Authors Proof

Carefully read the entire proof and mark all corrections in the appropriate place, using the Adobe Reader commenting tools (Adobe
Help), alternatively provide them in the Discussion Forum indicating the line number of the proof. Do not forget to reply to the queries.
We do not accept corrections in the form of edited manuscripts.
In order to ensure the timely publication of your article, please submit the corrections within 48 hours.
If you have any questions, please contact health.production.office@frontiersin.org

Author Queries Form

Query No.

Details required

Q1

Kindly confirm if the details appearing in the article title,

author group, and affiliations are fine.

Q2

The surnames of all of the authors have been highlighted.

Please check all of the names carefully and indicate if any
are incorrect. Please note that this may affect the indexing
of your article in repositories such as PubMed.

Q3

Please ask the following authors to register with Frontiers

(at https://www.frontiersin.org/Registration/Register.aspx)
if they would like their names on the article abstract page
and PDF to be linked to a Frontiers profile. Please ensure to
provide us with the profile link(s) when submitting the proof
corrections. Non-registered authors will have the default
profile image displayed.
Bharat Ram Dhungana
Salila Gautam.

Q4

Confirm that the email address in your correspondence

section is accurate.

Q5

Please reduce short running title to a maximum of five

words.

Q6

Verify that all the equations and special characters are

displayed correctly.

Q7

Ensure, if it applies to your study, the ethics statement is

included in the article

Q8

We have renumbered Tables 1, 1, 2, and 3 as Tables 1, 2, 3,

4, respectively. Kindly confirm if it is fine.

Q9

Ensure that all the figures, tables and captions are correct.

Q10

If you decide to use previously published, copyrighted

figures in your article, please keep in mind that it is your
responsibility, as the author, to obtain the appropriate
permissions and licenses and to follow any citation
instructions requested by third-party rights holders. If
obtaining the reproduction rights involves the payment of a
fee, these charges are to be paid by the authors.

Q11

Please provide high resolution Figure file for Figure 1.

Please make sure to use the original/source file when
generating the new Figure.

Q12

Please confirm if the details in Ref. (1, 4, 12, 17, 26) are fine
and also provide the DOI number.

Authors Response

Q13

Please provide city name for Ref. (5, 20).

Q14

Ensure to add all grant numbers and funding information,

as after publication this is no longer possible.

Q15

Please provide complete details for Ref. (13).

Q16

Please provide publisher name and city name for Ref. (14,
16, 19, 23).

Q17

Please update Ref. (15).

Q18

Please provide page range for Ref. (17).

Original Research
published: xx January 2016
doi: 10.3389/fpubh.2015.00289

001

051

002

052

003

053

004

054

005

055

Perceived Usefulness of a
Microfinance Intervention on Health
Awareness and Practices in Nepal

006
007
008
009
010
011
012

Bharat Ram Dhungana1, Jitendra Kumar Singh2, Dilaram Acharya3*, Salila Gautam4 and
Pravin Paudyal5

013
014
015

School of Business, Pokhara University, Pokhara, Kaski, Nepal, 2Department of Community Medicine, Janaki Medical
College, Tribhuvan University, Janakpur, Nepal, 3Department of Community Medicine, Devdaha Medical College and
Research Institute, Kathmandu University, Devdaha, Rupandehi, Nepal, 4Department of Public Health, Sanjeevani College of
Medical Sciences, Purbanchal University, Butwal, Rupandehi, Nepal, 5Clinical and Research Department, Everest
International Clinic and Research Centre, Kathmandu, Nepal
1

016
017
018
019
020
021
022
023
024
025
026
027
028
029
030
031
032
033
Q4

034
035

Edited by:
Joris Van De Klundert,
Erasmus University Rotterdam,
Netherlands
Reviewed by:
Damin Si,
Queensland Government, Australia
Nehama Lewis,
University of Haifa, Israel
Tarun Stephen Weeramanthri,
Government of Western Australia,
Australia
*Correspondence:
Dilaram Acharya
dilaramacharya123@gmail.com

