The Open Public Health Journal




ISSN: 1874-9445 ― Volume 12, 2019
RESEARCH ARTICLE

Factors Affecting Antenatal Care Utilization Among the Disadvantaged Dalit Population of Nepal: A Cross- sectional Study



Surendra Prasad Chaurasiya1, *, Nilesh Kumar Pravana1, *, Vishnu Khanal2, Dhiraj Giri3
1 Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
2 Nepal Development Society, Bharatpur, Nepal
3 Department of Natural Science, Kathmandu University, Kathmandu, Nepal

Abstract

Background:

Antenatal Care (ANC) visits are intended to prevent, identify and treat conditions that may threaten the health of the mother and newborn, and to increase the chance she has a smooth pregnancy and and safe childbirth. The most disadvantaged and underprivileged caste (Dalit) of Nepal has benefitted the least from maternal health service improvements in the recent years.

Objective:

This study was conducted to determine the rate and factors associated with the antenatal care service utilization among the most disadvantaged ethnic group (Dalit women) and recommend interventions to improve ANC utilisaiton, in the Mahottari district of Nepal.

Methods:

A cross-sectional study was conducted during July-December 2014 using a structured questionnaire. A total of 328 recently delivered mothers were interviewed covering the entire district. Descriptive statistics, binary and multivariable logistic regression analyses were computed. Statistical significance was considered at p < 0.05 and the strength of statistical association was assessed by odds ratios with 95% confidence intervals.

Results:

ANC utilization rate (≥ 4 ANC visit) was found to be 42%. Mother's education, husband's education, mother's occupation, perceived “good quality” ANC, hearing about incentive program, maternal health message, non-perception of health workers behaviours as discriminatory, and exposure to Female Community Health Volunteer were found to be significantly associated with ANC utilization.

Conclusion:

ANC service utilization is low. So, there is an urgent need to address the issue of ANC quality and discriminatory behaviour of health workers toward Dalit. A targeted & comprehensive maternal health program should be developed to raise awareness and motivate pregnant women for maximum utilisation of ANC services.

Keywords: Antenatal care, Disadvantaged dalit caste, Quality ANC, Discriminatory behaviour, Maternal health service, Nepal.


Article Information


Identifiers and Pagination:

Year: 2019
Volume: 12
First Page: 155
Last Page: 163
Publisher Id: TOPHJ-12-155
DOI: 10.2174/1874944501912010155

Article History:

Received Date: 26/02/2019
Revision Received Date: 09/03/2019
Acceptance Date: 04/04/2019
Electronic publication date: 29/04/2019
Collection year: 2019

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© 2019 Chaurasiya et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: (https://creativecommons.org/licenses/by/4.0/legalcode). This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to these authors at Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal;
Tel: + 977-9841519232, 977-9841196741; Fax:+97714418186;
E-mails: spchaurasiya@gmail.com, nk.pravana12@gmail.com






