Engaging Female Community Health Volunteers (FCHVs) for cardiovascular diseases risk screening in Nepal

Introduction Non-Communicable Diseases (NCDs) have become the leading public health problems worldwide and the cardiovascular diseases (CVDs) is one of the major NCDs. Female Community Health Volunteers (FCHVs) in Nepal are the key drivers to implementing frontline health services. We explored the potential for engaging FCHVs for CVD risk screening at the community level in Nepal. Methods We used multiple approaches (quantitative and qualitative) for data collection. The trained FCHVs administered CVD risk screening questionnaire among 491 adults in rural and urban areas and calculated the CVD risk scores. To maintain consistency and quality, a registered medical doctor also, using the same risk scoring chart, independently calculated the CVD risk scores. Kappa statistics and concordance coefficient were used to compare these two sets of risk screening results. Sensitivity and specificity analyses were conducted. Two focus group discussions among the FCHVs were conducted to determine their experiences with CVD risk screening and willingness to engage with CVD prevention and control efforts. Results The mean level of agreement between two sets of risk screening results was 94.5% (Kappa = 0.77, P<0.05). Sensitivity of FCHV screening was 90.3% (95% CI: 0.801–0.964); and the specificity was 97% (95% CI: 0.948, 0.984). FCHVs who participated in the FGDs expressed a strong enthusiasm and readiness to using the CVD risk screening tools. Despite their busy workload, all FCHVs showed high level of motivation and willingness in using CVD risk screening tools and contribute to the prevention and control efforts of NCDs. The FCHVs recommended needs for providing additional training and capacity building opportunities. Conclusion We conclude that there is a potential for engaging FCHVs to use simple CVD risk screening tools at the community level. The findings are promising, however, further studies engaging larger number of FCHVs and larger population would warrant feasibility of such tools within the existing healthcare systems in Nepal.

Community Health Workers (CHWs) to Improve Primary Health Care Services Delivery: A Case of Female Community Health Volunteers (FCHV) Program in Nepal

Community health workers (CHWs) have played a vital role in improving primary healthcare services in different parts of the world, in particular, for those services related to the prevention and control of communicable diseases, immunization services, reproductive health, maternal and child health, HIV/AIDS prevention and care and nutrition promotion. The Female Community Health Volunteers (FCHVs) program, which was introduced in 1988 in Nepal, has now reached over 51,000 FCHVs. They are key community level CHWs in Nepal and have contributed significantly in achieving several health and related outcomes and meeting several Millennium Development Goals. In such, there is also a potential and needs for engaging them to prevent and control emerging health challenges such as non-communicable diseases prevention and control and re-emerging health issues. Their effective involvement to ongoing health programs would be critical to achieving Sustainable Development Goals, agenda in particular “SDG 3 – Health and Wellbeing” by 2030.

HEALTH FACILITY AND HUMANRESOURCE FACTORS SUPPORTING UPTAKE OF CERVICAL CANCER SCREENING IN KAKAMEGA COUNTY, KENYA

Main objective was to describehealth facility and human resource related factors supporting uptake of cervical cancer screening in Kakamega County.Design; descriptive cross-sectional study adopting quantitative methods. Setting; Kakamega County within 16 community units in 8 sub counties.Sampling;multistage sampling was used to sample 48 community health volunteers and 16 health facilities.Interviewer administered questionnaire was used to collect data from Community Health Volunteers and the heads of link health facilities.Validity and reliability of questionnaire was ensured through expert review.Analysiswasby use of descriptive statistics. Results;Majority of participants were female (91.7%) aged between 30-50 years (75%), with primary level of education(47%) and had worked for more than five years as Community Health Volunteers (60%). More than 95% ofCommunity Health Volunteers visited clients’ homeson monthly schedule(77%).Regarding cervical cancer screening,60% of Community Health Volunteers agreed that they were involved in referring women for cervical cancer screening.Almost all(92%)of Community Health Volunteers had not been trained on aspects of cervical cancer screening. Further, 94% of Community Health Volunteers confirmed that cervical cancer screening was part of the health education package they discuss with women. Approximately 81% of health facilities were health centers and offeredcervical cancer screening services weekly (75%).Conclusion;Health facilities offer cervical cancer screening adequately. Community Health Volunteers have established network to reach women but lack capacity to sensitize women on cervical cancer screening. Recommendation: Community Health Volunteersshould be empowered to mobilize women for cervical cancer screening.

