A cultural and contextual analysis of health concepts and needs of women in a rural district of Nepal

Abstract

Introduction:

Globally, individuals and groups have different notions of health promotion influenced by their social and cultural contexts. Effective primary health care and healthy public policy depend on a clear understanding of people’s perceptions of health and their health needs. Women in the Far Western Region (FWR) of Nepal live in one of the most remote and rural areas in that country, and their general health status is one of the worst in that country. In this study we explored the socio-cultural health concepts and needs of women in a district of Nepal’s FWR.

Methods:

Qualitative research methods and a culture-centred approach guided the study, with 30 women from the district of Dadeldhura in the FWR participating in in-depth interviews. Data were analysed through qualitative content analysis.

Results:

The women’s concepts of health included ‘absence of disease’, ‘no tension’, ‘peace in the family’ and ‘being able to work’. The participants felt good health required good food, wealth, education and employment for their children, and a healthy community (free of drug or alcohol addiction). ‘Money is everything’ also emerged as a main theme, linking the concept of wealth to good health. To improve health, respondents recommended that the government provide financial support for education and employment and a focus on listening to and caring for the country’s rural poor.

Conclusions:

Overall, participants’ perceived health as not just about themselves but their families and communities. Socially as well as culturally determined gender roles influenced the health concepts and needs of the women. This study’s findings can be used to guide public health leaders in priority-setting and in determining strategies for women’s health promotion in rural districts of Nepal and other similar cultures.

Keywords

culture health concepts health needs Nepal qualitative research rural

Introduction

Worldwide, people’s understanding of health and health needs differ relative to their culture, with health concepts having inherently unique meanings in each society (1 –3). Many South Asians have a generally holistic conceptualization of health that incorporates spiritual, physical, and psychosocial factors (4). The culture of each South-Asian country has unique perspectives of health and of these related factors (4). In order to translate healthy public policy into effective health services that improve individual and community health, health perspectives and local needs must be well understood (5). However, not enough is known about the health needs among women, particularly those residing in rural areas. The focus of rural women’s health promotion research should include an understanding of this population’s health experiences and how their health needs differ among diverse cultural groups (6).

Nepal consists of five Development Regions – Eastern, Central, Western, Mid-Western, and Far Western Region (FWR) – and 75 districts. Those living in the FWR, the area of this study, are particularly poor, with 49% living below Nepal’s poverty line (7). The remote districts in the FWR have insecure food supplies and poor sanitation, resulting in high rates of malnutrition and infant and maternal mortality (7). A country analysis conducted by the United Nations found that women in the FWR were among Nepal’s 19 most vulnerable groups targeted for national development and indicated that Nepal’s socio-cultural factors contribute to the vulnerability of women in the FWR (8). Women’s health in the FWR is worse than that of their male counterparts, and sex-based health disparities remain serious concerns. The Nepal government reported that the FWR features a male-dominated society, with women suffering from domestic violence linked with alcohol consumption and being given fewer opportunities for education and economic support than the men (7). The Nepali government has been working to increase access to health services to promote health for residents nationwide since 1991, but progress is slow in rural communities, particularly for women (9,10). In a study of a rural district of Nepal similar to the FWR, 72% of household residents could not obtain health care services at government health facilities due to insufficient medicine (61%), poor accessibility to the facilities (22%), and staff unavailability (19%) (10). These factors create severe barriers to preventive health education and health promotion services as well as to health care delivery.

Specific public health goals related to promoting good health within a community have not been consistently defined in Nepal, and there have been no apparent published investigations about health needs from the residents’ perspectives in a rural area, particularly among these under-resourced rural women. In a review of the published literature, one study was found that documented the meaning of reproductive health among young Nepalese women in poverty and focused on safe motherhood (11), and other researchers investigated the quality of life among Nepalese women refugees (12). The majority of Nepal’s residents live in rural areas, comprising 82.0% of the general population in 2013 (13). In this study, we wanted to explore the concepts of health and health promotion held by women in the FWR. A better understanding of the perceptions of health and perceived health needs among Nepalese rural women could assist with the planning and implementation of health promoting services and policies for these women and their families.

