHW programme implementation are also needed.

Role of female community health volunteers in ischemic stroke prevention, identification, referral and rehabilitation in Nepal

For the past three decades, female community health volunteers (FCHVs) have been at the forefront of Nepal's health map and have contributed significantly to its improving health indicators such as maternal mortality rate and infant mortality rate. Given the changing epidemiology of Nepal and the shift of burden from communicable to non-communicable diseases (NCDs), it is important to revitalize their role with the changing times. The prevalence of ischemic stroke in Nepal is on the rise. However, very few people make it to the hospital within the time frame for thrombolysis and the patient's knowledge about ischemic stroke seems to play a major part. FCHVs can play a significant role in improving ischemic stroke care by raising awareness about the condition, its risk factors, and informing the public about the need for timely treatment. They can help screen for common risk factors such as obesity, hypertension and diabetes as well as monitor for treatment in previously diagnosed individuals. Randomized controlled trials have shown to yield favorable results in NCDs with engagement of FCHVs. With proper training and support, they can play an important role in improving ischemic stroke care in low- and middle-income countries like Nepal.

Exploring The Challenges Faced by Informal Home Based Palliative (HBP) Caregivers in Ndola District, Zambia

In order to explore informal Home-based palliative caregivers' challenging experiences, this study gives an overview of the need of Home-based palliative caregivers in communities. Dialogs using In-depth interviews (IDI's) with twenty-five (25) purposively and conveniently selected respondents aged 18 years and over were conducted. They were not professional caregivers but volunteers from within the community attached to health facilities in Ndola. Discussions on global, Africa and Zambian' situations, and Ndola in particular were included. The findings, using thematic analysis, were lack of supporting resources, inadequate coordination, lack of training, undesirable working conditions and unreliable transport network. The study will facilitate formulation of guiding principles and policies for palliative care practices through recommendations based on results from this study to improve and sustain palliative care services.

The community health worker as service extender, cultural broker and social change agent: a critical interpretive synthesis of roles, intent and accountability

This paper is a critical interpretive synthesis of community health workers (CHWs) and accountability in low-income and middle-income countries. The guiding questions were: What factors promote or undermine CHWs as accountability agents? (and) Can these factors be intentionally fostered or suppressed to impel health system accountability? We conducted an iterative search that included articles addressing the core issue of CHWs and accountability, and articles addressing ancillary issues that emerged in the initial search, such as 'CHWs and equity.'CHWs are intended to comprise a 'bridge' between community members and the formal health system. This bridge function is described in three key ways: service extender, cultural broker, social change agent. We identified several factors that shape the bridging function CHWs play, and thus, their role in fomenting health system accountability to communities, including the local political context, extent and nature of CHW interactions with other community-based structures, health system treatment of CHWs, community perceptions of CHWs, and extent and type of CHW unionisation and collectivisation.Synthesising these findings, we elaborated several analytic propositions relating to the self-reinforcing nature of the factors shaping CHWs' bridging function; the roles of local and national governance; and the human resource and material capacity of the health system. Importantly, community embeddedness, as defined by acceptability, social connections and expertise, is a crucial attribute of CHW ability to foment local government accountability to communities.

Factors affecting the utilization of antenatal care services among women in Guinea: a population-based study

INTRODUCTION

Evidence suggests that a better understanding of determinants of antenatal care (ANC) utilization is crucial to reducing maternal and child deaths. Little is known about the utilization of ANC services in Guinea.

OBJECTIVE

The aim of this study was to explore factors determining utilization of skilled ANC in Guinea.

METHODS

This study focused on a sample of 7812 ever married women. Using multivariate logistic regression, factors associated with the utilization of ANC were identified. The output of the multivariate logistic regression was presented using adjusted odds ratio and the corresponding 95% confidence interval (CI).