036
037
038
039
040
041
042
043
044
045
046
047
048
049
050

Specialty section:
This article was submitted to Public
Health Policy,
a section of the journal
Frontiers in Public Health
Received: 20August2015
Accepted: 25December2015
Published: xxJanuary2016
Citation:
DhunganaBR, SinghJK, AcharyaD,
GautamS and PaudyalP (2016)
Perceived Usefulness of a
Microfinance Intervention on Health
Awareness and Practices in Nepal.
Front. Public Health 3:289.
doi: 10.3389/fpubh.2015.00289

056
057
058
059
060
061
062
063
064
065
066
067
068
069

Background: Economic constraints may lead to poor health among people from the
developing world. Microfinance has proven to be useful in improving health outcomes
elsewhere, but it still remains a neglected issue in Nepal. This study aims to assess
perceived usefulness of the microfinance on health awareness and practices among
different ethnic groups of Nepal.

070

Method: A community-based cross-sectional study was conducted in four districts of

western Nepal. A total of 500 microfinance clients representing different ethnic groups
(upper caste, aadibasi and janajati, and dalit) were selected by using systemic random sampling. Health awareness and practices among different ethnic groups were
compared by logistic regression after adjustment for age, level of education, sex of
household heads, occupation, and place of residence. Since participants were asked
about their health awareness and practices, before and after microfinance intervention,
during a single interview, there was a strong possibility of recall bias with respect to their
preintervention awareness and other measures.

077

Results: Microfinance intervention positively influenced self-reported health awareness

and practices among different ethnic groups in Nepal, which was highest among the
upper caste group (7792%, rate ratios around 1.72.6), followed by the aadibasi/
janajati (6076%, rate ratios around 1.41.8) and dalit group (3352%, reference group).
Self-reported awareness about environment and sanitation, family planning methods,
and available health services at local level improved from 11.2 to 69.2, 9.2 to 65.0, and
3.8 to 59.8%, respectively, among the clients after microfinance intervention (p<0.001).
Similarly, the practices of eating nutritious food/balanced diet, drinking safe water, using
toilet, immunizing the children, and regularly visiting the healthcare facility were improved
from 4.2 to 63.8, 12.6 to 66.8, 15.2 to 70.4, 15.8 to 73.8, and 3.6 to 61.4%, respectively
(p<0.001).

088

Frontiers in Public Health|www.frontiersin.org

January 2016|Volume 3|Article 289

Q1

071
072
073
074
075
076
078
079
080
081
082
083
084
085
086
087
089
090
091
092
093
094
095
096
097
098
099
100

Q2
Q3

Perceived Usefulness of a Microfinance Intervention on Health Awareness and Practices in Nepal

Q5

Conclusion: Despite lack of control group and potential recall bias, this study
reports positive effect of microfinance on self-reported health awareness and
practices among different ethnic groups of Nepal. This finding supports further
implementation and evaluation of equity-based microfinance to improve health and
economic conditions of Nepalese people.

158

Dhungana et al.

101
102
103
104
105
106
107

111
Q6

112

Q7

113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157

161
162
163
165

109
110

160

164

Keywords: ethnicity, health awareness, health practices, microfinance, Nepal

108

159

166

INTRODUCTION

the microfinance on health awareness and practices among the

different ethnic groups of Nepal.

Every year, 25 million households (more than 100 million people)

