Factors affecting health-seeking behavior among people in Nepal: Exploratory study on institutional delivery, routine child immunization and COVID-19 vaccination.

Research Report.

SUMMARY:
Background Health care-seeking behaviour is defined as, “The actions that people undertake when they perceive themselves to have some health problems or have some illness.” The behaviour guides people to find an appropriate remedy for their health concerns. People are influenced by various factors when they seek to make decisions concerning their health. This study aims to explore factors that act as facilitators and barriers to institutional delivery. The study also aims to explore the barriers and facilitators to routine child immunization and vaccination against Coronavirus Disease 2019 (COVID-19). A mixed method study was adopted in which the national data on coverage of institutional delivery, routine child immunization and COVID-19 vaccination was obtained through desk review followed by identification of study sites (local governments) having the lowest coverage of at least two indicators; institutional delivery, routine child immunization or COVID-19 vaccination for each selected sites. To collect information on the barriers to, and facilitators of, the participants’ health-seeking behaviour, and to explore stakeholders’ perceptions for those indicators, a focused ethnographic study design was applied. In-depth interviews (IDIs), Key informant interviews (KIIs), kuragraphy and transect walk were used to collect information. Two hundred and nineteen interviews were conducted, of which IDIs were conducted with 174 participants and KIIs with 45 participants. Kuragraphy was also conducted with villagers. Through the transect walk, researchers observed community settings, community practices, distance to the health facility, water sources, and available health care facilities in the study sites. This study was conducted in all seven provinces of the country. In each province, a rural municipality and an urban municipality was selected, while in Bagmati province, an urban slum area was also selected along with both rural and urban municipalities. Therefore, in total, 15 sites were selected for the study. Participants were selected purposively. Interview guidelines were used for IDIs with participants who had not used the services and those who had chosen to use the health services. KIIs were also undertaken with service providers. Interviews were recorded with the help of a recorder. They were then transcribed and translated into English language. Thematic analysis was performed using the RQDA package of R software.


Institutional delivery Various activites on safe motherhood and newborn health programme such as: community level maternal and newborn health interventions, rural ultrasound programme, expansion and quality improvement of service delivery sites, emergency referral funds, aama surakshya program and free newborn programme implemented by the Government of Nepal, the number of people choosing institutional delivery has increased over time. Greater understanding of the decrease in risks in institutional delivery has been an important factor in influencing people to choose institutional delivery. The additional provision of benefit packages such as providing clothes for newborn baby and mother, oil, eggs and other food supplies provided by selected local government has given further motivation to make the recommended antenatal care (ANC), delivery and postnatal (PNC) visits at health facilities. There has been a change in practice, as mothers-in-law who used to deliver at home are now increasingly sending their daughters-in-law for institutional delivery. Despite those positive changes, some women still deliver at home. This was found to occur especially in areas where a health facility’s accessibility is challenged by difficult roads, unavailability of regular transport, and disruption of travel by landslides during the monsoon. A high cost of transportation not covered by the government incentive is another challenge for poorer people. Further barriers to institutional delivery include, unavailability of birthing centre facilities in nearby health posts, unavailability of Ultrasonography (USG) services at the entire local level, unavailability of adequate service providers,
especially trained birth attendants. These factors are the main reasons why delivery happens at home or en route to the health facility. In some settings, privacy also influenced the decision to opt for home delivery. In some places, cultural factors such as untouchability of women in their postpartum period along with the family culture of home deliveries supported by similar practices in the community also acted as reasons not to choose institutional delivery. Those that chose to deliver at home also included many who either had previously multiple or uncomplicated deliveries at home and women who had married early and did not fully understand the risks involved in the process of delivery. However, many people chose to deliver in higher centres that provided comprehensive emergency obstetrical and nenoatal care (CEmONC) in cities. Some were also referred to higher centres by local health facilities. This was a significant factor for the institutional delivery data appearing to be very low at the local level.


Routine Child Immunization Vaccination has been taken as the practice in the present day, which acted as a facilitator for the routine child vaccination in Nepal. Better educational status, availability of relevant information and a significant role played by the Female Community Health Volunteer (FCHV) in tracing and tracking children eligible for routine immunization in their catchment area are the major factors responsible for complete immunization of children. The work of the national government plus the efforts made by local government in bringing immunization services closer to target households irrespective of challenges in transportation, seasonal road blocks and the pandemic are the major factors that have helped in child immunization coverage. However, there are some instances where children missed their vaccination. Loss of vaccination cards followed by the fear of being scolded by the health worker at the vaccination site, along with the child’s illness at the time of immunization were important factors observed in many areas of the country. Internal migration at the time of child’s immunization and migration to multiple places for work were also found to explain children missing their immunization. In brick factories particularly, missed vaccinations were found where there was no FCHV reach and parents there did not have adequate knowledge of vaccination sites and schedules for their child. Other factors influencing children missing their routine immunization include non-availability of FCHV to publicize immunization schedules, and mental illness in parents and family members. The status of broken families and decision-making largely by males who may be busy at work and therefore give less importance to their child’s immunization were also observed to hinder immunization. Despite some laudable efforts made for routine child immunization, coverage appeared not to reach the desired level, the national data suggests. However, health workers and representatives mentioned there being no or very few cases of missed immunization in their area. From the key informant interviews, it was found that the discrepancy observed in the national data and the ground reality at the local level concerning routine child immunization is due to the setting of impractically high levels of targets.


COVID-19 vaccination The extensive vaccination programme launched by the Government of Nepal resulted in good Coronavirus Disease 2019 (COVID-19) vaccination coverage throughout the country. Media campaigns to inform people about COVID-19 and the available vaccines helped to generate public awareness of the vaccine and of vaccine demand. The trace and vaccination activities carried out by health workers and local community groups at the community level strengthened the COVID-19 vaccination campaign. Despite efforts made by the government and others, some people were found not to have taken the vaccine. Personal choice was found to be the most important factor in choosing not to be vaccinated. Those who claimed themselves to be illiterate attributed their instinct for not accepting the vaccine, while those that were more educated often claimed that the vaccination is propaganda and there is no assurance about the long-term safety of a vaccine developed in foreign countries. Among people with multiple comorbidities, a fear of side effects post-vaccination made them decide to not take the vaccine. The decision of husbands who decided not to have the vaccine influenced their wives, many of whom also rejected the vaccine. Because of being pregnant, females were deprived of vaccination; however, along with the course of time, they did not give importance to vaccination and remained unvaccinated. That was also the case for people who could not get the vaccine because of the large crowds in the early days, as they too lost interest in vaccination and stayed unvaccinated. Physical disability was a factor that made the family decides on there being no need to vaccinate the family member and, in another situation, the high transportation cost required to transport physically disabled people for vaccination also resulted in unvaccinated status. In conclusion, the government has made great efforts in promoting institutional delivery, routine child immunization and, more recently, vaccination against COVID-19. People have also realized the importance of such services and have adopted behaviour to seek health care services for the prevention of disease and promotion of health using those services. However, there are scattered cases of people who do not seek health services whose decisions were influenced by their level of awareness, cultural beliefs, and access to service centres along with issues in the quality of services provided at the health facilities and by the service providers. The findings of this study provide local evidence that help policy makers and implementers to develop strategies for improvement of institutional delivery, routine child immunization and COVID-19 vaccination. Local evidence will help to prepare context-specific micro planning to increase their coverage.