RESULTS

Several factors had significant association with utilization of skilled ANC service in Guinea: having decision-making power (2.21, 95% CI: 1.63, 3.00), employment status (1.86, 95% CI: 1.39, 2.48), media exposure (1.60, 95% CI: 1.26, 2.02), maternal education (2.68, 95% CI: 1.36, 5.28), husband/partner education status (1.66, 95% CI: 1.08, 2.55), household economic status (2.19, 95% CI: 1.40, 3.44), place of residence (0.29, 95% CI: 0.16, 0.50) and ethnicity (0.40, 95% CI: 0.23, 0.69).

CONCLUSIONS

These findings suggest a variety of socio-demographic and economic factors as well as media exposure are associated with women's use of ANC. Policymakers should implement appropriate measures to address the existing variations and gaps in ANC services utilization among different subgroups of women in Guinea.

A review of the maternal iron and folic acid supplementation programme in Nepal: Achievements and challenges

In the late 1990s, an estimated 75% of pregnant women in Nepal were anaemic. Although iron and folic acid (IFA) supplements were available free of charge, coverage among pregnant women was very low. In response, the Government of Nepal launched the Iron Intensification Programme (IIP) in 2003 to improve the coverage of IFA supplementation and anthelminthic treatment during pregnancy, as well as promote the utilization of antenatal care. This review examined how the IIP programme contributed to Nepal's success in increasing the consumption of IFA supplements during pregnancy. Nepal's cadre of Female Community Health Volunteers were engaged in the IIP to support the community‐based distribution of IFA supplements to pregnant women and complement IFA distribution through health facilities and outreach services. As a result, the country achieved a fourfold increase in the proportion of women who took IFA supplements during pregnancy between 2001 and 2016 (from 23% to 91%) and a 12‐fold increase in the proportion who took IFA supplements for at least 90 days during pregnancy (from 6% to 71%). The increase in coverage of IFA supplements accompanied an increase in the coverage of antenatal care during the same period. By 2016, the prevalence of anaemia in pregnant women decreased to 46%, highlighting the need to tackle other causes of anaemia and improve haemoglobin concentration before pregnancy, while maintaining the successful efforts to reach pregnant women with IFA supplements at the community level.

Experiences and impact of international medical volunteering: a multi-country mixed methods study

OBJECTIVE

To assess the experience and impact of medical volunteers who facilitated training workshops for healthcare providers in maternal and newborn emergency care in 13 countries.

SETTINGS

Bangladesh, Ghana, India, Kenya, Malawi, Namibia, Nigeria, Pakistan, Sierra Leone, South Africa, Tanzania, UK and Zimbabwe.

PARTICIPANTS

Medical volunteers from the UK (n=162) and from low-income and middle-income countries (LMIC) (n=138).

OUTCOME MEASURES

Expectations, experience, views, personal and professional impact of the experience of volunteering on medical volunteers based in the UK and in LMIC.

RESULTS

UK-based medical volunteers (n=38) were interviewed using focus group discussions (n=12) and key informant interviews (n=26). 262 volunteers (UK-based n=124 (47.3%), and LMIC-based n=138 (52.7%)) responded to the online survey (62% response rate), covering 506 volunteering episodes. UK-based medical volunteers were motivated by altruism, and perceived volunteering as a valuable opportunity to develop their skills in leadership, teaching and communication, skills reported to be transferable to their home workplace. Medical volunteers based in the UK and in LMIC (n=244) reported increased confidence (98%, n=239); improved teamwork (95%, n=232); strengthened leadership skills (90%, n=220); and reported that volunteering had a positive impact for the host country (96%, n=234) and healthcare providers trained (99%, n=241); formed sustainable partnerships (97%, n=237); promoted multidisciplinary team working (98%, n=239); and was a good use of resources (98%, n=239). Medical volunteers based in LMIC reported higher satisfaction scores than those from the UK with regards to impact on personal and professional development.

CONCLUSION

Healthcare providers from the UK and LMIC are highly motivated to volunteer to increase local healthcare providers' knowledge and skills in low-resource settings. Further research is necessary to understand the experiences of local partners and communities regarding how the impact of international medical volunteering can be mutually beneficial and sustainable with measurable outcomes.