1. INTRODUCTION

Developing countries account for 99 percent of the global maternal deaths, with the sub-Saharan Africa region alone accounting for 62% followed by Southern Asia 24% [1World Health Organization. Trends in Maternal Mortality: 1990 to 2013 2014.]. Antenatal care (ANC) can be defined as “the care provided by skilled health-care professionals to pregnant women and adolescent girls in order to ensure the best health conditions for both mother and baby during pregnancy” [2Organization AY. WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience. World Health Organization 2017.]. Utilization of Antenatal care service promotes institutional delivery and decreases maternal morbidity and mortality both directly and indirectly [2Organization AY. WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience. World Health Organization 2017.-4Pandit RD. Role of antenatal care in reducing maternal mortality. Asia Oceania J Obstet Gynaecol 1992; 18(1): 1-6.
[http://dx.doi.org/10.1111/j.1447-0756.1992.tb00291.x] [PMID: 1627 055]
]. ANC provides a mother the opportunity to familiarize and interact with the health system and with the health facility, thereby increasing the chance that she chooses to deliver in a health institution [5Gabrysch SC, Oona M R. Still too far to walk: Literature review of the determinants of delivery service use. BMC Pregnancy Childbirth 2009; 9(1): 34.
[http://dx.doi.org/10.1186/1471-2393-9-34] [PMID: 19671156]
]. As recommended by World Health Organization (WHO), Nepal has required at least four ANC services scheduled in the following way: first visit at the 4th month, second at the 6th month, third at the 8th month and fourth at the 9th month of pregnancy [6Ministry of Health and Population. Annual Report of Department of Health Services (DoHS) 2011/2012.]. In Nepal, ANC services are based on monitoring of mother's blood pressure, weight and fetal heart rate; providing information education and communication and behavior change communication for danger signs, care during pregnancy, timely referral to the appropriate health facilities; birth preparedness and complication readiness; early detection and management of complications; and provision of tetanus-toxoid immunization, iron and de-worming tablets to all pregnant women and malaria prophylaxis as needed [6Ministry of Health and Population. Annual Report of Department of Health Services (DoHS) 2011/2012.]. Further, the government of Nepal provides financial incentives to women and health facilities to promote ANC and institutional delivery [6Ministry of Health and Population. Annual Report of Department of Health Services (DoHS) 2011/2012.-8Ministry of Health and Population Government of Nepal. Nepal health sector programme-implementation Plan-II 2010-2015 2010.]. Despite these efforts, Nepal is still one of the countries in South and Southeast Asia where women are less likely to receive ANC from health professionals (doctors, nurse/midwife) and low proportion of births are delivered in a health facility [9Anjushree Pradhan and P.G. Prakash Dev Pant. Trends in Demographic and Reproductive Health Indicators in Nepal 2007.].

Nepal has made impressive improvements in maternal health during the years between 1990 and 2015. Several statistics point to this progress, for example: the decrease in Maternal Mortality Ratio (MMR) from 850 per 100,000 Live Births (LB) in 1990 to 229 per 100,000 LB in 2010 [10Government of Nepal. Nepal Millennium Development Goals Progress Report 2013., 11Pradhan A, et al. Nepal Maternal Mortality and Morbidity Study 2008/2009 2010.]; the increase in institutional delivery from 8% in 1996 to 57% in 2016; the increase in percentage of women receiving four or more ANC visits from 9% in 1996 to 69% in 2016 [7Ministry of Health and Population. Nepal Demographic and Health Survey 2011 2011., 9Anjushree Pradhan and P.G. Prakash Dev Pant. Trends in Demographic and Reproductive Health Indicators in Nepal 2007., 12Ministry of Health. Nepal Demographic and Health Survey 2016 2017.]. However, these gains are unevenly distributed, with the most disadvantaged group of caste (Dalit) benefitting the least. For example, the national MMR is 229/100,000 LB, versus 273/100,000 LB among Dalits and the percentage of women with four or more ANC visits is 64% among upper caste (Brahmin/Chhetri) and 40% among Dalits [11Pradhan A, et al. Nepal Maternal Mortality and Morbidity Study 2008/2009 2010.]. Dalit communities continue to suffer from caste-based discrimination and are considered “untouchable.” As a result, Dalits are considered some of the most “backward” in social, economic, educational, political and religious dimensions and unsurprisingly have lower developmental indicator than other castes [13 http://www.dwo.org.np/dalit.php [cited 2014 25 July].].

This study was conducted to understand the rate and factors associated with the antenatal care service utilization among the most disadvantaged ethnic group (Dalit women) and recommend interventions to improve ANC utilisaiton, in the Mahottari district of Nepal.

