Female community health volunteers’ knowledge and confidence in providing community-based diabetes self-management support in Nepal: A biphasic mixed method evaluation

Self-management support by community health workers, referred to as Female Community Health Volunteers (FCHVs) in Nepal, can enhance diabetes care in resource-constrained settings. We assessed FCHVs' knowledge, perceived self-efficacy, and barriers to supporting diabetes self-management before and after training. Guided by the Health Belief Model, we conducted a biphasic, Qual + quan, concurrent, embedded mixed-methods evaluations among 28 FCHVs in four wards in rural mid-Western Nepal. We evaluated the program into two phases, each consisting of focus group discussions (FGDs); trainings that included didactics, hands-on-practice, and role play demonstrations; and pre- and post-training surveys. Phase 2 occurred nine months after Phase 1. We conducted trainings and evaluations over 4-5 hours/ward/phase. FGD data were analyzed using both deductive and inductive coding and emerging themes were then examined for patterns and relationships among the codes. We summarized quantitative data using descriptive statistics and integrated with qualitative data during interpretation. FCHVs' mean age was 48 years, 32.1% had completed secondary education, and 75% had served as FCHVs for >10 years. We identified five themes in qualitative analysis: (1) diabetes knowledge, (2) diet and lifestyle counseling, (3) FCHV's confidence, (4) training and education, and (5) barriers and motivators for community-based self-management support. Mixed-methods evaluations showed knowledge of diabetes and confidence in self-management skills improved after the training. Although barriers, such as inadequate incentives, persisted in Phase 2, communities' trust in FCHV as diabetes self-management supporter improved. These findings suggest that FCHVs may be willing to take a greater role in diabetes self-management support, and that even short training sessions have the potential to enhance their confidence and knowledge, particularly if our findings are further substantiated. Ensuring appropriate incentives, ongoing training and system-level support are important for sustainability of such programs.