Effects of Female Community Health Volunteer Capacity Building and Text Messaging Intervention on Gestational Weight Gain and Hemoglobin Change Among Pregnant Women in Southern Nepal: A Cluster Randomized Controlled Trial

Introduction: Public health interventions such as text messaging are commonly evaluated in high-income countries and that the evaluation reports of the effectiveness of community health volunteers in low-income countries like Nepal is scarce. This study aimed to determine whether female community health volunteer (FCHV) capacity building and text messaging to expectant mother increases gestational weights and hemoglobin levels of pregnant women living in southern Nepal.

Methods: A cluster randomized control trial was carried out in 52 clusters of 6 Village Development Committees in southern Nepal between July 2015 and March 2016. A total of 413 pregnant mothers of gestation age between 13 and 28 weeks (214 in the intervention group and 199 in the control group) were included in the analysis. Intervention consisted of FCHV capacity building followed by regular supervision and monitoring and mobile phone text messaging to expectant mothers. Regression analysis, controlled for confounders, was conducted to assess gestational weight gains and changes in hemoglobin levels.

Results: At the end of the pregnancy, the mean weight gain difference between the intervention and control groups was 1.1 kg (95% CI: 1.0, 1.9). Rates of weight increases in the intervention and control groups were 0.504 kg/week (95% CI: 0.371, 0.528), and 0.399 kg/week (95% CI: 0.362, 0.465), respectively. Similarly, the mean inter group difference in hemoglobin levels was 0.11 gm/dl (95% CI: 0.09, 0.15), and rates of hemoglobin increases (gm/dl/week) in the intervention and control groups were 0.02 gm/dl (95% CI: 0.01, 0.09) and 0.004 gm/dl (95% CI: 0.02, 0.12), respectively.

Conclusions: The study shows that FCHV capacity building and mobile text messaging have a positive effect on the gestational weights and hemoglobin levels of expectant mothers. Our findings suggest that mobile text messaging coupled with FCHV capacity building services should be supported and would usefully expand in resource poor settings.

Trial registration: ISRCTN60684155.

Evaluation of a health promotion intervention associated with birthing centres in rural Nepal

INTRODUCTION

Birthing centres (BC) in Nepal are mostly situated in rural areas and provide care for women without complications. However, they are often bypassed by women and their role in providing good quality maternity services is overlooked. This study evaluated an intervention to increase access and utilisation of perinatal care facilities in community settings.

METHODS

This longitudinal cross-sectional study was conducted over five years in four villages in Nepal and included two BCs. An intervention was conducted in 2014-2016 that involved supporting the BCs and conducting a health promotion programme with local women. Population-based multi-stage sampling of women of reproductive age with a child below 24 months of age was undertaken. Household surveys were conducted (2012 and 2017) employing trained enumerators and using a structured validated questionnaire. The collected data were entered into SPSS and analysed comparing pre- and post-intervention surveys.

RESULTS

The intervention was associated with an increase in uptake in facility birth, with an increase in utilisation of perinatal services available from BCs. The post-intervention survey provided evidence that women were more likely to give birth at primary care facilities (OR 5.60, p-value <0.001) than prior to the intervention. Similarly, the likelihood of giving birth at a health facility increased if decision for birthplace was made jointly by women and family members for primary care facilities (OR 1.76, p-value 0.023) and hospitals/tertiary care facilities (OR 1.78, p-value 0.020. If women had less than four ANC visits, then they were less likely to give birth at primary care facilities (OR 0.39, p-value <0.001) or hospitals/tertiary care facilities (OR 0.63, p-value 0.014). Finally, women were less likely to give birth at primary care facilities if they had only primary level of education (OR 0.49, p-value 0.014).

CONCLUSION

BCs have the potential to increase the births at health facilities and decrease home births if their services are promoted by the local health promoters. In addition, socio-economic factors including women's education, the level of women's autonomy and having four or more ANC visits affect the utilisation of perinatal services at the health facility.