are pushed into poverty due to recurrent illnesses and expensive
healthcare. Access to the good health services and health protection are key components for fighting against poverty (1, 2).
Microfinance refers to a provision of financial services such as
loans, savings, and business trainings for the poor (3). In Asian
context, formal microfinance institutions (MIFs) are generally
regulated under the banking legislation and are supervised by
central banks (4). As health and poverty are interrelated to each
other (5), improving health of the poor necessitates poverty
reduction and an increased access to healthcare.
Microfinance organizations can implement health programs
that increase knowledge, change health-related behaviors, and
improve access to health services (6). Microfinance has been
shown to have a positive impact on many health issues, such as
malaria and tuberculosis control (7, 8), maternal (9), and child
health (10). In sub-Saharan Africa, microfinance improved
both the financial and various non-financial aspects such as
health, nutrition, food security, education, child labor, womens
empowerment, housing, job creation, and social cohesion (11).
Microfinance was also found to similarly improve population
health and value for money for such programs in South Asia (12).
Nepal is a landlocked country with per capita income of just
US$ 703 in 2013, and 23.8% of its population still live below the
poverty line (13). Nepalese banks and financial institutions have
been classified as commercial banks (class A), development banks
(class B), finance companies (class C), and microfinance development banks (class D) (14, 15). Savings and Credit Cooperatives
(SCCs), Small Farmers Cooperatives Limited (SFCLs), Financial
Intermediary NGOs (FI-NGOs), and Microfinance Development
Banks are the four major active types of MIs in Nepal (16). Nepals
microfinance sector has expanded significantly to provide services
to its clients through the outreach services (14, 15, 17). Despite
the hostile topography of Nepal, microfinance aims to alleviate
poverty through rural development. It has focused on very poor
and addresses the challenges of sustainability and outreach (16,
18). A previous Nepalese study on the impact of microfinance
services for womens socioeconomic empowerment found a
positive effect on womens participation in community work,
healthcare, childrens education, and their speaking and decisionmaking abilities (19). However, to the best of our knowledge, no
research about the effect of membership-based microfinance
intervention on health awareness and practices in Nepalese
population has ever been performed and published. Therefore,
the current research aimed to assess the perceived usefulness of

Frontiers in Public Health|www.frontiersin.org

172

The survey included 500 microfinance clients from four districts

(Nawalparasi, Kaski, Parbat, and Baglung) of western development region, which consist of 300 government microfinance
institutions (GMFIs) clients and 200 private MFIs (PMFIs)
clients who were involved regularly in microfinance program for
last 5years. This research includes the D class MFIs working
in western development region of Nepal (14, 15). Data were collected between September 2, 2013 and February 3, 2014.
A cross-sectional survey was used in this study. The multistage
cluster sampling method was applied by covering a wide geographical area to ensure the representation from each zone of
the western development region of Nepal in sample as shown in
Figure1 and Table1.
The survey included the sample size of 500 microfinance clients from four districts (Nawalparasi, Kaski, Parbat, and Baglung)
of western development region of Nepal, which was estimated
using formula for estimating the optimal sample size (20).
2

Z pqN
e ( N 1) + Z 2 p q
2

176
177
178
179
180
181
183
184
185
186
187
188
189
190
191
192

195
196
197
198
199
200
201
202
203
204
205

(1.96) 0.5 0.5 1, 815

= 317
(0.05) (1, 815 1) + (1.96)2 0.5 0.5

The clients, who are involved in different clusters of MIFs for five
or more years, are the total population (N) for the clients survey.
The sample size before adjustment of design effect was 317. The
sample size was adjusted to account for intracluster correlation.
The adjusted n=ndesign effect. Here, the design effect 1.5 was
taken as recommended for social rating. Thus, adjusted sample

175

194

Z2 p q N
n= 2
e ( N 1) + Z 2 p q

174

193

where n=optimal sample size, N=size of population, Z=value

of standard variant at 5% level if confidence interval = 1.96,
p = variability (variability has been assumed 0.5), q = 1 p,
and e=level of precision or acceptable sampling error tolerated
(assumed 5.0%).
Then,

173

182

Study Design and Sampling

169
171

Study Setting

168
170

MATERIALS AND METHODS

n=

167

January 2016|Volume 3|Article 289

206
207
208
209
210
211
212
213
214

Q8

Dhungana et al.

215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
242

Perceived Usefulness of a Microfinance Intervention on Health Awareness and Practices in Nepal

size after incorporating design effect was 476. Also, by allowing

the 5% potential non-response, we inflated the final sample size
to 500. All the participants were users of microfinance services
with membership of MIF. Out of 565 such membership-based
microfinance clients visited, 65 did not consent for an interview
with 88.5% of response rate.

modifications were made as required. It was also translated to

Nepali and back translated to English to ensure that the meanings of the questions were not altered. The final approval of the
questionnaire was obtained during submission of PhD proposal
in the Department of Commerce, Banaras Hindu University,
India. The questionnaire consisted of two parts: (i) respondents
general characteristics and (ii) health awareness and practices
of respondents before and after a microfinance intervention.
Seven research assistants, who were trained on questionnaires,
conducted the interview and they were constantly supervised.