Methods

We interviewed women in the FWR to identify their concepts of health and to describe what they perceived as their health needs and what would help promote health among them and their community. Qualitative methods were used to explore the behaviours, meanings, perceptions, and experiences of the residents within the context of their culture and with regard to health (14). An approach embracing culture as a constitutive space and including the researcher’s role as a listener of the marginalized within their micro-context guided the study (11 –15).

Study area

The FWR consists of nine districts and 90% of its households are agricultural (16). The Dadeldhura district of the FWR was chosen as a representative district of a remote, rural area in this poor Nepali region.

Participants

A woman was eligible for the study if she was Nepalese, was 18 years of age or older, and had lived in the Dadeldhura district for more than 5 years. Ten participants were recruited through an introduction to the study by the female village leader, and 20 participants were added to the study through snowball sampling. There were no women approached who declined participation.

Data collection

An interview guide describing all procedures, including greetings, consent, and open-ended questions, was developed and consistently used during interviews. The three interview questions used were:

Imagine you live a healthy life and describe what your life is like.

What are the conditions you and your family need to live a healthy life?

What would you recommend if the government would listen to your desires to improve the health of you and your family?

Interviews were conducted in the Nepali language and administered by a specially trained bilingual female assistant working with the study team. The interviews took place in a quiet room in the participant’s house or in an office temporarily rented for this study. Participants were informed of the study purpose and process, and about their right to withdraw at any time. Written informed consent was obtained from the participants prior to interviewing, and the interviews were conducted until data saturation was reached. Along with the open-ended questions, demographic questions and a visual analogue scale of health and quality of life (0–10) were used to obtain a general health profile from each participant. Each interview lasted between 10 and 56 minutes, with an average of 38 minutes per interview.

All interviews were digitally audio-recorded with the permission of the participant, transcribed verbatim in the Nepalese language, and translated into English by a professional and experienced translator. The translator double-checked the transcripts by listening to the audio files of the interviews. The translator verifying the translations was a native of Dadeldhura, and was thus able to understand the women’s dialect. Questionable phrases, words, and ideas were discussed within the research team. Upon completion of the interview, each participant received the local cash equivalent of $5 USD in appreciation of her time. The study was approved by the Chonbuk National University (CBNU) human subjects review committee (CBNU 2013-11-007-001 PubMed).

Data analysis

We analysed interviews using inductive content analysis (17,18) with open coding, followed by category creation and abstraction (17). While reading text data, two research team members wrote notes and noted themes, then grouped lists of thematic categories under higher order headings by collapsing those that were similar or dissimilar. When formulating thematic categories, the team conducted cross-checking to ensure consistency among team members until arriving at consensus, then made a general description of each category. The text data were managed using Atlas.ti 6.0, a computer-assisted qualitative data analysis software program. In order to maintain study trustworthiness, analysis was consistently monitored throughout the period of data collection and analysis via the use of reflective daily diaries and the careful scrutiny of interview interpretations, tape recording transcriptions, and script translations.

Results

Characteristics of study participants

The resulting sample of participants was similar to the average and range of age, education, and income of married women in the Dadeldhura district. All 30 participants were married, and the average participant was 35 years old, and ranged from 20 to 50 years of age. The mean level of education for the participants was 5.8 years and 11 women had no official education. They had lived in the Dadeldhura district for an average of 17.9 years and had household incomes ranging from $0 to $500 USD per month, with an average of $147 USD. According to the visual analogue scale used, they perceived their health and quality of life as mid-level, with a mean of 5.2 and 5.7, respectively.

Concept of health

Our findings suggest that the women’s concept of health can be summarized into four categories of meaning: absence of disease, no tension, peace in the family, and being able to work. Representative quotes of each category are presented (Table 1).

Table 1.

Categories of health concepts and representative quotes.

Category	Representative quote
Absence of disease	If there is no one suffering with sickness in the family and if there is no pain, no hurt, that is considered healthy life. (W01, age 35)
No tension	I worried about my son and my daughter’s job. I don’t have any disease. But I suffer much, thinking about my children’s future. I would be very healthy and I think that there will not be any tension in my life, if their life is good. I think then my health would be very good. (W12, age 27)
Peace in the family	There is harmony and peace in the family, and everything is in order, we can get good health. Otherwise our health gets weaker. (W24, age 39)
Being able to work	If our health is good, we can do all our work easily. But if we are suffering with disease, we cannot do anything. There are so many women among [my] neighbours who are suffering with prolapsed uterus problems and who are not able to work easily. (W12, age 27)

