Barker Fred, Jha Radhakat, Morrish Jasmine, Sah Arbind, Choudhary Ramesh, Walker Richard W, Lavender Mike
The Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom.
Newcastle University, Newcastle-upon-Tyne, United Kingdom.
PLOS Glob Public Health. 2025 Apr 29;5(4):e0004458. doi: 10.1371/journal.pgph.0004458. eCollection 2025.
Establishing and building grassroots, community-based healthcare systems is a key approach to improving healthcare access sustainably in low-income regions of the world. One prominent early example of this was the Comprehensive Rural Health Project (CRHP), inspiring the framework for subsequent large-scale programs globally. However, many community health projects do not provide the same breadth of services as CRHP, which may have impacts on health outcomes. This qualitative study focused on 12 Dalit villages in rural Nepal following an intervention - known as the Village Alive Project (VAP) - to boost healthcare provision through a CRHP-style health system. Villagers' and health workers' impressions of changes in healthcare access were assessed through 42 semi-structured interviews. Thematic analysis was performed using NVIVO by two independent authors; themes were finalized by reaching consensus. Three generated themes were shared by VAP and control villages: 'changes in access to healthcare services'; 'changes in health promotion and disease prevention' and 'inequalities and their effects on health'. A fourth theme, 'views on the expansion of VAP to non-VAP villages', was generated uniquely for the control group. Lack of health education and sanitation facilities, as well as social stigma, were listed as barriers to health prior to VAP's establishment; most participants felt these have been largely addressed since the arrival of VAP. Implementing more comprehensive primary healthcare on top of pre-existing community-based healthcare systems is feasible, with encouraging findings from this low-income region of rural Nepal. Participants felt VAP improved understanding of diseases such as leprosy, which may benefit future vertical interventions. Improvements in various aspects of health and healthcare were reported for most or all study themes across intervention-group villages; improvements were also noted in control villages but with more evidence of ongoing barriers to health. Further studies looking at key quantitative outcomes are required to triangulate findings.
建立和构建基层社区医疗体系是在世界低收入地区可持续改善医疗服务可及性的关键途径。这方面一个突出的早期例子是综合农村卫生项目（CRHP），它为全球后续大规模项目提供了框架。然而，许多社区卫生项目提供的服务广度与CRHP不同，这可能会对健康结果产生影响。这项定性研究聚焦于尼泊尔农村的12个达利特村庄，这些村庄在实施了一个名为“村庄焕活项目”（VAP）的干预措施后，通过类似CRHP的卫生系统来加强医疗服务提供。通过42次半结构化访谈评估了村民和卫生工作者对医疗服务可及性变化的看法。由两位独立作者使用NVIVO进行主题分析；通过达成共识确定主题。VAP村庄和对照村庄共同出现了三个主题：“医疗服务可及性的变化”；“健康促进和疾病预防的变化”以及“不平等及其对健康的影响”。第四个主题“关于将VAP扩展到非VAP村庄的看法”是对照组独有的。在VAP建立之前，健康教育和卫生设施的缺乏以及社会耻辱感被列为健康障碍；大多数参与者认为自VAP到来后这些问题已基本得到解决。在现有的社区医疗体系基础上实施更全面的初级医疗是可行的，尼泊尔农村这个低收入地区的研究结果令人鼓舞。参与者认为VAP提高了对麻风病等疾病的认识，这可能有利于未来的垂直干预措施。干预组村庄的大多数或所有研究主题在健康和医疗的各个方面都有改善的报告；对照村庄也有改善，但仍有更多证据表明存在持续的健康障碍。需要进一步研究关键的定量结果以验证研究发现。