The Intervention

The interventions were related to financial and non-financial

aspects of microfinance services taken by respondents exactly
5years prior to the data collection. The financial services were
microcredit, micro-savings, microenterprises, or business creation. The non-financial services were the women empowerment
and awareness creation in terms of health awareness and practices,
education, and other social dimension provided during monthly
meetings of MIFs.

The research proposal was approved by the Institutional Review

Board, Banaras Hindu University, India. Respondents provided
consent before the interview. Personal identifiers were removed
before data analysis.
The outcome variables of the study were health awareness and
health practices. Health awareness included three variables:
awareness of environment and sanitation, family planning methods, and available health services at their local levels. Health
practices included use of nutritious foods/balanced diet, use of
safe drinking water, use of toilet, use of traditional healers when
they get sick, immunization of children, and visits to health facility for heath checkup. All these variables had Yes or No responses.
Five confounding variables were defined as follows.
Respondents ages were categorized into four groups (2029,
3039, 4049, and 50 or above years). Education status was
recorded as illiterate, literate only, primary, secondary, and above
secondary levels. Respondents household heads were male or
female. Occupation was coded as livestock, agriculture, business,
and others (labor, daily wages). Place of residence was categorized
as rural and urban.
Ethnicity was based on the caste system in Nepal and was
divided into three major groups based on available literature

243
244
245
246
247
248
Q9
Q10
Q11

249

FIGURE 1 | Clients having at least 5years membership.

250
251
252
253
254

Zone

District

Lumbini

Nawalparasi

258
259
260
262

Gandaki

Kaski

263
264
265
266

276
277
278
279
280
281
283
284
285
286
287
289
290
291
292
293
294
295
296
297
298
299
300
301
302
303
304
305
306
307
309

TABLE 1 | Distribution of population and sample size.

256

261

275

308

255
257

274

288

Definition of Variables

The research was based on primary data. The primary data were
collected by structured questionnaire during face-to-face interviews. MFIs had a list of clients who had been getting microfinance
services for at least 5years. Based on these institutional information, research assistants visited clients and conducted interviews.
Participants were interviewed about their health awareness and
practices before and after microfinance intervention during the
same interview.
The English version of the questionnaire was prepared,
checked, pretested in the neighboring district and necessary

273

282

Ethics

Data Collection

272

Types of
microfinance
institutionsa

Branchb

PAGBB
PAGBB
PAGBB
NUBL
DLBB

310
Number of
centers

Sampled
center

Total number clients of the sampled

center (having at least 5years
membership in MFIs)

Sample size
Clients

Kawasoti
Beldiha
Chormara
Daldale
Parasi

34
22
26
96
55

5
4
5
10
9

135
112
134
138
128

32
23
35
40
30

23.7
20.5
26.1
29.0
23.4

PAGBB
PAGBB
NUBL
DLBB
DLBB

Lekhnath
HB
SC
IC
Bagar

56
60
106
119
72

7
4
12
15
8

146
155
175
145
124

42
38
60
37
33

28.8
24.5
34.3
25.5
26.6

311
312
313
314
315
316
317
318
319
320
321
322

Dhawalagiri Parbat
Baglung

PAGBB
PAGBB

Parbat
Baglung

25
27

9
8

182
241

50
80

27.5
33.2

323

267
268

12

698

96

1,815

500

27.5

325

269

270
271

PAGBB, Paschimanchal Grameen Bikas Bank (government-owned MFI); NUBL, Nirdhan; Utthan Bank Limited (private-owned MFI); DLBB, Deprosc Laghubitta Bikas Bank (privateowned MFI).
b
HB, Hemja-Bagar; SC, Shrijana Chok, and IC, Indra Chok.