As many as 16 participants imagined health as primarily the condition of ‘not having disease’. Participants felt that the term disease encompassed sickness, fever, headaches, accidents, and pains such as stomach or body pain. For seven of the women, a healthy life meant being free from tension resulting from suffering, worries, and sorrows. Worries about food and their children’s education created some of the primary tensions they described as hindering their health. Good health was perceived as peace in the family by six of the participants. This peace was fundamentally rooted in the idea that no family members suffer from an illness requiring hospitalization. Those describing family peace as integral to their health also mentioned feeling peace when their husbands and sons do not drink or smoke – activities that they perceived as leading to family quarrels. To these women, good relationships among family members meant good health. Lastly, five women described functional aspects of life being required for good health, like the ability to work and move. Being able to do housework without difficulty was important to being healthy for these women. They had witnessed how hard it was for many women to function due to common disabilities such as a prolapsed uterus or other illness.

Health needs

The health needs participants described were summarized into five categories: enough food, good personal hygiene and sanitation, wealth, education and employment for their children, and healthy community (Table 2).

Table 2.

Categories of health needs and representative quotes.

Category	Representative quote
Enough food	If the food is enough, why do I worry? Then I would not worry about food. I would get to relax. Then I would not get any disease or other problems. I would be healthy. (W10, age 30)
Good personal hygiene and sanitation	If the surroundings are not clean we might suffer with diarrhoea, cholera, fever, flu, diabetes, tuberculosis and so on. (W20, age 20)
Wealth	If there is money, we can purchase or pay for whatever we need and regularly check up on our health and get proper treatment. In this way in order to be healthy the basic thing a person needs is money. (W29, age 28)
‘Money is everything’	Without money it is impossible to exist. Without money nothing can be planned. Money is everything. To be healthy, to get a livelihood, money is required. (W07, age 28)
Education and employment	Our children will get health, if they study well. If they get [a] good education, they may live better lives and they may not suffer like us. (W21, age 38)
Healthy community	We have to eradicate drug and alcohol addiction. We alone cannot do better in society but in unity we can do many good activities for good community. If together we provide children with education, care for them well, keep them away from addiction and bad habits from childhood, it is important. (W19, age 45)

Mentioned by 19 respondents, food was the most frequently listed answer to the question of what was needed to maintain good health. The women indicated that they did not have worries if they had enough food for everyone in their families. Ten women mentioned the need for good personal hygiene and sanitation in order to be healthy. One woman indicated that diarrhoea, cholera, fever, and flu occurred when hygiene was poor. Seven women participants believed wealth was essential to having good health. Money was required to purchase necessities like food and clothing and enabled participants and their families to receive regular medical check-ups and treatments. Money also relieved worries about their children’s educations and futures. The women reported they felt wealthy people could rest and did not need to be involved in hard work. In addition, the theme ‘Money is everything’ was derived from this health need. Six women regarded money as the primary factor in a family’s good health and central to all of the other characteristics they considered important to health.

Education and employment for their children were also mentioned as part of the notion expressed as health needs. The women felt a good education would allow their children to have better lives and lessen their suffering. They felt education enabled their children to seek better job opportunities and provided children with the knowledge needed for good health practices. The desire to fund schooling for their children if families had enough money, revealed three participants’ passions for their children’s education. Finally, five women considered the condition of the community as part of maintaining good health. They felt a community needed to have harmony among neighbours and be free from drug and alcohol addiction. Providing community support for children and freedom from addiction, especially for adolescents, was a priority. The women also pointed out that educating children was critical to eradicating addiction because bad habits often start in childhood and peer groups are important in forming life habits.

Health promotion recommendations to the government

The women recommended that the Nepali government provide adequate medical facilities, as well as offer financial support for education, create jobs, and focus on listening to and caring for the country’s poor as major steps for health promotion within the region (Table 3). Thirteen women requested that the government provide free medical facilities and medicine in the region to treat illnesses early, before they worsen. Since there was no hospital within a reasonable travelling distance, some of these 13 participants had been forced to sell their land and personal belongings in order to travel to the city for medical treatment when needed. These women also told of occurrences when babies were born on the side of the road due to the lack of ambulances and of women dying in childbirth because they were not close to medical assistance. Ambulance availability was emphasized as a benchmark of adequate medical treatment for people in rural areas. Some women were not satisfied with doctors often staying for a short period (one or two months) in their village areas and working for the sole purpose of making money.