Multilevel factors influencing contraceptive use and childbearing among adolescent girls in Bara district of Nepal: a qualitative study using the socioecological model

ObjectivesThis study aimed to identify the multilevel factors that influence contraceptive use and childbearing decisions in Nepal and examine relationships among these factors.DesignThe study drew on qualitative data collected through in-depth interviews (IDIs) and key informant interviews (KIIs) and triangulated results.SettingAn urban municipality and a rural municipality in Bara district, Nepal.ParticipantsWe recruited a total of 60 participants (e.g., 20 married adolescent girls aged 15–19, 20 husbands, 20 mothers-in-law) for IDIs and 10 (e.g., four healthcare providers, three health coordinators, three female community health volunteers) for KIIs.ResultsMarried adolescent girls faced a range of barriers that are inter-related across different levels. Patriarchal norms and power imbalances between spouses limited their decision-making power regarding contraception. Social pressures to give birth soon after marriage drove the fear of infertility, abandonment and the stigmatisation of childless married couples, which leads to lack of women’s autonomy in making decisions about family planning. Mothers-in-law and religion exerted considerable influence over couples’ decisions regarding contraception. Limited access to information about the benefits and methods of family planning contributed to fear of the side effects of contraceptives and low awareness about the risks involved in adolescent pregnancy.ConclusionsThe convergent results from triangulation confirm that the decision to postpone childbearing is not merely the personal choice of an individual or a couple, highlighting the importance of targeting families and communities. The study underscores the need to challenge restrictive sociocultural norms so that adolescent girls become empowered to exercise greater control over contraceptive use.

For Love of Money: Rewards of Care for India’s Women Community Health Workers

What are the rewards of paid care work for frontline health workers? I focus on India’s women community health volunteers, the largest such workforce in the world. Appointed since 2007 and numbering one million, these women are paid per-case incentives to connect the poor and marginalized to government-run health services. Using 14 months of ethnographic fieldwork in Delhi and Punjab, including 80 interviews, I find that women community health volunteers (called Accredited Social Health Activists or ASHAs) experience extrinsic rewards in paid care work. ASHAs earn not only from their official wages, but also from two unofficial streams: a) a boost of income from non-ASHA work and b) commissions from private hospitals. I also find that the intrinsic rewards ASHAs report—emotional gratification, relative autonomy, and skill-building—are co-constituted with extrinsic rewards; that is, they are tied to their earnings. This calls into question the “Love versus Money” binary, used to frame much of the discussion on care work. I argue instead for a “Love of Money” framing—that is, money as a reward and money as begetting other rewards. My findings highlight the significance of globalizing the empirical research on paid care work.

Training and Assessing Model for the Ability of Community Health Volunteers in Anthropometric Measurement Using the Rasch Stacking and Racking Analyses

Background. Inappropriate anthropometric measurements of infants and toddlers lead to a misclassification in nutritional status and loss of important interventions. Considering the practice conducted in this program within a country, its impact on millions of children must be considered. This study assesses the ability of community health volunteers (CHVs) before and after anthropometric training on infants and toddlers. Methods. This study used a quantitative approach with a quasiexperimental and pretest-posttest design. The pre- and posttraining assessments of CHVs were conducted by standardized trainers using instruments developed according to WHO standards. There were 11 and 13 statement items for infants’ and toddlers’ indicators of assessment in anthropometric measurements, respectively. The result of the assessment was then analyzed using Rasch modeling with stacking and racking data analysis techniques. Results. The CHVs’ skills before training were far from adequate. Although widely varied, all trainees improved their abilities. Stacking analysis showed that the skills of all CHVs in measuring infants and toddlers increased by 2.68 and 3.34 logits ( p < 0.01 ), respectively. Racking analysis showed a decrease in the perceived difficulty of all items by 2.61 and 3.07 logits for infant and toddler measurements, respectively ( p < 0.01 ). The results of the racking analysis showed that the difficulty in measuring the anthropometrics of infants decreased more than that of toddlers. Conclusions. CHVs’ capacity to monitor child growth must be refreshed regularly. Standardized and proper training and assessment were developed to make CHVs reliable in taking anthropometric measurements of infants and toddlers.