Frontiers in Public Health|www.frontiersin.org

January 2016|Volume 3|Article 289

324
326
327
328

Dhungana et al.

329
330
331
332
333
334
335
336
337
338
339
340
341
342
343
344
345

Perceived Usefulness of a Microfinance Intervention on Health Awareness and Practices in Nepal

and similarities between the caste/ethnic groups: (i) advantaged

upper caste, (ii) disadvantaged aadibasi/janajati (J&A), and (iii)
disadvantaged dalit. The advantaged group included Brahmin,
Chhetri, Thakuri, and Sanyasi. The disadvantaged J&A included
indigenous groups of Nepal. Disadvantaged dalit included the
castes that were considered lower in the caste-based stratification
within the Nepalese society (21).

(30.4%). Majority of dalit (59.1%) were from rural area compared

to aadibasi/janajati (46.0%) and upper caste (50.7%).
Self-reported health awareness and practices of the respondents
after 5years of membership-based microfinance intervention is
shown in Table3. Awareness about environment and sanitation,
family planning methods, and available health services at local
level seemed to increase from 11.2 to 69.2%, 9.2 to 65.0%, and
3.8 to 59.8%, respectively among clients after the microfinance
intervention (p < 0.001). Similarly, the use of nutritious food/
balanced diet, safe drinking water, toilet, immunization of children, and regular visits to health facility were found to increase
from 4.2 to 63.8, 12.6 to 66.8, 15.2 to 70.4, 15.8 to 73.8, and 3.6
to 61.4%, respectively (p < 0.001). However, use of traditional
healers seemed to decrease from 15.6 to 1.4% (p<0.001). Among
the three ethnic groups, the highest rates of health awareness and
practices were observed among the upper caste group (7792%),
followed by the aadibasi/janajati group (6076%) and the dalit
group (3352%).These results altogether indicate toward a positive effect of microfinance intervention in the study population.
Multivariable analysis of self-reported health awareness and
practices in relation to ethnicity of the respondents after microfinance intervention has been demonstrated in Table4. Compared
with the dalit group, the rate ratios related to health awareness
and practices for the aadibasi/janajati group ranges from 1.4 to
1.8 and for the upper caste group 1.7 to 2.6. Rate ratio for the
use of traditional healers among the aadibasi/janajati group was
around 0.6, and for the upper caste groups, the rate ratios was
around 0.3 as compared to dalit.

Statistical Analysis

The data were analyzed with the help of descriptive and inferential
statistics mainly chi-square test and logistic regression methods
to analyze the health awareness and practices of the clients by
Nepalese ethnicities. Odds ratios were converted into rate ratios
with adjustment of confounding variables (22). A p value 0.05
was considered statistically significant. Data were analyzed
using Statistical Package for Social Sciences (SPSS version 17 for
windows).

346
347
348
349
350
351
352
353
354
355
356

RESULTS
Table 2 presents the sociodemographic characteristics of the
respondents. Majority of the dalit (73.7%), aadibasi/janajati
(73%), and upper caste (72.3%) were from 30 to 49years of age.
Two-fifth of the dalit (40.1%) were illiterate compared to only
(22.8%) aadibasi/janajati and (10.1%) upper caste. Majority of the
household heads were males among all ethnic groups. Slightly
more than half of dalit (52.6%) had occupation of livestock and
agriculture compared to aadibasi/janajati (29.7%) and upper caste

357
358
359
360
361

364
365
366
367
368
369
370
371
372
373
374
375
376
377
378
379
380
381
382
383
384
385

387
388
389
390
391
392
393
394
395
396
397
398
399
400
401
402
403
404
405
406
407
408
409
410
411
412
413
414

TABLE 2 | Sociodemographic characteristics of the respondents.