2. MATERIALS AND METHODS

2.1. Variables

Utilization of ANC was considered as the practice in which recently delivered women had visited health facility for four or more ANC checkups during her last pregnancy. The outcome variables ANC visit were four or more ANC visit coded ‘1’ and less than four ANC visits coded as ‘0’. The independent variables were broadly categorized into four groups [5Gabrysch SC, Oona M R. Still too far to walk: Literature review of the determinants of delivery service use. BMC Pregnancy Childbirth 2009; 9(1): 34.
[http://dx.doi.org/10.1186/1471-2393-9-34] [PMID: 19671156]
]: Socio-cultural factors, economic accessibility factors, physical accessibility factors, and perceived health need factors. Age of respondent as reported by individual was recorded and categorized into four groups: 15-19, 20-24, 25-29 and 30 years or above [14Sudesh Raj Sharma AKP. Bharat Mani Devkota and Sarswoti Singh Factors associated with place of delivery in rural Nepal 2014.]. Educational status was recorded as no formal education, primary, secondary, and certificate and above [7Ministry of Health and Population. Nepal Demographic and Health Survey 2011 2011.]. Occupation of the mother was broadly categorized into a housewife, daily wage, agriculture and job. Similarly, occupation of husband was categorized into daily wage, agriculture, business and job. The family was considered as a nuclear family when husband, wife and their unmarried sons and daughters live together otherwise, they live in joint family. Wealth status and the autonomy of women were adapted from NDHS 2011, and categorized into three groups: poor to least poor corresponding from lowest to the highest status, and low autonomy to high autonomy from the lowest to the highest, respectively [7Ministry of Health and Population. Nepal Demographic and Health Survey 2011 2011.]. The Dalit caste included in the study was ‘Terai Dalit’- Chamar, Mushahar, Dusadh/Paswan, Tatma, Khatabe, Banter, Dom, Chidimar, Dhobi, Halkhor and the ‘Hill Dalit’-Kami, Damai, Sarki, Gaine, Badi [15Jhabindra PrasadPandey MRD, Sujan Karki, Pradeep Poudel, Meeta Sainju Pradhan. Maternal and Child Health in Nepal: The Effects of Caste, Ethnicity, and Regional Identity: Further analysis of the 2011 Nepal Demographic and Health Survey 2013.]. Perceived “good quality” of ANC was considered when mother received iron supplementation, medical checkup, at least two tetanus toxoid injections, measurement of blood pressure, provision of intestinal parasitic drugs and health education, and counseling on danger signs. If a single component was missed, ANC was not regarded to have perceived“ good quality” [16Chandni Joshi ST. Ray Hodgson and Andrew Hayen, Factors associated with the use and quality of antenatal care in Nepal: A population-based study using the demographic and health survey data 2014.].

2.2. Study Setting

This study was carried out in the Mahottari district of Nepal, which lies about 253 kilometers to the Southeast of Kathmandu, the capital city of Nepal. According to the National Population and Housing Census 2011, the total population of the district was 627,580 (male 311,016 and female 316,564) [17Statistics CBo. National Population and Housing Census 2011 2013; 25.].

2.3. Study Design and Participants

This was a cross-sectional study conducted in the Mahottari district during July-December, 2014. The mothers were included in the study if: (i) they had childbirth during the last one year (ii) were local residents of the districts, (iii) were not migrated to the district after childbirth, and (iv) belonged to Dalit ethnic group [18Daniel WW. Biostatistic A foundation for Analysis in the Health Science 2005.]. This district constitutes six electoral areas and each area constitutes 11 to 14 Village Development Committees (VDC) – the smallest administrative unit. Two VDCs were selected randomly from each electoral area to increase representations of the district. A list of all Dalit eligible mothers of total 12 VDCs (2 VDCs per electoral area) was prepared with the help of local public health facilities’ community-based newborn program records, and Female Community Health Volunteers (FCHV). All 328 eligible Dalit mothers were interviewed and 15 mothers were not interviewed because they had migrated out of the district.