Table 3.

Categories of recommendations and sample quotes.

Category	Representative quote
Financial support for education and employment	It is not easy for me to educate my children with earnings from selling milk. We think that we have to pay high fees for education so that they get a good life. But it is not easy to get jobs in Nepal for poor people like us. (W27, age 48)
	If they provide the poor farmers in the village with farming training about how to harvest crops in the field properly, we would get support. (W20, age 20)
Listening to and caring for the poor	I request that they provide medicine and treatment services at reasonable prices or free of cost to the poor and vulnerable people; and to give equal opportunity in jobs and provide free education and training to the poor. (W12, age 27)
Medical facilities and medicine	There is no hospital [so] people are spending lots of money. Some are selling land for treatment. People are compelled to go to Dhangadhi and Kathmandu. Many women in labour sometimes give birth to [their] baby on the way. Many women died on the way. They cannot afford the ambulance. (W02, age 40)
	I request that the government hire a permanent doctor. Now, doctors come on salary. They work for one or two months, then they go. (W02, age 40)

In connection with improving health, eight women wished that the government would provide financial support for their children’s education and create jobs. In the midst of extreme poverty, the women did not give up educating their children; believing that education brings a bright future with permanent employment and better health promotion. Six participants requested short workshops about farming or training in vocational skills for women and poor farmers. Lastly, seven women recommended that the government listen to and care for the poor, mentioning specific individuals who were too poor to access medical facilities. The poor have no jobs but often have big families, thus exacerbating their need. One accused some business people of privately selling medicine that was supposed to be provided at no cost to the poor. She also charged the government with hiring the rich but uneducated instead of certain poor residents who were better educated. Another woman described the children of rich families easily finding good jobs. Some participants described experiencing discrimination throughout life because of a lack of wealth.

Discussion

In this study, we identified specific cultural nuances regarding how women living in a rural area in Nepal perceive health and their health needs. Overall, the participants were remarkably broad in their concepts of health and health promotion, describing specific physical health issues, issues of family peace, the comfort of wealth, and the opportunity for personal development through education and jobs.

The social norms and culture-determining gender roles affected the concepts of health defined by the women. The sources of satisfaction identified by the study participants were mainly related to sufficient basic supplies such as food and money for things like children’s educational fees. Other studies of women in developing countries reinforce this positive association between poverty and the risk of poor mental health (19 –21). A functional aspect of health that was tied to ‘being able to work’ was associated with the gender-specific roles and social norms of the women within their families, including housework and such responsibilities as collecting grass for goats and cows. In particular, many women complained of prolapsed uteruses keeping them from completing their house duties. A prolapsed uterus is attributable to engagement in extremely hard work, like heavy lifting, with little or no rest during pregnancy or the postpartum period (22). In 2011, about 10% of Nepal’s women were found to have experienced a prolapsed uterus; among these, only 55% sought medical treatment (22). The same 2011 survey conducted by Nepal’s Ministry of Health found a prolapsed uterus to be the most frequently reported cause of health problems among women of reproductive age and postmenopausal women (22). Uterine prolapse is particularly serious in the FWR (7). Specific attention by the Nepali government to medical care, poverty reduction, and education for women is required to eliminate disability caused by a prolapsed uterus and to improve women’s health in the FWR.

Having enough food was one of the first needs identified by many of the participants in the study, demonstrating the seriousness of household food insecurity in this rural area of Nepal. In the FWR, the depth and severity of food insecurity varies disproportionately based on social caste, with the higher castes being more food secure (23). Agricultural development in the FWR is hindered by a lack of irrigation systems, by high-sloping agricultural land in mountain areas, and by a lack of government investment in updated agricultural technologies (24). Among the districts in the FWR, Dadeldhura has been found to be one of those districts with the worst food deficits (7). Governmental policies and non-governmental organizations could provide support for purchasing more locally grown agricultural products.