Characteristics

Ethnicity
Dalit

362
363

386

Age
2029
19 (13.9)
3039
56 (40.9)
4049
45 (32.8)
50years
17 (12.4)
Education
Illiterate
55 (40.1)
Literate only
15 (10.9)
Primary
52 (38.0)
Secondary
15 (10.9)
Above secondary
0 (0.0)
Household head
Male
125 (91.2)
Female
12 (8.8)
Occupation
Livestock
52 (38.0)
Agriculture
20 (14.6)
Business
54 (39.4)
Others
11 (8.0)
Residence
Rural
81 (59.1)
Urban
56 (40.9)
Total
137 (100)

Aadibasi/
janajati

Total
Upper caste

26 (12.1)
85 (39.5)
72 (33.5)
32 (14.9)

23 (15.5)
63 (42.6)
44 (29.7)
18 (12.2)

68 (13.6)
204 (40.8)
161 (32.2)
67 (13.4)

49 (22.8)
34 (15.8)
73 (34.0)
49 (22.8)
10 (4.7)

15 (10.1)
19 (12.8)
48 (32.4)
57 (38.5)
9 (6.1)

119 (23.8)
68 (13.6)
173 (34.6)
121 (24.2)
19 (3.8)

189 (87.9)
26 (12.1)

131 (88.5)
17 (11.5)

445 (89.0)
55 (11.0)

39 (18.1)
25 (11.6)
130 (60.5)
21 (9.8)

24 (16.2)
21 (14.2)
95 (64.2)
8 (5.4)

115 (23.0)
66 (13.2)
279 (55.8)
40 (8.0)

99 (46.0)
116 (54.0)
215 (100)

75 (50.7)
73 (49.3)
148 (100)

255 (51.0)
245 (49.0)
500 (100.0)

Source: Field Survey, 2014.

Frontiers in Public Health|www.frontiersin.org

DISCUSSION

415

Previously, health benefits, in addition to financial and other

non-financial benefits of microfinance, have been reported in
sub-Saharan Africa and South Asia (11, 12). Our current study
indicates that microfinance intervention might improve the
components of awareness and practices related to health except
for the use of traditional healers. However, this study could not
completely rule out the possibility of recall bias with respect to
their preintervention awareness and other measures. Similarly,
the positive impact of microfinance on knowledge of maternal
and child health has been demonstrated in the studies from
Bangladesh and Indonesia (9, 10). This could be due to the
increased access to health information to the clients as well as
their improved economic status after microfinance intervention.
Many microfinance organizations have implemented health programs to increase knowledge about health-related behaviors and
improve access to health services (6). The study suggests that the
incorporation of microfinance strategy to health strategy could
possibly be effective in developing countries like Nepal.
Interestingly, use of traditional healers to manage health problems in this study was significantly lowered after microfinance
interventions. Moreover, the highest level of health awareness
and practices were observed among microfinance clients of
upper caste group, followed by aadibasi/janajati group and the
dalit group. This could be due to the increased uptake of health
information, higher education level, and better communication and economic benefits among upper caste. Based on these

417

January 2016|Volume 3|Article 289

416
418
419
420
421
422
423
424
425
426
427
428
429
430
431
432
433
434
435
436
437
438
439
440
441
442

Dhungana et al.

Perceived Usefulness of a Microfinance Intervention on Health Awareness and Practices in Nepal

443

TABLE 3 | Self-reported health awareness and practices of respondents (N=500) before and after microfinance interventiona.

444

Variable/ethnicity

445

Response

Intervention

446
447
448

Awareness of environment and sanitation

449

480

Dalit
Aadibasi/janajati
Upper caste
Awareness of family planning methods
Dalit
Aadibasi/janajati
Upper caste
Awareness of available health services at local level
Dalit
Aadibasi/janajati
Upper caste
Use of nutritious food/balanced diet
Dalit
Aadibasi/janajati
Upper caste
Use of safe drinking water
Dalit
Aadibasi/janajati
Upper caste
Use of toilet
Dalit
Aadibasi/janajati
Upper caste
Use of traditional healers
Dalit
Aadibasi/janajati
Upper caste
Immunization of children
Dalit
Aadibasi/janajati
Upper caste
Regular visit to health facility for health checkup
Dalit
Aadibasi/janajati
Upper caste

481

450
451
452
453
454
455
456
457
458
459
460
461
462
463
464
465
466
467
468
469
470
471
472
473
474
475
476
477
478
479

