Background
Nepal- a low income country with substantial health and development challenges
Health-related sustainable development Goal 3 (SDG3)
Methods
Study design
Search strategy
Inclusion and exclusion criteria
Theoretical framework
Data extraction
Synthesis of review
Quality assessment
Results
S N | Author/Year | Objectives | Type of study | Sample size | Relevant findings |
---|---|---|---|---|---|
1 | (Acharya 2010) [52] | To establish the most important socio-background characteristics associated with women’s decision-making power | Cross sectional | 8257 married women | Women with high education level have greater autonomy in the decision making for their own healthcare. |
2 | (Allendorf 2007a) [37] | To comparing spouses’ reports of women’s autonomy with health outcomes in Nepal. | Cross sectional | 1858 currently married couples | Women with higher autonomy for household decisions have more access to healthcare. |
3 | (Allendorf 2007b) [42] | To explore the connections among women’s land rights, women’s empowerment, and child health in Nepal | Cross sectional | 4884 women | Children of women with decision making power in the family were less undernourished. |
4 | Atteraya 2010 [41] | To examine the relationship between women’s autonomy and ability to negotiate safer sex practices among married women. | Cross sectional | 8896 married women | Women with higher autonomy in household decision making could also negotiate safe sex. |
5 | Baral 2010 [63] | To identify the issues associated with women’s role and choices regarding use of Skilled Birth Attendants and to explore factors affecting utilisation of maternal health services in Nepal. | Review | Number of papers not mentioned | Availability of transportation and distance to the health facility, lack of infrastructure and services, availability and accessibility of the services, healthcare cost; inadequate staff, women’s status in the society; women’s involvement in decision making; contribute to utilisation of Skilled Birth Attendance for delivery. |
6 | Baral 2012 [33] | To identify the range and pattern of maternal health service utilisation in Nepal over | Review | Number of papers not mentioned | Women with higher education and living in urban areas are more likely to use maternal health services. |
7 | Bhatta 2015 [30] | To assess associated paternal factors and degree of inequity in access to maternal healthcare service utilization. | Cross sectional | 2200 men | Husbands with higher education and higher income facilitate their wives to make ANC visits and institutional delivery. |
8 | Bhattarai 2015 [47] | To explore health seeking behavior and utilization of healthcare services in the rural places in VDCs of Ilam district | Cross sectional | 300 men and women | People seek healthcare from traditional healers due to perception of high cost in modern medicine. Private institutions are preferred compared to the public. |
9 | Bhusal 2011 [48] | To find out the effectiveness and efficiency of Aama Surakshya Karyakram to address barrier in accessing maternal health services in Nepal. | Cross Sectional | 47 women | Pregnant mothers were not aware of the provision of incentive for institutional delivery. Of those who were aware, did not know what the incentive was for. Financial incentives are seen to increase the utilisation of maternal health services. |
Methods: | |||||
10 | Budhathoki 2014 [60] | To find the factors associated with awareness of occupational hazards and protective measures and the use of protective measures, and the possible relationship between awareness and actual use of PPE. | Cross sectional | 300 welders | Welders with higher education are more aware of the hazards and utilise more protective measures. |
11 | Brunson 2010 [55] | To identify impediments to receiving obstetric care in a context where the infrastructure and services were in place. This | Qualitative | 30 women | Women are not aware about the general danger signs of pregnancy, which in turn hinders timely seeking of pregnancy care. |
12 | Byrne 2013 [65] | To identify demand-side barriers to the utiliza- tion of formal RMNCH services in the Mountains ecological region of Nepal | Review | 23 papers | Low status of women, caste discrimination, less knowledge of healthcare, less active mothers groups, dissatisfaction quality of care, health worker attitudes and cultural/spiritual traditions affect healthcare utilisation. |
13 | Chapagain 2006 [39] | To appraise conjugal power relations and explore the nexus between such relations and couples’ participation in reproductive health (RH) decision-making. | Cross sectional | 223 married couples | Gender power relations, traditional gender roles and cost associated with service affects reproductive healthcare decision making. |
14 | Choulagain 2013 [56] | To examine the characteristics associated with utilization of SBA services in mid- and far-western Nepal | Cross Sectional | 2,481 women | Women’s awareness of danger signs of pregnancy, distance from health facilities and inadequate transportation pose major barriers to the utilisation of skill birth attendants’ services. |
15 | Furuta 2006 [36] | To examine the influence of four indica- tors of women’s household position on the receipt of skilled antenatal and delivery care: their involvement in decision making about their own healthcare and about large household purchases, their employment and control over their own earnings, and their discussion of family planning with their husbands. | Cross sectional | 4,695 currently married women | Women supported by husbands, women with higher education were more likely to seek maternal healthcare. |
16 | Ghimire 2009 [64] | To identify the barriers of access to sexual health services by FSWs in Nepal | Mixed-method | 425 female sex workers (FSWs) for quantitative survey and 15 FSWs for in-depth interview | Lack of confidentiality, discriminatory attitudes by healthcare providers, communication gap with service providers and fear of public identification as a sex worker were barriers in seeking sexual health services by the female sex workers. |
17 | Gubhaju 2009 [54] | To provide indepth examination of the link between husbands’ and wives’ education levels and method of choice of family planning. | Cross Sectional | 21,057 women | Level of education of husband and wives affects the choice of family planning method adopted by women. |
