community health volunteers

Child labour is common in Nepal and may expose children to specific additional hazards. Forty percent of all children aged 5 to 17 years in Nepal are classified as ‘working children’ [15]. Almost 70% of the children in Nepal are deprived of at least one of the seven indicators mentioned in the Bristol deprivation score calculation [16] i.e. food, shelter, sanitation, water, information, education and health. Forty percent of Nepali children are thought to be deprived of at least two of these indicators [17]. Almost half of Nepal’s population is comprised of children below the age of 18 years [18]. About 80% of the country’s population lives in rural areas but the rate of urbanisation is 5% per year i.e. increase in urban population [19]; 39% of its population living below the poverty lines of 1.25 US Dollar a day [20]. Nepal thus has many factors that are likely to contribute to its increased risk of injuries. There are few published trials of child injury prevention interventions in low-income settings. Social mobilisation for child injury prevention is recommended in low-income settings as it has been shown to be effective [21,22]. In Bangladesh, community-based interventions were found to reduce the rates of injury related hospitalisation by one-third [22]. Community mobilisation has been proven to be effective and cost-effective to improve maternal, child and perinatal health in rural Nepal; the mobilisation of local women’s groups led by female community health volunteers (FCHVs) has been well documented [23-25]. A community survey of child injuries and qualitative study exploring injury prevention awareness has been conducted in this setting [26]. We describe the development of a participatory intervention utilising women’s group mobilisation for the prevention of child injuries and a study exploring the feasibility of delivering and evaluating such an intervention in rural Nepal

Community Health Volunteers (CHVs) have taken an active role in the delivery of community- based primary healthcare interventions linked to the health facility, as posited by Alma Alta Conference agreement (WHO, 1978).A Community Health Volunteer (CHV) / Worker (CHW) is any health worker (paid or not paid) carrying out functions related to health care delivery at community level; trained in some way in the context of the intervention, and having no formal professional or paraprofessional certificate or degree in tertiary education (Lewin et al., 2010). They play an integral role in primary health care service delivery at community level and globally recognized for their success in reducing morbidity and averting mortality in mothers, newborns and children. They also represent a strategic solution to address the shortages of highly skilled health workers to help meet the growing demands for health services among rural populations (Perry et al., 2017).

The study population for this study was 156 fully functional CU’s from the three selectected Counties. Using Mugenda and Mugenda formula of populations below 10,000, a sample size of 122 functional CUs were selected randomly and 3 Community Health Volunteers were interviewed from each CU which formed a total sample of 366 CHVs as respondents for this study (see table 1). Three (3) Focus Group Discussion were done on 3 Functional community health committees (CHCs) i.e. one from each county. Six Key informants (Community Health Extention Workers (CHEW) and County Coordinator) were considered i.e. two from each county. Only CHVs who had been trained using the community strategy curriculum and had been in operation for at least one year in the selected counties were selected. Multi stage sampling was used to arrive at a desired sample size. Systematic sampling was used to identify the Community Units and purposive sampling was used to sample the three respondents per Community Unit. Data collection instruments used included; observation checklist, interviewer administered questionnaires, Key Informant guide and Focus group discussion guide

Lack of knowledge about childhood injuries was observed. However, lack of supervision was identified as a major risk factor for injuries to small children. Community people were keen to contribute in the prevention of injuries and to safeguarding children in the future. This project was founded largely upon this community assurance. The Royal Society for the Prevention of Accidents (RoSPA) funded this pilot project on Child Injury Prevention in Nepal for a duration of 10 months from August 2013 to May 2014. This project aimed to develop a culturally appropriate, educational programme for the Female Community Health Volunteers (FCHVs) and to determine the feasibility of evaluating its effectiveness through women’s groups. This intervention included both primary (safety information) and secondary (first-aid training) prevention components.