482

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

500
p-Value

Before
n (rate, %)

After
n (rate, %)

56 (11.2)

346 (69.2)

8 (5.8)
22 (10.2)
26 (17.6)
46 (9.2)
4 (2.9)
20 (9.3)
22 (14.9)
19 (3.8)
2 (1.5)
9 (4.2)
8 (5.4)
21 (4.2)
1 (0.7)
10 (4.6)
10 (6.7)
63 (12.6)
10 (7.3)
26 (12.1)
27 (18.2)
76 (15.2)
10 (7.3)
32 (14.9)
34 (23.0)
78 (15.6)
44 (32.1)
27 (12.6)
7 (4.7)
79 (15.8)
12 (8.8)
32 (14.9)
35 (23.7)
18 (3.6)
1 (0.7)
7 (3.2)
10 (6.7)

61 (44.5)
149 (69.3)
136 (91.9)
325 (65.0)
53 (38.7)
140 (65.1)
132 (89.2)
299 (59.8)
52 (38.0)
133 (61.9)
114 (77.0)
319 (63.8)
54 (39.4)
139 (64.7)
126 (85.1)
334 (66.8)
56 (40.9)
148 (68.8)
130 (87.8)
352 (70.4)
60 (43.8)
156 (72.6)
136 (91.9)
7 (1.4)
3 (2.2)
3 (1.4)
1 (0.7)
369 (73.8)
70 (51.1)
163 (75.8)
136 (91.9)
307 (61.4)
45 (32.8)
131 (60.9)
131 (88.5)

485
486
487
488
489
490
491
492
493
494
495
496
497
498
499

502
503
504

<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
0.07
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001

Health awareness and practices before and after microfinance intervention were taken from a single interview for all the respondents who were clients of microfinance up to 5years
after the start of the intervention.

483
484

501

505
506
507
508
509
510
511
512
513
514
515
516
517
518
519
520
521
522
523
524
525
526
527
528
529
530
531
532
533
534
535
536
537
538
539
540

observations, it is presumed that an equity-based microfinance

services with more emphasis to the lower caste groups would be
more effective in Nepal.
Our study indicates that awareness of environmental health
and sanitation, different family planning methods, and availability
of health services at local level were improved after microfinance
intervention among upper caste group more commonly than others. The findings of current study are in line with other studies
from India and Bangladesh (23, 24). Improved health awareness
and an increased access to formal health care through microcredit
have also been shown in the study from Bangladesh (25).
This study indicates a significant improvement in the use
of nutritious diet, safe drinking water, toilet, health checkup at
local health facility, immunization of their children after the
microfinance membership-based intervention. Some previous

Frontiers in Public Health|www.frontiersin.org

literatures reported that access to financial services improved

health conditions, such as nutrition, higher immunization rates,
and child health (10, 26). In Ghana, the use of maternal and child
health interventions, such as skilled care at birth, intranatal care,
use of modern contraceptives, and malaria control, were more
common in the rich population as compared to the poor (8).
A Dominican Republic study also reported an improvement
in water and sanitation as well as maternal and child health
indicators through microcredit and health promotion programs.
Moreover, significant improvement in 10 out of 11 such indicators was reported by the same study (27). Another Bangladeshi
study also confirmed that households relative poverty status, as
reflected by wealth quintiles, was a major determinant in healthseeking behavior. Mothers who were of the highest wealth quintile
were significantly more likely to use modern trained providers of

January 2016|Volume 3|Article 289

541
542
543
544
545
546
547
548
549
550
551
552
553
554
555
556

Dhungana et al.