2.4. Instrument and Data Collection

The questionnaire was adapted from the Nepal Demographic and Health Survey (NDHS) 2011 [7Ministry of Health and Population. Nepal Demographic and Health Survey 2011 2011.]. An observation check-list was prepared to observe the assets and animals in- the house based on the NDHS 2011. A few minor words were changed in the original questionnaire to adapt to the local context and increase the readability of the questions. The face-to-face interviews were conducted in the local language of the respondent at her house by two female interviewers who were trained by the first author of this study and were also involved in the pretesting of questionnaires.

2.5. Statistical Analysis

Descriptive analysis was performed as per the study variable in the initial stage and results were reported using frequencies and percentage. Association of ANC utilization and other independent variables were first tested using Chi-square test and significant factors (p-value<0.05) were further entered for multivariate analysis at 95% confidence interval to ascertain the association of these factors with ANC utilization using backward logistic regression methods [18Daniel WW. Biostatistic A foundation for Analysis in the Health Science 2005.]. Data analysis was performed using Statistical Package for Social Sciences Version 20.

2.6. Ethical Consideration

Ethics approval was obtained from the Institutional Ethical Review Board, Institute of Medicine, Tribhuvan University Nepal (Approval Number 79 (6-11-E)2 071/072). Informed written consent was also obtained from the district health office, Mahottari and from all participants of the study. Personal identifiers were removed before the analysis of data and data were only presented as aggregate.

3. RESULTS

3.1. Reasons for Low Utilization of ANC Service

The multiple response answers showed that there were numerous reasons for low ANC utilization. The most important reasons were lack of information, a long distance from health facility or unavailability of the transport, and lack of money. Full results are shown in Table 1.

Table 1
Reasons for low utilization of ANC service.


3.2. Socio-cultural, Economic and Physical Accessibility Characteristics of Participants

Table 2 presents the description of socio-cultural, economic and physical accessibility factors. The mean age of mother was 22.52 years (standard deviation 3.72) and around half of the mothers were age group 20-24 year. More than three - quarters of mothers (78%) and half of the husbands (58%) had no formal education. The majority of mothers (79%) were housewives and 80% of husbands were engaged in daily wage work.

Table 2
Description of socio-culture, economic and physical accessibility factors.


3.3. Health Related Characteristics of Participants

Among the participants shown in Table 3, only 42% of mothers had completed four or more ANC visit. Majority of the mothers (82%) received ANC services from government health facilities and 80% of mothers did not perceive ANC as “good quality”. Furthermore, 47% of mothers were multiparous and 56% of mothers had not planned their last pregnancy. Of mothers with any ANC visit, only 50% of them were suggested for delivery in a health facility. Similarly, less than one third (28%) of mothers were exposed to maternal health messages through one or more media and 21% of mothers were not visited by FCHVs during their last pregnancy. In addition, 31% of mothers reported that health staff was not available when they visited health facility and 27% of mothers perceived health workers' behavior as discriminatory while providing health services.

Table 3
Description of health needs factors.


3.4. Rates and Factors Associated with ANC Utilization

The ANC service utilization rate was found to be 42% with 95% CI (36.43 – 47.09). The bivariate analysis in Table 4 found that ANC utilization was significantly associated with the caste type, mother’s education, husband’s education, autonomy of women, mother’s occupation, husband’s occupation, wealth status, and availability of motorized transport. Some of the factors perceived for “good quality” ANC, were parity of mother, planning of last pregnancy, advice for HF delivery, mother's association with groups, knowledge about safe delivery incentive program(SDIP), exposure to maternal health message, availability of health worker, the positive and unbiased behavior of health exposure to FCHV, being significantly related to four or more ANC visits.

Table 4
Bivariate analysis of socio-cultural, economic, physical accessibility and health need factors of participants.


Table 5
Multivariate analysis of factors associated with ANC utilization.