C. L. Huang & Wang, 2005). However, community health volunteers may not only face negative attitudes that lead to frustration in their work, but also be engaged in other forms of volunteering, which could result in a high attrition rate. Research has demonstrated that the burden on other types of informal carers, such as carers of the elderly and the mentally ill, is immense. The burden for these carers includes work load about physical labour, emotional and time loading; deficiency of information; insufficient emotional support from family, volunteers, Community Health Nurses, and residents; lack of instrumental support; deficits in communication skills; lack of cooperation skills and lack of confidence (Campbell, et al., 2008; Chuang, 2001; Guan, 2002; Knight, et al., 2000; Nan, 2002; Zheng, 2001). A recent study on volunteers was undertaken in Japan to describe and validate a tool designed to measure the burden on health promotion volunteers in Japan, but due to insufficient information published, it was difficult to understand how the scale was developed and whether it was used to measure the exact type of volunteer behaviour that is the aim of this study (Murayama, et al., 2006). Other than the study conducted by Murayama et al. (2006), there is no available information that addresses the burden experienced by community health volunteers in the carrying out of their role in Taiwan or a similar country, or a scale developed for the purpose of the measurement of burden on this particular cohort.

The World Health Organization (2006) indicates that there was a shortfall of human resources workforce by 57 countries out of which 37 were from Sub Saharan African countries. This amounts to a global shortfall of 2.4 million trained health workers including doctors, nurses, mid wives among others cadres. The report notes that although Africa region had 24% disease burden, only 3% of the global health workers workforce were found in Africa. The foregoing called for new innovations that would accelerate progress towards attainment of MDGs among other global initiatives. Community based health volunteerism was one such innovation, which has observed skilled and non-skilled health volunteers make significant contributions towards improved healthcare for people. Some of these volunteers have served their respective communities for many years although high drop-outs have also been registered. A number of policies related to health and development in Kenya have underscored the importance of Community Health Volunteers (CHVs). Examples here include the Economic Recovery Strategy for wealth and Employment Creation (ERS) and the Kenya health sector reforms strategic plan. These initiatives have been taken against the backdrop of inadequate workforce in the health sector.

Burden, an accepted component of burnout, can be avoided or ameliorated if detected early. Most research on volunteer burden to date has focused on the burden experienced by family care givers in the community, espe- cially of the elderly with dementia. It has been suggested that non-family volunteers are affected by the same type of negative impacts, or burdens, as for example, those experienced by family carer givers [12-14]. However, pre- vious research on burden experienced by community health volunteers in countries other than Taiwan identi- fied the following: work related to the physical and emo- tional nature of the role, the time taken to undertake the activity, insufficient emotional support from family, other volunteers, community health nurses and residents, lack of instrumental support, poor communication skills, lack of cooperation and lack of confidence [15-17].

mortality despite a liberal abortion law and government supported abortion services [7 – 10], provision of MA up to 63 days gestation has already been extended to in- clude nurses and auxiliary nurse midwives trained as birth attendants, in addition to doctors [11, 12]. We evaluated the ability of a cadre of minimally-trained fe- male community health volunteers (FCHVs) in Nepal and literate Nepali women to determine the success of MA with mifepristone and misoprostol using a checklist. Their assessments were compared to those made by comprehensive abortion care (CAC) trained providers using Nepal ’ s current standard of care.

Despite the importance of the adverse impact of LBW on child survival, there have been few prospective studies evaluating effectiveness of community based intervention through trained volunteers for LBW infants in Nepal and in other developing countries, largely because of the diffi- culties inherent in community based data collection and the higher proportion of births occurring at home [12] [13]. As a result, there is inadequate information about ef- fectiveness of community based intervention preventing deaths among LBW infants from such settings. This has hindered the development of appropriate neonatal inter- ventions in the developing countries, especially within existing government health programs. This study explores the impact of community based management of LBW in- fants on mortality within two months of age, by mobiliz- ing Female Community Health Volunteers (FCHVs) from the Morang Innovative Neonatal Intervention (MINI) program, a prospective cohort study from Nepal. Infants 0 to 2 months were included in the study because Nepal’s IMCI guidelines at the beginning of the project (2005) only addressed illnesses in children from 2 months to 59 months [14].

There is a synergistic effect of local nongovernmental orga- nizations (NGOs) and performance of community health work- ers. In Nepal, Mother and Infant Research Activities (MIRA) is an NGO that conducts studies, launches interventions for improving maternal and infant health, and trains FCHVs. An effective program of neonatal sepsis identification and manage- ment with collaboration of local NGOs with community health volunteers has been reported in a previously published Nepalese article. 17 An analytical report on national survey of FCHVs of

