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Background In resource-poor settings, the provision of basic maternity care within health centres is often a challenge. Despite the difficulties, Nepal reduced its maternal mortality ratio by 80% from 850 to an estimated 170 per 100,000 live births between 1991 and 2011 to achieve Millennium Development Goal Five. One group that has been credited for this is community health workers, known as Female Community Health Volunteers (FCHVs), who form an integral part of the government healthcare system. This qualitative study explores the role of FCHVs in maternal healthcare provision in two regions: the Hill and Terai. Methods Between May 2014 and September 2014, 20 FCHVs, 11 health workers and 26 service users were purposefully selected and interviewed using semi-structured topic guides. In addition, four focus group discussions were held with 19 FCHVs. Data were analysed using thematic analysis. Results All study participants acknowledged the contribution of FCHVs in maternity care. All FCHVs reported that they shared key health messages through regularly held mothers’ group meetings and referred women for health checks. The main difference between the two study regions was the support available to FCHVs from the local health centres. With regular training and access to medical supplies, FCHVs in the hill villages reported activities such as assisting with childbirth, distributing medicines and administering pregnancy tests. They also reported use of innovative approaches to educate mothers. Such activities were not reported in Terai. In both regions, a lack of monetary incentives was reported as a major challenge for already overburdened volunteers followed by a lack of education for FCHVs. Conclusions Our findings suggest that the role of FCHVs varies according to the context in which they work. FCHVs, supported by government health centres with emphasis on the use of local approaches, have the potential to deliver basic maternity care and promote health-seeking behaviour so that serious delays in receiving healthcare can be minimised. However, FCHVs need to be reimbursed and provided with educational training to ensure that they can work effectively. The study underlines the relevance of community health workers in resource-poor settings.

Despite the efforts of community health workers to increase access to healthcare among ethnic minority groups in low- and -middle income countries, members of ethnic minorities are less likely than women from other ethnic groups to use maternal and child healthcare services. However, much less is known about the factors that limit access of ethnic minorities to healthcare services, including the services of community health workers in Nepal, who are known as Female Community Health Volunteers (FCHVs). To address this issue, we conducted a qualitative study to explore perceived barriers to accessing maternal and child healthcare services among ethnic minority groups in two different geographical locations (the hill and Terai regions- flatland bordering south India) with varying degrees of access to local healthcare centres. Between April 2014 and September 2014, semi-structured interviews were conducted with twenty FCHVs, 26 women service users and 11 paid local health workers. In addition, 15 FCHVs participated in four focus group discussions. A thematic analysis of the data identified five major themes underlying barriers to accessing available maternal and child healthcare services by ethnic minority groups such as Dalits, Madhesi, Muslim, Chepang and Tamang. These themes include: a) lack of knowledge among service users; b) lack of trust in volunteers; c) traditional beliefs and healthcare practices; d) low decision-making power of women; and e) perceived indignities experienced when using health centres. We conclude that community health programmes should focus on increasing awareness of healthcare services among ethnic minority groups, and the programmes should involve family members (husband and mothers-in-law) and traditional health practitioners. Both the FCHVs and local healthcare providers should be trained to communicate effectively in order to deliver respectful care among ethnic minorities if we want to achieve universal healthcare coverage for maternal and child health in low- and -middle income countries.

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.

Despite the efforts of community health workers to increase access to healthcare among ethnic minority groups in low- and -middle income countries, members of ethnic minorities are less likely than women from other ethnic groups to use maternal and child healthcare services. However, much less is known about the factors that limit access of ethnic minorities to healthcare services, including the services of community health workers in Nepal, who are known as Female Community Health Volunteers (FCHVs). To address this issue, we conducted a qualitative study to explore perceived barriers to accessing maternal and child healthcare services among ethnic minority groups in two different geographical locations (the hill and Terai regions- flatland bordering south India) with varying degrees of access to local healthcare centres. Between April 2014 and September 2014, semi-structured interviews were conducted with twenty FCHVs, 26 women service users and 11 paid local health workers. In addition, 15 FCHVs participated in four focus group discussions. A thematic analysis of the data identified five major themes underlying barriers to accessing available maternal and child healthcare services by ethnic minority groups such as Dalits, Madhesi, Muslim, Chepang and Tamang. These themes include: a) lack of knowledge among service users; b) lack of trust in volunteers; c) traditional beliefs and healthcare practices; d) low decision-making power of women; and e) perceived indignities experienced when using health centres. We conclude that community health programmes should focus on increasing awareness of healthcare services among ethnic minority groups, and the programmes should involve family members (husband and mothers-in-law) and traditional health practitioners. Both the FCHVs and local healthcare providers should be trained to communicate effectively in order to deliver respectful care among ethnic minorities if we want to achieve universal healthcare coverage for maternal and child health in low- and -middle income countries.

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.

Subsets of asthmatic children, particularly in the Caribbean, burden the health system through repeated emergency room (ER) visits. We examined children to determine predictors of repeated ER visits in Trinidad. Caregivers of 300 asthmatic children in primary healthcare in Trinidad reported on perceived factors of exacerbated wheeze requiring ER services. Prevalence of ER utilization in the past 12 months was 59.7% and 40.3% for repeated visits. Average age of wheezing onset was 2.8 (SD = 2.5) years. From the logistic regression analyses, independent predictors of repeat ER visits were mothers with a history of asthma (OR = 2.0, 95%Cl = 1.0-4.0), exposure to perfumes/odors (OR = 2.4, 95% Cl = 1.4-4.2), using inhaled corticosteroids (ICS) (OR = 2.2, 95% Cl = 1.2-4.0), and young age group (1-5 vs. 13-16 years) (OR = 2.7, 95% Cl = 1.1-6.4). More 1-5 year-olds (63.8%) and 6-12-year-olds (60.2%) wheezed in the dry and wet seasons, respectively (p = 0.04). Follow-up was poor (32.3%), and disease management did not include educational interventions. Repeated ER use in pediatric asthma underscores a pressing need for health providers and caregivers to develop an asthma management plan noting the identified predictors to assist in reducing Trinidad's asthma burden.