After adjusting for potential confounding variables, the multivariate analysis (Table 5) showed that mother’s education (AOR: 2.63, CI: 1.25 – 5.52), husband’s education (AOR: 1.81, CI: 1.01 -3.24), mother's non-daily wage occupation (AOR: 3.44, CI: 1.21-9.74), perception of “good quality” ANC service (AOR: 3.02, CI: 1.44 -6.34), knowledge about SDIP (AOR: 2.33, CI: 1.30 -4.18), exposure to maternal health message (AOR: 3.34, CI: 1.73 -6.46), positive and unbiased behaviour of health workers (AOR: 2.55, CI: 1.38 - 4.69), and exposure to FCHV (AOR: 2.48, CI: 1.07 -5.75) were significantly associated with utilization of four or more ANC visits. However, caste, autonomy of women, husband’s occupation, wealth status, parity of mother, planning of last pregnancy, advice for health facility delivery, association in women group/network were not found to be significantly associated with ANC utilization in multivariate analysis.

4. DISCUSSION

From the methodological point of view, this study was based on the literatures review of cross-sectional studies with a large sample size in Nepal and other countries; and the respondents were the mothers who had delivered their child within past one year [14Sudesh Raj Sharma AKP. Bharat Mani Devkota and Sarswoti Singh Factors associated with place of delivery in rural Nepal 2014., 19Choulagai B, Onta S, Subedi N, et al. Barriers to using skilled birth attendants’ services in mid- and far-western Nepal: A cross-sectional study. BMC Int Health Hum Rights 2013; 13(1): 49.
[http://dx.doi.org/10.1186/1472-698X-13-49] [PMID: 24365039]
, 20Agha S, Carton TW. Determinants of institutional delivery in rural Jhang, Pakistan. Int J Equity Health 2011; 10(1): 31.
[http://dx.doi.org/10.1186/1475-9276-10-31] [PMID: 21801437]
] and within last two year [21Sulochana Dhakal EvT, Edwin Amalraj Raja, Keshar Bahadur Dhakal. Skilled Care at Birth among Rural Women in Nepal. Practice and Challenges 2011.]. In this study, mothers with formal education were found to be three times more likely to have four or more ANC visits than mothers who did not have formal education. This is in keeping with other literature, the NDHS 2016 showed that non-educated mother constituted a higher proportion (12%) of those who had no ANC at all, while School Leaving Certificate (SLC) or the above-educated mothers constituted only 1% of women with no ANC [12Ministry of Health. Nepal Demographic and Health Survey 2016 2017.]. Similarly, a number of studies showed that by increasing education levels of women, the probability of receiving four or more ANC visits also increased [16Chandni Joshi ST. Ray Hodgson and Andrew Hayen, Factors associated with the use and quality of antenatal care in Nepal: A population-based study using the demographic and health survey data 2014., 19Choulagai B, Onta S, Subedi N, et al. Barriers to using skilled birth attendants’ services in mid- and far-western Nepal: A cross-sectional study. BMC Int Health Hum Rights 2013; 13(1): 49.
[http://dx.doi.org/10.1186/1472-698X-13-49] [PMID: 24365039]
, 20Agha S, Carton TW. Determinants of institutional delivery in rural Jhang, Pakistan. Int J Equity Health 2011; 10(1): 31.
[http://dx.doi.org/10.1186/1475-9276-10-31] [PMID: 21801437]
, 22van Eijk A, Bles HM, Odhiambo F, et al. Use of antenatal services and delivery care among women in rural western Kenya: A community based survey. Reprod Health 2006; 3: 2.
[http://dx.doi.org/10.1186/1742-4755-3-2] [PMID: 16597344]
-27Babalola S, Fatusi A. Determinants of use of maternal health services in Nigeria-looking beyond individual and household factors. BMC Pregnancy Childbirth 2009; 9(1): 43.
[http://dx.doi.org/10.1186/1471-2393-9-43] [PMID: 19754941]
]. The increased education may have also brought increased knowledge and awareness of health services, higher receptivity to new health-related information, better communication with the husband, more decision making power, increased self-worth, negotiating skills, and ability to demand adequate services. Higher education of husband level has shown similar effect, wife receiving twice ANC utilization than their counterparts. This is similar to the result of systematic review carried out in low-income countries [28Simkhada B, Teijlingen ER, Porter M, Simkhada P. Factors affecting the utilization of antenatal care in developing countries: Systematic review of the literature. J Adv Nurs 2008; 61(3): 244-60.