Implementation of community case management of malaria in malaria endemic counties of western Kenya: are community health volunteers up to the task in diagnosing malaria?

BackgroundCommunity case management of malaria (CCMm) is an equity-focused strategy that complements and extends the reach of health services by providing timely and effective management of malaria to populations with limited access to facility-based healthcare. In Kenya, CCMm involves the use of malaria rapid diagnostic tests (mRDT) and treatment of confirmed uncomplicated malaria cases with artemether lumefantrine (AL) by community health volunteers (CHVs). The test positivity rate (TPR) from CCMm reports collected by the Ministry of Health in 2018 was twofold compared to facility-based reports for the same period. This necessitated the need to evaluate the performance of CHVs in conducting malaria RDTs.MethodThe study was conducted in four counties within the malaria lake endemic zone in Kenya with a malaria prevalence in 2018 of 27%; the national prevalence of malaria was 8%. Multi-stage cluster sampling and random selection were used. Results from 200 malaria RDTs performed by CHVs were compared with test results obtained by experienced medical laboratory technicians (MLT) performing the same test under the same conditions. Blood slides prepared by the MLTs were examined microscopically later as a backup check of the results. A kappa score was calculated to assess level of agreement. Sensitivity, specificity, positive and negative predictive values were calculated to determine diagnostic accuracy.ResultsThe median age of CHVs was 46 (IQR: 38, 52) with a range [26, 73] years. Females were 72% of the CHVs. Test positivity rates for MLTs was 42% and for CHVs was 41%. The kappa score was 0.89 indicating an almost perfect agreement in mRDT results between CHVs and MLTs. The overall sensitivity and specificity between the CHVs and MLTs were 95.0% (95% CI: (87.7, 98.6) and 94.0% (95% CI; 88.0, 97.5) respectively.ConclusionEngaging CHVs to diagnose malaria cases under CCMm yielded results which compared well with results of qualified experienced laboratory personnel. CHVs can reliably continue to offer malaria diagnosis in the community setting.

Application of the Ultra-Poverty Graduation Model in understanding community health volunteers’ preferences for socio-economic empowerment strategies to enhance retention: a qualitative study in Kilifi, Kenya

Background A significant shortage of healthcare workforce exists globally. To achieve Universal Healthcare coverage, governments need to enhance their community-based health programmes. Community health volunteers (CHVs) are essential personnel in achieving this objective. However, their ability to earn a livelihood is compromised by the voluntary nature of their work; hence, the high attrition rates from community-based health programmes. There is an urgent need to support CHVs become economically self-reliant. We report here on the application of the Ultra-Poverty Graduation (UPG) Model to map CHVs’ preferences for socio-economic empowerment strategies that could enhance their retention in a rural area in Kenya. Methods This study adopted an exploratory qualitative approach. Using a semi-structured questionnaire, we conducted 10 Focus Group Discussions with the CHVs and 10 Key Informant Interviews with County and Sub-county Ministry of Health and Ministry of Agriculture officials including multi-lateral stakeholders’ representatives from two sub-counties in the area. Data were audio-recorded and transcribed verbatim and transcripts analysed in NVivo. Researcher triangulation supported the first round of analysis. Findings were mapped and interpreted using a theory-driven analysis based on the six-step Ultra-Poverty Graduation Model. Results We mapped the UPG Model’s six steps onto the results of our analyses as follows: (1) initial asset transfer of in-kind goods like poultry or livestock, mentioned by the CHVs as a necessary step; (2) weekly stipends with consumption support to stabilise consumption; (3) hands-on training on how to care for assets, start and run a business based on the assets transferred; (4) training on and facilitation for savings and financial support to build assets and instil financial discipline; (5) healthcare provision and access and finally (6) social integration. These strategies were proposed by the CHVs to enhance economic empowerment and aligned with the UPG Model. Conclusion These results provide a user-defined approach to identify and assess strategic needs of and approaches to CHVs’ socio-economic empowerment using the UPG model. This model was useful in mapping the findings of our qualitative study and in enhancing our understanding on how these needs can be addressed in order to economically empower CHVs and enhance their retention in our setting.