Introduction: World Health Organization (WHO) recommends use of Community Health Volunteers (CHVs) for community health service delivery. Kenya adopted the use of CHVs through Community Health Strategy program in 2006 with free maternal and child health services. Regardless of the efforts made women still die from preventable pregnancy related causes majorly due to unskilled attendance at birth. The context in which the CHVs deliver their health care services has been cited as a pivotal consideration for increasing the skilled attendance at birth. A few studies have been done on how context influences the CHVs performance but little is known on evidence based frameworks to overcome the barriers to CHVs performance improvement. Globally Maternal Mortality Ratio (MMR) is 216 per 100,000 live birth while Neonatal Mortality Ratio (NMR) is 19 per 1000 live births and all is attributed to unskilled birth attendant which is at 78% worldwide. These figures are higher at rural sub-Sahara Africa (510 MMR and 31 NMR). Kenya, the maternal and neonatal mortalities are at 366 and 22 respectively. Nyando Sub-County, the high (58%) unskilled attendance at birth is highly attributed to the NMR (28/1000) which surpasses that of the country (22/1000).

Experience has shown that CHVs represent important and unique resources. Trained CHVs can deliver crucial and culturally sensitive health messages, empower individ- uals to make informed decisions and increase local access to life-saving curative measures [3–7]. However, the per- formance of CHVs is being questioned by the public health community: high attrition rates and poor quality services have been reported in many programmes in- volving CHVs [8–11]. Others report how CHVs’ ability to deliver is contingent on the scope of their work and workload [12, 13]. In their guidelines on task shifting, the World Health Organization acknowledges the contri- bution of short-term or part-time volunteers but states that “there is virtually no evidence that volunteerism can be sustained for long periods” [14, 15].

This study was conducted in specific areas of Nepal and therefore there are potential dangers in extrapolat- ing findings across the whole diverse country. While this research sheds light on the subjective experience of FCHVs, no research to date has been able to demon- strate that the FCHVs roles themselves have an impact on maternal mortality or other health outcomes; quanti- tative studies are needed to do this. Yet qualitative methods is the best method for exploring people’s expe- riences or perspectives [61]. The multiple methods of data collection, interviews, FGDs and field notes; and the use of triangulation enabled the researcher to in- clude more comprehensive views of study participants. While most interviews went as planned, a few were interrupted. A FCHV who had been interviewed also participated in a focus group (Table 1) despite SP ’ s at- tempt to stop her involvement. The FCHV was enthusi- astic to contribute to the group discussion. Sometimes participants ’ family members or neighbours often inter- rupted the interviews as they were generally held on ve- randas outside houses. Questions directed at mothers or

Information is any entity or form that resolves uncertainty or provides the answer to a question of some kind. It is thus related to data and knowledge, as data represents values attributed to parameters, and knowledge signifies understanding of real things or abstract concepts. Information is not an end in itself, but a means to better decision making in policy design, health planning, management, monitoring and evaluation of health programs and services including patient care (Jeremie et al., 2014a). Decision makers in many developing countries lack the required data needed for evidence-based health care management. One reason for this is that the routine national health management information systems (HMIS) do not extend to the ‘last mile’, the communities and the informal setting of villages, where a significant proportion of health events occur (Asangansi, 2012). A Community based health Information System (CBHIS) is a type of health information system that is based in the rural community and informal settlements of urban areas. The development of comprehensive community based health information systems is increasingly becoming important for measuring and improving the quality of health services. In Sub Saharan Africa (SSA), there is recognition of the importance of Health Information Systems (HIS) in the generation of reliable data and information. Little change is evident in the use of data to improve health care despite an increase data production at the community level. Many developing countries including Kenya have made efforts to strengthen their national health information systems to provide information for decision-making in managing health care services (Jeremie et al., 2014a). Processes form an integral part of performance (Aqil et al., 2009). Performance of Routine Information System Management (PRISM) framework was developed to improve routine health information systems (RHIS) and data use (Aqil et al., 2009). The framework is innovative in that it puts emphasis on RHIS performance and the three interrelated determinants of that performance: technical, behavioral, and organizational determinants. Process intervention components in this study was evaluated using the following indicators : Assesments; feedback; dialogue and action days; and reporting channels.

to assist staff in assessment and management and to ensure that they are trained in their use [12]. The deaths in the community especially in KEEA were related to delayed care-seeking. Consequently, the district health officials also need to explore the issues of poor health- seeking behavior and access to care as possible factors contributing to the deaths in the community. It is key to highlight the importance of providing regular community education on cholera signs and symptoms and prevention and treatment measures even in periods outside epidemics [12, 20, 21]. Capacity of community health volunteers should be built to educate community members on making water safe for drinking, regular hand washing with soap and other proper hygiene and sanitation practices, promote early reporting to health facilities and to report insanitary conditions that may predispose the community to future outbreaks to relevant authorities for action [18]. The relevant authorities should regularly inspect sanita- tion facilities to ensure good working order and to prevent and address problems arising from improper disposal of excreta and contamination of drinking sources.

