Perceived Barriers to Accessing Female Community Health Volunteers' (FCHV) Services Among Ethnic Minority Women in Nepal: A Qualitative Study

Ethnic minority groups are likely to have worse maternal and child health (MCH) outcomes and more difficulty in using health care than the general population in Nepal. To promote women's use of health care, female community health volunteers (FCHVs) are mobilised across the country, as has been a practice in other low- and middle-income countries (LMICs) such as India, Bangladesh, Afghanistan, and Uganda. Dalit women especially, along with indigenous groups such as Chepang and Tamang in the hill regions and Madhesi and Muslim in the Terai (flatland bordering south of India), are reported to underuse healthcare services despite their availability in local communities. This study explores perceived barriers to accessing FCHVs' MCH care services among ethnic minority groups in rural Nepal.

The government of Nepal established the FCHV programme in 1988 in an effort to increase local women's participation in health promotion so that improvement in MCH can be achieved at a low cost even in remote places. Local women are selected to work as volunteers in every village unit and are usually selected by their communities. They initially receive 18 days of basic training and refresher training every 5 years on topics such as MCH and family planning. Although volunteers are often not compensated for their time, the retention rate is extremely high (97%). Over 52,000 volunteers currently work across the country and are often the first point of contact for rural women, thereby filling a gap between the community and formal healthcare providers.

Between April 2014 and September 2014, the researchers conducted semi-structured interviews with 20 FCHVs, 26 women service users, and 11 paid local health workers. In addition, 15 FCHVs participated in 4 focus group discussions.

A thematic analysis of the data identified 5 major themes underlying barriers to accessing available MCHC services by ethnic minority groups such as Dalits, Madhesi, Muslim, Chepang, and Tamang. These themes include:

• Lack of knowledge among service users - Some FCHVs were concerned that their service users, particularly those from indigenous ethnic minority groups, did not understand the importance of healthcare services and hence did not access them. One volunteer said, "I walked two to three hours up hill to provide polio drops. The woman did not accept the medicine. She said, 'Our children do not need medicine, they will survive'." This was consistent with views of some service users for whom the concept of modern medicine was new and hence they did not see its value. A Tamang mother reported that she had not vaccinated her children: "People in the village say, 'why do you need to vaccinate? People from the past are surviving without a single injection.' For this reason, my two kids are not vaccinated."
• Lack of trust in FCHVs - Perhaps due to illiteracy or inadequate training, there were inadequate skills among health workers and volunteers in communicating the importance of healthcare services.
• Traditional beliefs and healthcare practices - For example, the FCHVs reported that service users from Muslim families were reluctant to accept immunisation, as they believed that immunisation would anger their god, and this belief was reinforced by mothers-in-law.
• Low decision-making power of women - Husbands, mothers-in-law, or other relatives frequently perceived healthcare services as irrelevant or unnecessary to them and their families.
• Perceived indignities experienced when using health centres - Both volunteers and their service users reported how health workers' rough attitude towards pregnant women and mothers dissuaded their use of healthcare services.

The researchers conclude that community health programmes should focus on increasing awareness of healthcare services among ethnic minority groups and that the programmes should involve family members (husbands 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. "The findings also have relevance to similar resource poor settings."