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. 2018 Mar 29;13(1):53.
doi: 10.1186/s13012-018-0741-x.

An integrated community health worker intervention in rural Nepal: a type 2 hybrid effectiveness-implementation study protocol

Sheela Maru  1   2   3 , Isha Nirola  1   4 , Aradhana Thapa  1 , Poshan Thapa  1 , Lal Kunwar  1 , Wan-Ju Wu  1   5 , Scott Halliday  1   6 , David Citrin  1   6   7   8 , Ryan Schwarz  1   9   10   11 , Indira Basnett  12 , Naresh Kc  13 , Khem Karki  14 , Pushpa Chaudhari  15 , Duncan Maru  16   17   18   19
Affiliations

An integrated community health worker intervention in rural Nepal: a type 2 hybrid effectiveness-implementation study protocol

Sheela Maru et al. Implement Sci. .

Abstract

Background: Evidence-based medicines, technologies, and protocols exist to prevent many of the annual 300,000 maternal, 2.7 million neonatal, and 9 million child deaths, but they are not being effectively implemented and utilized in rural areas. Nepal, one of South Asia's poorest countries with over 80% of its population living in rural areas, exemplifies this challenge. Community health workers are an important cadre in low-income countries where human resources for health and health care infrastructure are limited. As local women, they are uniquely positioned to understand and successfully navigate barriers to health care access. Recent case studies of large community health worker programs have highlighted the importance of training, both initial and ongoing, and accountability through structured management, salaries, and ongoing monitoring and evaluation. A gap in the evidence regarding whether such community health worker systems can change health outcomes, as well as be sustainably adopted at scale, remains. In this study, we plan to evaluate a community health worker system delivering an evidence-based integrated reproductive, maternal, newborn, and child health intervention as it is scaled up in rural Nepal.

Methods: We will conduct a type 2 hybrid effectiveness-implementation study to test both the effect of an integrated reproductive, maternal, newborn, and child health intervention and the implementation process via a professional community health worker system. The intervention integrates five evidence-based approaches: (1) home-based antenatal care and post-natal care counseling and care coordination; (2) continuous surveillance of all reproductive age women, pregnancies, and children under age 2 years via a mobile application; (3) Community-Based Integrated Management of Newborn and Childhood Illness; (4) group antenatal and postnatal care; and 5) the Balanced Counseling Strategy to post-partum contraception. We will evaluate effectiveness using a pre-post quasi-experimental design with stepped implementation and implementation using the RE-AIM framework.

Discussion: This is the first hybrid effectiveness-implementation study of an integrated reproductive, maternal, newborn, and child health intervention in rural Nepal that we are aware of. As Nepal takes steps towards achieving the Sustainable Development Goals, the data from this three-year study will be useful in the detailed planning of a professionalized community health worker cadre delivering evidence-based reproductive, maternal, newborn, and child health interventions to the country's rural population.

Trial registration: ClinicalTrials.gov Identifier: NCT03371186 , registered 04 December 2017, retrospectively registered.

Keywords: Child health; Community health workers; Implementation research; Maternal health; Nepal; Public health surveillance; RE-AIM; Reproductive health; Telemedicine; Type 2 hybrid-effectiveness-implementation.

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Conflict of interest statement

Ethics approval and consent to participate

The Nepal Health Research Council (#461/2016) and Brigham and Women’s Hospital Institutional Review Board (2017P000709/PHS) approved the study protocol. We will obtain verbal informed consent from all study participants.

Consent for publication

We will obtain verbal informed consent from all study participants from which qualitative data will be used in publications.

Competing interests

SM, WJW, RS, and DM work in partnership with and AT, PT, LK, SH and DC are employed by a nonprofit healthcare company (Possible) that delivers free healthcare in rural Nepal using funds from the Government of Nepal and other public, philanthropic, and private foundation sources. At the time of intervention implementation, IN and IB were employed by Possible. SM is employed at an academic medical center (Boston Medical Center) that receives public sector research funding, as well as revenue through private sector fee-for-service medical transactions and private foundation grants. SM is a faculty member at a private university (Boston University School of Medicine). WJW is an academic fellow at and RS and DM are employed at an academic medical center (Brigham and Women’s Hospital) that receives public sector research funding, as well as revenue through private sector fee-for-service medical transactions and private foundation grants. IN is a student at a private university (Harvard T.H. Chan School of Public Health). SH and DC are employed part time at and DC is a faculty member at a public university (University of Washington). RS is employed at an academic medical center (Massachusetts General Hospital) that receives public sector research funding, as well as revenue through private sector fee-for-service medical transactions and private foundation grants. RS and DM are faculty members at a private university (Harvard Medical School). IB, NKC, and PC are employed by the Government of Nepal. KK is a faculty member at a public university (Tribhuvan University, Institute of Medicine). DM is a non-voting member on Possible’s board of directors but receives no compensation. All authors have read and understood BioMed Central’s policy on competing interests and declare that we have no competing financial interests. The authors do, however, believe strongly that healthcare is a public good, not a private commodity.

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