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. 2023 Jan 24;3(1):e0001512.
doi: 10.1371/journal.pgph.0001512. eCollection 2023.

A Type II hybrid effectiveness-implementation study of an integrated CHW intervention to address maternal healthcare in rural Nepal

Aparna Tiwari  1 , Aradhana Thapa  1 , Nandini Choudhury  1   2 , Rekha Khatri  3 , Sabitri Sapkota  2   3 , Wan-Ju Wu  1   4   5 , Scott Halliday  1   6 , David Citrin  1   2   6   7 , Ryan Schwarz  1   8   9   10 , Duncan Maru  1   2   11   12   13 , Hari Jung Rayamazi  14 , Rashmi Paudel  14 , Laxman Datt Bhatt  14 , Ved Bhandari  14 , Nutan Marasini  14 , Sonu Khadka  15 , Bhawana Bogati  14 , Sita Saud  16 , Yashoda Kumari Bhat Kshetri  17 , Aasha Bhatta  18 , Kshitiz Rana Magar  19 , Ramesh Shrestha  19 , Ranjana Kafle  20 , Roshan Poudel  14 , Samiksha Gautam  14 , Indira Basnett  3 , Goma Niroula Shrestha  21 , Isha Nirola  22 , Samrachana Adhikari  23 , Poshan Thapa  24 , Lal Kunwar  25 , Sheela Maru  1   2   11   26
Affiliations

A Type II hybrid effectiveness-implementation study of an integrated CHW intervention to address maternal healthcare in rural Nepal

Aparna Tiwari et al. PLOS Glob Public Health. .

Abstract

Skilled care during pregnancy, childbirth, and postpartum is essential to prevent adverse maternal health outcomes, yet utilization of care remains low in many resource-limited countries, including Nepal. Community health workers (CHWs) can mitigate health system challenges and geographical barriers to achieving universal health coverage. Gaps remain, however, in understanding whether evidence-based interventions delivered by CHWs, closely aligned with WHO recommendations, are effective in Nepal's context. We conducted a type II hybrid effectiveness-implementation, mixed-methods study in two rural districts in Nepal to evaluate the effectiveness and the implementation of an evidence-based integrated maternal and child health intervention delivered by CHWs, using a mobile application. The intervention was implemented stepwise over four years (2014-2018), with 65 CHWs enrolling 30,785 families. We performed a mixed-effects Poisson regression to assess institutional birth rate (IBR) pre-and post-intervention. We used the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework to evaluate the implementation during and after the study completion. There was an average 30% increase in IBR post-intervention, adjusting for confounding variables (p<0.0001). Study enrollment showed 35% of families identified as dalit, janjati, or other castes. About 78-89% of postpartum women received at least one CHW-counseled home visit within 60 days of childbirth. Ten (53% of planned) municipalities adopted the intervention during the study period. Implementation fidelity, measured by median counseled home visits, improved with intervention time. The intervention was institutionalized beyond the study period and expanded to four additional hubs, albeit with adjustments in management and supervision. Mechanisms of intervention impact include increased knowledge, timely referrals, and longitudinal CHW interaction. Full-time, supervised, and trained CHWs delivering evidence-based integrated care appears to be effective in improving maternal healthcare in rural Nepal. This study contributes to the growing body of evidence on the role of community health workers in achieving universal health coverage.

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Conflict of interest statement

I have read the journal’s policy and the authors of this manuscript have the following competing interests: A. Tiwari and A. Thapa are employed by a US-based non-profit (Possible) and based in Nepal. S. Sapkota and R. Khatri are employed by a Nepal-based non-governmental organization, Possible that operates with support from US-based Possible. VB, BB, HJR, R. Paudel, SG, NM, R. Poudel and LDB are employed by a Nepal-based non-governmental organization (Nyaya Health Nepal) that delivers free healthcare in rural Nepal using funds from the Government of Nepal and other public, philanthropic, and private foundation sources. NC, DM, SM are employed by, and SM, DC, DM, and S. Sapkota are faculty members at a private medical school (Icahn School of Medicine at Mount Sinai). DM is a member on US-based Possible’s Board of Directors, for which he receives no compensation. IB is a board chair of Nepal-based Possible. WW is a faculty member at a private university (Boston University School of Medicine). DC is a faculty member and SH is a graduate student at a public university (University of Washington). R. Schwarz is 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. R. Schwarz is a faculty member at a private medical school (Harvard Medical School) and 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. SA is a faculty member at a private medical school (NYU School of Medicine). SK is a nursing student at Gandaki Medical College Teaching Hospital and Research Center. IN is a graduate student at a private university (Harvard T.H. Chan School of Public Health). LK is employed by a non-profit (Medic). PT is a graduate student at a public university (University of New South Wales). S. Saud is employed by a government hospital of Nepal (Civil Service Hospital). YKBK is employed by a government hospital of Nepal (COVID Hospital in Shikhar municipality). AB is employed by the local government of Nepal (Amargadhi municipality). R. Shrestha and KRM are employed by a non-profit hospital (Dhulikhel Hospital, Kathmandu University Hospital). R. Kafle is employed by a Nepal-based non-profit (Nick Simons Institute). GNS is a director of the Nursing and Social Security Division under the Government of Nepal Ministry of Health and Population. All authors declare that we have no competing financial interests.

Figures

Fig 1
Fig 1. Conceptual model for antenatal and postnatal components of the integrated intervention.
Fig 2
Fig 2. Study enrollment.
Fig 3
Fig 3. Unadjusted institutional birth rates by intervention time period.
Fig 4
Fig 4. Postnatal counseled home visits within 60 days of birth.
Fig 5
Fig 5. Postnatal counseled home visits within a week of birth.
See this image and copyright information in PMC

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