Research on the sustainability of training FCHVs on PPFP and PPIUD in Morang District, Province 1, Nepal

Background:

Female Community Health Volunteers (FCHVs) are recognized as the pillar of the health system in Nepal and an important bridge linking the communities to health care services. They are often the first point of contact for the people in the communities in need of health services. Despite the importance of FCHVs in improving community health and maternal and newborn health in Nepal, their involvement in post-partum family planning (PPFP) in Nepal is limited.

NESOG and FIGO had jointly implemented the intervention on orientation on FCHVs on PPFP including Post-partum intrauterine contraceptive device (PPIUD) from November to December 2018. The intervention focused on a cascading process for orientation of FCHVs in the selected communities. At the provincial level in Province One, under the leadership of Provincial Health Directorate, a pool of 15 facilitators were trained for the orientation of PPFP programs. The provincial level facilitators then trained 92 health providers at the peripheral health facility-level from the 23 peripheral health facilities in Morang district of Province One. These health providers then oriented 9-10 FCHVs each from the communities within the catchment areas of their peripheral health facilities. As a result, 230 FCHVs were oriented in December 2018.

The findings from the early evaluation of the intervention showed that the orientation improved the FCHV’s knowledge of PPFP and their community-based counseling. The improved proportion of mothers being counseled by FCHV was reflected in the facility-based results. However, the early evaluation was not able to directly measure the actual uptake of PPFP/PPIUD methods amongst the women counseled by FCHV in the communities. Moreover, the study lacked the perspectives of the key stakeholders at the provincial level and health post levels about the sustainability of involving FCHV in PPFP program. Furthermore, no data was available related to the coverage of the facility based counseling in the peripheral health facilities.

A carefully designed follow-up study addressing the limitations of the baseline study is crucial. It could provide an opportunity to assess the sustainability and understand the changes in perspectives, knowledge, and behaviors related to community-based counseling in the long run. Moreover, it could help assessing the impact of FCHV’s role in changing the PPFP related intention and behaviors of mothers in the long run.

General objective:

To assess the sustainability of the orientation of FCHV on PPFP and its effect on improving the counseling coverage and uptake of PPFP methods

Specific objectives:

-To assess the knowledge retention on PPIUD among the FCHV who had participated in the early evaluation study

-To assess the trend of counseling coverage on PPFP and uptake of PPFP methods by women in the communities through peripheral health facility records

- To understand the perspectives of the key stakeholders including Provincial leadership and health posts and FCHV on sustainability of the PPFP service coverage at community level

-To triangulate the effect of FCHV’s community coverage on the uptake of PPIUD among the women giving birth in the two selected facilities implementing PPIUD initiative

Methods:

Study design: This is will be a sequential explanatory mixed study in line with the early evaluation study. The quantitative data will include data trends on PPFP/PPIUD counseling coverage and uptake of different PPFP/PPIUD methods by the women in the communities and selected facilities. Qualitative data will include the perspectives of the key stakeholders such as Provincial health directorate, health providers from the peripheral health facilities, and FCHVs.

Study participants: All FCHVs who had participated in the early evaluation study; mothers in their immediate postpartum period who have delivered and are admitted in the selected two hospitals implementing PPIUD initiative; and stakeholder including Provincial health directorate, representative from the peripheral health facilities, and FCHVs will be included in this study.

Study sites: The 23 peripheral health facilities that were involved in the baseline study and FCHV orientation from Morang district, Province One. Two hospitals that were part of PPIUD initiative will also be included -Koshi Zonal Hospital and Nobel Medical College Teaching Hospital.

Sampling: All 230 FCHVs who had participated in the baseline study will be requested to participate in the follow-up study. For recruiting postpartum mothers, simple random sampling will be done to collect the data from the two hospitals. We will attempt to collect 400 data of mothers (200 from each facility) considering incomplete response rate. The sample size calculation and simple random sampling will follow the same process as in previous study.

Data collection: The coordination activities such as meeting with the Provincial leadership, peripheral facilities, hospitals and FCHVs will begin as soon as the ethical approval will be obtained from NHRC. The data collection officers/enumerators will be trained on data collection. The formal data collection will tentatively begin from October to December. Quantitative data will be collected through the facility records of the peripheral facilities as well as through interviews with the study participants. Qualitative data will be collected through in-depth interviews and focus group discussions. The quantitative data will be collected using mobile tablets. Open data kit (ODK) will be used to develop the mobile based questionnaire for FCHV and same ODK software used in previous study or modified version will be used for postpartum mothers.

Study tools: The same questionnaire adapted from the FCHV’s user guide on PPFP/PPIUD will be used to assess the knowledge of FCHV on PPIUD.  The data trends from the peripheral facilities will be used based on the standardized checklists that was developed during the orientation and baseline study period for the peripheral facilities to collect the data trend during monthly FCHV meetings. The same or modified questionnaire developed in the early evaluation study will be used for postpartum mothers.

Data analysis: Quantitative data analysis will include descriptive as well as multivariable analysis. Qualitative data will include thematic content analysis. Direct comparison will be done for knowledge retention of FCHVs with previous study. Other data will also be compared as appropriate.

Manuscript writing: Manuscript writing will be completed by 31st January 2020 in the format of the targeted journal.

Logistics: Green Tara Nepal (GTN) will hire a consultant to lead this research which will include proposal writing, coordination, data collection, data analysis and manuscript writing. The Country Director and GTN team will facilitate in overall supervision, management, coordination, and logistics of the research including ethical approval and government approvals. A research assistant and two field coordinators involved in early evaluation study will be hired to coordinate the research. Two data collection officers will be hired to collect the data from the selected two hospitals. Four data collection officers will be hired to collect data of FCHV from 23 peripheral health facilities. Regular meetings will be conducted with NESOG and FIGO for the updates and necessary approvals.