18 | Halim 2011 [51] | To examine the correlates and consequences of antenatal care utilization in Nepal | Cross sectional | 3,549 mothers and 2,460 children (0–36 months) | Maternal & paternal education play important role in the utilisation of routine antenatal care. |
19 | Hotchkiss 2001 [25] | To assess the impact of this investment on the use of maternal healthcare services. | Cross Sectional | 1,434 women of reproductive age | Physical access to a healthcare facility affects the utilisation of maternal health services. |
20 | Iriyama 2007 [59] | To examine the associations between two subscales, perceived severity and perceived susceptibility, and the abstinence intentions of male adolescent students in Nepal. | Cross sectional | 297 male students | Knowledge of HIV AIDS among adolescents affected their sex behavior. |
21 | Jahn 2000 [66] | To assess the performance of maternity care and its specific service components (preventive interventions in antenatal care, antenatal screening, referral, obstetric care) in Banke District, Nepal | Cross Sectional | 136 pregnant women, 146 postnatal women | Availability of comprehensive maternal healthcare was associated with higher utilisation of the services. |
22 | Mishra 2005 [29] | To analyse the contribution of socio- economic status to non-adherence to DOTS. | Case–control | 50 cases of tuberculosis and 100 controls | High travel cost to reach the treatment facility, low socioeconomic status affects non-adherence to anti-tuberculosis treatment. |
23 | Mullany 2006 [44] | To understand the barriers to male involvement in maternal health and explore men’s, women’s, and providers’ attitudes towards the promotion of male involvement in antenatal care and maternal health. | Qualitative | 31 couples and 9 women | Low levels of knowledge are associated with less involvement of males in maternal healthcare of their wives. |
24 | Mullany 2007 [40] | To test the impact of involving male partners in antenatal health education on maternal healthcare utili- zation and birth preparedness in urban Nepal | Randomised controlled trial | 442 antenatal women | Women who received education with their husbands have better birth preparedness. |
25 | Mullany 2005 [45] | To investigate patterns of household decision-making and the context of male involvement behaviors in Katmandu, Nepal | Cross sectional | 592 pregnant women | Good communication between husband and wife leads to increased involvement of husband in maternal healthcare. |
26 | Onta 2014 [57] | To explore the perceptions of service users and providers regarding barriers to skilled birth care | Qualitative | 12 FGDs (7–10 women per group) & 12 FGDs (7–10 ANC service providers) | Inadequate knowledge of services, distance to health facilities, unavailability of transportation, and poor availability of skilled birth attendants, poor infrastructure, less service coverage, inadequate awareness about services/facilities, cultural practices and beliefs, and low prioritization of birth care are barriers to maternal healthcare. |
27 | Pokhrel 2004 [31] | To map out a hierarchical scale of household decision-making regarding child healthcare. | Cross sectional | 8,112 adults | Household income and mother’s education is associated with healthcare seeking for children. |
28 | Poudel 2015 [50] | To find the existing knowledge gap about the economic burden of HIV/AIDS at the household level in Nepal | Review | 7 papers | Lack of awareness of potential economic burden of HIV/AIDS upon household exists in the community. |
29 | Poudel 2004 [62] | To identify Nepali migrants’ vulnerability to HIV/STIs, and to explore the possible role of migration in causing the HIV/STI epidemic in far western Nepal. | Qualitative | 60 migrants | Low knowledge on and low perceived vulnerability to HIV/STIs led to risky behaviour among migrants. |
30 | Powell-Jackson 2009 [49] | To explore early implementation of the programme at the district-level to understand the factors that have contributed to its low uptake | Qualitative | 55 key informants from district health service | Bureaucratic delays in the disbursement of funds, gaps in policy communication to implementers and prople affects utilisation of safe delivery services. |
31 | Puri 2006 [61] | To analyze the sexual behavior, perceived risk of contracting STIs and HIV/AIDS, and protective behaviors of migrant workers | Cross sectional | 1,050 factory workers | Migrant workers are not aware about the consequences of unsafe sex and transmission of HIV. |
32 | Regmi 2010 [76] | To explore the barriers to using sexual health services, including condom-use among young people in Nepal | Qualitative | 50 youth for FGD and 31 in depth interviews | Poor sexual and reproductive health knowledge is a barrier in utilisation of sexual health services among the young people |
33 | Shah 2015 [38] | To identify the socio-demographic, socio-cultural, and health service-related factors influencing institutional delivery uptake in rural areas of Chitwan district, | Cross sectional | 673 women | Role of the husband, role of wife in household decision making, access to material resources, literacy rates, dependency on husband, geographical accessibility, and lack of established transportation infrastructure affects the utilisation of institutional delivery services by women. |
34 | Sharma 2007 [32] | To examine the association of access to health services and women’s status with utilization of prenatal, delivery, and postnatal care | Cross sectional | 3,845 women | Maternal health worker visits, educational status of women, household economic status, number of living children and place of residence are associated with utilisation of maternal health services. |
35 | Simkhada 2006 [53] | To identify some challenges and suggests way forward in the improvement of maternal health in Nepal. | Review | Number of papers not mentioned | Lack of access to basic maternal healthcare, difficult geographical terrain, poorly developed transportation and communication systems, poverty, illiteracy, women's low status in the society, political conflict, and shortage of healthcare professional are barriers to maternal health in Nepal. |
36 | Smith-estelle 2003 [46] | To identify isues that affect vulnerability to HIV/STI infection among rural women from migrant communities in Nepal | Cross Sectional | 900 ever-married women | Gender discrimination, lack of access to healthcare and education in rural areas, and the precarious economic, legal and social circumstances make the women more vulnerable to HIV/STI. |