Models of health service provided by lay health workers are operational in several underresourced countries, in- cluding India, Kenya, Uganda, Ghana, Ethiopia, South Africa, and China [30]. Previous studies have shown that community health worker programs for health care de- livery are significantly beneficial in maternal and child health as well as infectious disease control [30, 31]. However, involving community health workers for non- communicable diseases has not gained much attention until recently. This study pioneers the investigation of a community-based intervention to reduce blood pressure in resource-poor countries. If our study shows that the intervention is effective, a scaled-up approach could pro- duce an important reduction in cardiovascular disease burden due to hypertension. The proposed study will in- crease knowledge on how to control blood pressure by mobilizing community health volunteers in Nepal. Thus, the research output of this study has the potential to bring immediate benefits to address noncommunicable

This study was conducted among participants from three different groups. First group comprised of healthcare professionals (HCPs) including medical interns and nurses working at KIST Medical College. Second group was the media personnel. The third group was female community health volunteers (FCHVs) working at the adjacent health posts. The number of participants was twenty from each group and sixty in total. The sampling method used was convenience sampling and the type of the study was cross sectional. The participation was based on the availability and willingness of the study participants.

Global Brigades claims to be different from its non-profit competitors because of its ‘holistic model.’ The holistic model “is a system of collectively implementing health, economic, and education programs to meet a community’s development goals”. Global Brigades believes they are achieving sustainability through their holistic process that includes six factors. The first factor is research and evaluation, which includes using program-monitoring tools to measure impact. Global Brigades develops a set of short-term and long-term success indicators that it aims to reach for each program (medical, dental, water, etc). The progress of these success indicators are tested with on-going evaluation (Global Brigades’ Holistic Model | Global Brigades n.d.). For example, the short-term success indicators for Global Medical Brigades includes providing consultations to 150,000 patients each year with mobile medical clinics who would not otherwise be able to afford or have access to healthcare, provide all 126 community partners with a team of licensed doctors and appropriate medicine at least three times per year, and provide funding for 90% of patient referrals identified on clinic days or by Community Health Workers. The long-term quality of life improvements over the next three years include ensuring that 50% of community partners have year-round primary care access with a resident community health worker, increase the percentage of chronic pain patients to seek consistent treatment to 70%, and increase early detection of cervical cancer by 10% (PROGRAMS | Global Brigades n.d.).

Recruitment strategies Participating community sites used various combinations of the following recruitment strategies: public advertising (e.g., media interview, press releases, brochures), community talks (e.g., presentations to societies serving seniors), and focused communication with healthcare providers (e.g., presenting at team meet- ings, letters to physicians, meetings with strategic part- ners). Participants were surprised by the difficulty they encountered with client recruitment because they per- ceived a great need for the program, as indicated in the baseline focus groups. A coordinator reflected. “You know we reached out to so many different places. And I was very surprised how long it took us to get clients and how there wasn’t the kind of uptake that we thought was going to be there.” (VC) A healthcare partner in a community that ex- perienced difficulty identifying older persons said, “I think that piece is a really big and a fascinating element to this research and trying to figure out”, “Okay, if it worked so well on these other communities, what was the struggle for our community? What’s different about our community?” Participants identified two factors they felt influenced cli- ent recruitment: public perceptions of palliative care and professional gatekeeping.

9% of the women are counseled on family planning dur- ing their postpartum period in Nepal, and 54% have an unmet need for family planning within the 2 years fol- lowing a birth [8]. Despite the World Health Organiza- tion’s (WHO) recommendation of waiting at least 2 years after a live birth before attempting the next preg- nancy to reduce the risk of adverse maternal, perinatal and infant outcomes [9], 25% of women in Nepal be- come pregnant within 24 months postpartum [10]. Hence, there is a gap in postpartum family planning (PPFP) coun- seling and uptake in Nepal, and with rising coverage of antenatal care (ANC) and institutional delivery, an oppor- tunity to understand whether an attempt to integrate post- partum family planning services into maternity care would improve uptake of postpartum family planning in Nepal.