[http://dx.doi.org/10.1111/j.1365-2648.2007.04532.x] [PMID: 1819 7860]
]. Studies conducted in Nepal [16Chandni Joshi ST. Ray Hodgson and Andrew Hayen, Factors associated with the use and quality of antenatal care in Nepal: A population-based study using the demographic and health survey data 2014.], Ethiopia and Shanghai [25Tarekegn S, L Lieberman, V Giedraitis. DeDeterminants of maternal health service utilization in Ethiopia: Analysis of the 2011 Ethiopian Demographic and Health Survey. BMC Pregnancy Childbirth 2014; 14(1): 161.
[http://dx.doi.org/10.1186/1471-2393-14-161] [PMID: 24886529]
, 29Zhao Q. The utilization of antenatal care among rural-to-urban migrant women in Shanghai: A hospital-based cross-sectional study 2012.] support the similar findings. This could be explained on the basis that educated husbands may be aware of ANC's benefits, put fewer constraints on their wives' mobility and decision-making and able to communicate with health workers to demand appropriate service. Another finding from our study was that non-daily waged mothers had utilized three times ANC services than their counterparts. This is consistent with another study conducted in the mid and far western region of Nepal found that women having occupation-service, business, wage labor and housewife had more ANC visit than women having occupation- agriculture [19Choulagai B, Onta S, Subedi N, et al. Barriers to using skilled birth attendants’ services in mid- and far-western Nepal: A cross-sectional study. BMC Int Health Hum Rights 2013; 13(1): 49.
[http://dx.doi.org/10.1186/1472-698X-13-49] [PMID: 24365039]
] while another study of Sindhupalchok district of Nepal showed that the mother's occupation whether agriculture/labor or business/service was not significantly associated with ANC utilization [14Sudesh Raj Sharma AKP. Bharat Mani Devkota and Sarswoti Singh Factors associated with place of delivery in rural Nepal 2014.]. This dissimilarity may be due to the different basis of categorizing the occupation. Our study showed that Perceived “good quality” of ANC was significantly associated with the ANC utilization. Other studies have shown that women reported better quality of care in private facilities but the cost prevented them from the utilization of those services [5Gabrysch SC, Oona M R. Still too far to walk: Literature review of the determinants of delivery service use. BMC Pregnancy Childbirth 2009; 9(1): 34.
[http://dx.doi.org/10.1186/1471-2393-9-34] [PMID: 19671156]
]. Consequently, the mother who perceived getting all the components of ANC services was more likely to repeat the ANC visit. In this study, a mother exposed to maternal health messaging was found to be, on average, three times more likely to use ANC services. These findings were echoed in studies conducted in Pakistan and Nigeria [20Agha S, Carton TW. Determinants of institutional delivery in rural Jhang, Pakistan. Int J Equity Health 2011; 10(1): 31.
[http://dx.doi.org/10.1186/1475-9276-10-31] [PMID: 21801437]
, 27Babalola S, Fatusi A. Determinants of use of maternal health services in Nigeria-looking beyond individual and household factors. BMC Pregnancy Childbirth 2009; 9(1): 43.
[http://dx.doi.org/10.1186/1471-2393-9-43] [PMID: 19754941]
]. Mothers who had not perceived health workers behavior as discriminatory had three times ANC utilization than mothers who had perceived health workers behavior as discriminatory, indicating that the discriminatory behavior of health workers lower the ANC utilization which was similar to Nepal Maternal Mortality and Morbidity Study [11Pradhan A, et al. Nepal Maternal Mortality and Morbidity Study 2008/2009 2010.]. This is likely because positive past experiences encourage future utilization, and negative experiences discourage them. The mothers exposed to FCHV were about twice more likely to utilize ANC service than their counterparts. This is because exposure to FCHV increases the possibility of sharing information about health services.