Study participants connected household wealth directly to good health, with money perceived as leading to better health conditions through good education, employment, and better access to medical facilities. Poverty rates in rural areas in Nepal are high, and poverty in the FWR region is particularly serious; only 7.9% of FWR residents fall into the highest of the country’s five income categories, while 26.1% of Central Region residents fall into the same category (22). When considering the direct connection between wealth and health cited by the study participants, poor health in the households of the impoverished FWR may be partly explained just by the burden of poverty.

There was also a notion of health promotion as a responsibility of the greater community. Participants mentioned environmental and community conditions, aside from individual characteristics and behaviours alone. This notion can be understood in terms of the ecological model of health addressing changes at the interpersonal, organizational, community and public policy levels for health promotion (25). For example, respondents expressed deep concerns about youth drug addiction and smoking in their region. About 28% of Nepali youth have been reported to use drugs (26). As a large proportion of the Nepalese population (37%) is under the age of 15 (22), intervention programmes are urgently needed to reduce drug abuse among the country’s youth to further promote community health.

Study participants also recommended establishment in their region of government medical facilities staffed by long-term medical doctors. Researchers have documented a nationwide shortage of health care workers in Nepal (7 per 10,000) (28). This shortage is more serious in rural areas because of a preference among health personnel to stay in urban and wealthier areas. Innovative policy strategies for addressing this issue should consider providing incentives, improving salaries and working conditions, and delivering education and training opportunities to recruit and retain health care workers in rural areas (27).

Women’s health in Dadeldhura was perceived by our participants to be made more vulnerable by poor conditions for childbirth, such as long travel distances to facilities and unavailability of ambulances. Recent reports of maternal health in Nepal are grim, indicating that support for maternal health services is imperative for the health promotion of women. Maternal mortality was 190 deaths per 100,000 live births in 2013, and the rate of births in 2011 attended by skilled health care personnel (doctors, nurses, or midwives) and postnatal care visits within 2 days of birth were only 36.0% and 44.5%, respectively (28).

The women we interviewed also suggested financial support for children’s education and employment as needs associated with improving health. The majority of the participants revealed high ambitions for their children’s education and employment irrespective of their backgrounds. They believed that education leads to a healthier life and hoped that the cycle of generational suffering could be broken for their children. According to the government of Nepal, almost half (43.7%) of all rural residents in Nepal in 2011 possessed no formal education (22). In particular, a low level of investment in education for women in Nepal has been shown in other research to constrain women’s access to health services and reduce their control over their own earnings (9). Policies in support of children’s and women’s education were strongly perceived as capable of promoting better health in their community.

Our study findings may not be generalizable to all rural women in Nepal, although the women’s experiences and perspectives appeared to be similar irrespective of the age, education, or income. Further investigation is therefore needed for understanding health concepts and needs among women living in other rural areas of Nepal. Scales could ultimately be developed and tested to measure Nepalese rural women’s concepts of health promotion, making comparisons across groups and over time. Males’ perceptions of health and health needs could also be explored and compared with their female counterparts to inform gender-sensitive programmes for health improvement.

Conclusions

This study was conducted to establish the unique meaning of health and health needs among a very poor rural community of Nepalese women. The 30 married women living in the FWR’s Dadeldhura district who participated in these interviews expressed broad concerns about health that were affected by the condition of their families and community and their futures. Their health needs were described as encompassing broad social issues such as employment, child education, and justice for the poor – in addition to food and medical services. This study thus highlights unique health needs and the broad conceptual perspectives of health that are held by these very rural women in terms of their cultural and social context, suggesting opportunities for success in engaging these women and their communities around social policies and interventions that will impact the underlying social determinants that they perceive as impacting their health. Understanding such needs and perspectives is critical to prioritizing, designing, and gaining support for meaningful health and policy interventions and for achieving effective health promotion from a cross-cultural and global perspective. This study also suggests that, in order to improve health and to respond to urgent health promotion recommendations for rural women in this district and perhaps in other remote rural areas of Nepal and elsewhere, high-priority services and supportive healthy national policies should be implemented that focus specifically on helping these communities to overcome issues of food insecurity, geographic difficulties that limit access to preventive services and related health personnel, and low levels of literacy and education. Future similar studies of the unique needs of very rural and impoverished women in other settings and countries may also find common themes regarding health concepts, needs, and recommendations that could guide broader efforts focused on rural women’s health improvement.

Footnotes

Declaration of conflicting interests

None declared.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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