37 | Updhyay 2014 [43] | To determine the perceived influential person on a woman’s decision to utilize antenatal and delivery care services among teen, young adult and adult pregnant women | Cross sectional | 315 women | Involvement of husband in family planning decision for healthcare seeking for maternal health services. |
38 | Witter 2011 [71] | To understand the effects of the policy on health facilities. Study methods included structured forms to retrieve financial and activity data from national, district and facility records | Qualitative | Health managers from 22 health facilities | The utilisation of delivery services is facilitated by availability of free services. |
Income and price
Culture and gender
Knowledge and education
Quality of services
Discussion
1. Health literacy is required to enable people to access and utilize healthcare | |
People in Nepal have many potential barriers to access and use healthcare services. Barriers include cost of services, cost of transport, low income and unemployment. Existing gender roles and discrimination related to local culture, knowledge of services and health problems, limited availability of services, low quality services provide large challenges for people to access and utilize services. | |
To overcome these barriers, the health literacy of community members needs to be high such that people are empowered to be able to make decisions about healthcare and overcome access barriers. | |
2. Health literacy is required to enable people to have high quality interactions with health service providers | |
Many barriers to quality interactions were identified, including: local culture and gender norms, education, knowledge of health services and health problems, access to good quality information, communication skills of staff, health worker’s attitudes and organizational policy on communication with community members. | |
When there are one or more of these potential barriers to quality interaction with health service providers, the health literacy of a community member will need to be high. | |
3. Health literacy is required to optimize caring for one’s own health and the health of others | |
The identified determinants of this area included gender roles and women’s autonomy, spousal support along with knowledge and education. | |
Improving health literacy increases understanding of health and disease as well as the available services, hence people are able to take decisions to take care of their own self and others. | |
4. Health literacy is required to enable participation in health negotiations and decision-making | |
The review identified few determinants of participation including the ability to engage in discussions related to gender roles and discrimination, women involvement in decision making, men’s involvement in women’s health, women’s autonomy, spousal support, knowledge and education and the health system responsiveness including communication skills of staff and the quality of health services. Another relevant ability in the community level is the ability of an individual to be able to discuss health matters and make decisions about health. This requires adequate health literacy in an individual and across a community. A strong background mechanism is likely to be educational attainment, including having an understanding of basic biomedical concepts including anatomy and basic medical terms. Without these, being empowered to participate in health negotiations and decision making is unlikely. |
Relationship between factors influencing public health, SDGs and health literacy
Health related of SDG 3: ensure healthy lives and promote well-being for all at all ages | Factors influencing the attainment of targets |
---|---|
3.1 By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births | Income and Cost |
- Cost of Services | |
3.2 By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1000 live births and under-5 mortality to at least as low as 25 per 1,000 live births | - Cost of Transport |
- Income status | |
- Employment status | |
3.3 By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases | - Socioeconomic status |
Culture and gender | |
- Gender roles/discrimination | |
3.4 By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being | - Cultural norms of women involvement in decision making |
- Men’s involvement in women's health | |
- Womens' autonomy | |
3.5 Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol | - Spousal support |
Knowledge and Education | |
3.6 By 2020, halve the number of global deaths and injuries from road traffic accidents | - Education status |
- Knowledge of services | |
3.7 By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes | - Knowledge of health problems |
- Knowledge of hazards | |
- Knowledge of Economic burden | |
3.8 Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all | - Access to good quality information |
Quality of services | |
3.9 By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination | - Health system responsiveness |
- Infrastructure | |
3.a Strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all countries, as appropriate | - Availability of Services |
- Communication skills of staff | |
3.b Support the research and development of vaccines and medicines for the communicable and non-communicable Diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines, in accordance with the Doha Declaration on the TRIPS Agreement and Public Health, which affirms the right of developing countries to use to the full extent the provisions in the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) regarding flexibility to protect public health, and in particular provide access to medicines for all | - Health worker’s attitude |
- Human resources for health | |
- Technical/Managerial competence of staff | |
- Policy and its implementation | |
- Policy communication with people | |
- Privacy/Confidentiality | |
3.c Substantially increase health financing and the recruitment, development, training, and retention of the health workforce in developing countries, especially in the least-developed countries and developing small island states | - Satisfaction regarding healthcare |
3.d Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction, and management of national and global health risks |