CONCLUSION

This is the first study conducted among the most disadvantaged caste (Dalit) that identified ANC utilization rate and critically analysed factors affecting them in the Mahottari district of Nepal.

Despite the provision of ANC service to community level by the government, its full utilization was lower (42%) in Dalit caste, which was lower than the national figure (69.4%). The major reasons reported by women interviewed for the low utilization of ANC were-lack of information regarding ANC service and the prohibitively far distance of health facility. ANC utilization was significantly associated with the education of women and husband, the non-waged occupation of mother, perceived “good quality” of ANC, exposure to SDIP and maternal health message and FCHV, and the perceived unbiased behaviors of health workers

Maternal health intervention targeted to Dalit women recommended to increase ANC utilization among Dalits. The program should focus on improving the quality of ANC service, promoting unbiased behavior of health workers, increasing the mobilization of FCHV and community health workers of government health facilities in Dalit community; and implementing awareness activities and dissemination of health messages to support demand generation and the uptake of ANC service by Dalits. Simultaneously, improving the education of a couple could be a strategy to improve the ANC utilization in the long term. Further, coordination with other sectors would be vital for Dalit women to have daily income.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

Ethics approval was obtained from the Institutional Ethical Review Board, Institute of Medicine, Tribhuvan University Nepal (Approval Number 79 (6-11-E)2 071/072).

HUMAN AND ANIMAL RIGHTS

No animals/humans were used for studies that are basis of this research.

CONSENT FOR PUBLICATION

All participants signed the study consent before participating in the study

AVAILABILITY OF DATA AND MATERIALS

The authors confirm that the data supporting the findings of this research are available within the article and its supplementary materials.

FUNDING

None.

CONFLICT OF INTEREST

The authors declare that there is no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

The authors wish to thank the Department of Community Medicine and Public Health, Institute of Medicine, Maharajgunj Medical Campus, Mahottari District Public Health Office, health facilities and FCHV of study areas, and respondent of this research for their support to accomplish this study.

SUPPLEMENTARY MATERIAL

Supplementary material is available on the publishers Website along with the published article.

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Endorsements



"Open access will revolutionize 21st century knowledge work and accelerate the diffusion of ideas and evidence that support just in time learning and the evolution of thinking in a number of disciplines."


Daniel Pesut
(Indiana University School of Nursing, USA)

"It is important that students and researchers from all over the world can have easy access to relevant, high-standard and timely scientific information. This is exactly what Open Access Journals provide and this is the reason why I support this endeavor."


Jacques Descotes
(Centre Antipoison-Centre de Pharmacovigilance, France)

"Publishing research articles is the key for future scientific progress. Open Access publishing is therefore of utmost importance for wider dissemination of information, and will help serving the best interest of the scientific community."


Patrice Talaga
(UCB S.A., Belgium)

"Open access journals are a novel concept in the medical literature. They offer accessible information to a wide variety of individuals, including physicians, medical students, clinical investigators, and the general public. They are an outstanding source of medical and scientific information."


Jeffrey M. Weinberg
(St. Luke's-Roosevelt Hospital Center, USA)

"Open access journals are extremely useful for graduate students, investigators and all other interested persons to read important scientific articles and subscribe scientific journals. Indeed, the research articles span a wide range of area and of high quality. This is specially a must for researchers belonging to institutions with limited library facility and funding to subscribe scientific journals."


Debomoy K. Lahiri
(Indiana University School of Medicine, USA)

"Open access journals represent a major break-through in publishing. They provide easy access to the latest research on a wide variety of issues. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. Articles are of uniformly high quality and written by the world's leading authorities."


Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


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