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

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.

Evaluation of index-overlay methods for groundwater vulnerability and risk assessment in Kathmandu Valley, Nepal.

This study aimed at evaluating three index-overlay methods of vulnerability assessment (i.e., DRASTIC, GOD, and SI) for estimating risk to pollution of shallow groundwater aquifer in the Kathmandu Valley, Nepal. The Groundwater Risk Assessment Model (GRAM) model was used to compute the risk to groundwater pollution. Results showed that DRASTIC and SI methods are comparable for vulnerability assessment as both methods delineate around 80% of the groundwater basin area under high vulnerable zone. From the perspective of risk to pollution results, DRASTIC and GOD methods are comparable. Nevertheless, all the three methods estimate that at least 60% of the groundwater basin is under moderate risk to NO3-N pollution, which goes up to 75% if DRASTIC or GOD-based vulnerabilities are considered as exposure pathways. Finally, based on strength and significance of correlation between the estimated risk and observed NO3-N concentrations, it was found that SI method is a better-suited one to assess the vulnerability and risk to groundwater pollution in the study area. Findings from this study are useful to design strategies and actions aimed to prevent nitrate pollution in groundwater of Kathmandu Valley in Nepal.