557
558
559
560

Perceived Usefulness of a Microfinance Intervention on Health Awareness and Practices in Nepal

Dependent variables

Ethnicity

Rate ratio
(RR)

95% CI

Dalit
Aadibasi/janajati
Upper caste

1.0
1.5
2.0

1.00
1.12.1
1.52.8

Awareness of family planning Dalit

methods
Aadibasi/janajati
Upper caste

1.0
1.6
2.3

1.00
1.22.3
1.63.2

Awareness of available
health services at local level

Dalit
Aadibasi/janajati
Upper caste

1.0
1.6
2.0

1.00
1.12.2
1.42.8

Use of nutritious food/

balanced diet

Dalit
Aadibasi/janajati
Upper caste

1.0
1.6
2.1

1.00
1.12.2
1.53.0

Use of safe drinking water

Dalit
Aadibasi/janajati
Upper caste

1.0
1.6
2.1

1.00
1.22.3
1.52.9

Dalit
Aadibasi/janajati
Upper caste

1.0
1.6
2.0

1.00
1.22.2
1.52.8

Dalit
Aadibasi/janajati
Upper caste

1.0
0.6
0.3

1.00
0.084.7
0.0053.8

Dalit
Aadibasi/janajati
Upper caste

1.0
1.4
1.7

1.00
1.11.9
1.32.4

Dalit
Aadibasi/janajati
Upper caste

1.0
1.8
2.6

1.00
1.32.6
1.93.8

561
562
563

Awareness of environment
and sanitation

564
565
566
567
568
569
570
571
572
573
574
575
576
577

Use of toilet

578
579

Use of traditional healers

580
581
582

Immunization of children

583
584
585
586

the lack of a control group, the methods do not allow to assess

whether the improvements in health awareness and practices
are indeed due to the intervention. This also holds true for the
differences between the three subpopulations. In particular, it is
not clear how the intervention has affected equity. Although the
study explored an important area and the current observations
are encouraging, better-controlled experimental designs would
provide stronger evidence for the effectiveness of microfinance.
Second, there was potential for a recall bias in data collection,
particularly for the data related to outcome measures before the
intervention as one set of interviews was conducted after the
intervention had taken place.

TABLE 4 | Multivariable analysis of self-reported health awareness and

practices in relation to ethnicity of the respondents after microfinance
intervention.

Regular visit to health facility

for health checkup

587

592
593
594
595
596

599
600
Q12

601
602
603
604
605
606
607

Q13

608
609
610
611

617
618
619
620
621
622
623
624
625
627

This study found positive effects of microfinance on health

awareness and practices in different ethnic groups of Nepal. The
positive health awareness and practice were more commonly
observed among upper caste group. Therefore, the study indicates
toward a need for an equity-based microfinance intervention for
improving the health and economic status of the Nepalese people.
Additional follow-up interventional studies are recommended in
this regard.

629

628
630
631
632
633
634
635
636
637

AUTHOR CONTRIBUTIONS

638

JS and BD participated in the design of the study. DA and JS

performed statistical analysis. DA and JS wrote manuscript with
significant contribution of BD and SG. BD, SG, and PP contributed in the analysis, interpretation of the results, and literature
review. All of the authors contributed in revision and agreed on
the final manuscript.

640

639
641
642
643
644
645
646

antenatal care, birth attendance, postnatal care, and child health

care than the mothers in the lowest wealth category (28).
Our results suggest that microfinance has been useful to improve
health awareness and practices. To the best of our knowledge, no
such previous study has been conducted on effect of microfinance
on health awareness and practices in Nepal. Nevertheless, despite
our best effort, this study also has some limitations. First, due to

ACKNOWLEDGMENTS

647

We thank our research assistants and all the respondents who

participated in this study. We are grateful to Deepak Adhikari,
Ph.D. (Department of Anatomy and Developmental Biology,
Monash University, Melbourne, VIC, Australia) for final English
check and editing of our manuscript.

649

597
598

616

CONCLUSION

589
591

615

626

588
590

614

648
650
651
652
653
654

REFERENCES

7. Boccia D, Hargreaves J, Lonnroth K, Jaramillo E, Weiss J, Uplekar M, etal.

Cash transfer and microfinance interventions for tuberculosis control: review
of the impact evidence and policy implications. Int J Tuberc Lung Dis (2011)
15(Suppl 2):S3749. doi:10.5588/ijtld.10.0438
8. Zere E, Kirigia JM, Duale S, Akazili J. Inequities in maternal and child health
outcomes and interventions in Ghana. BMC Public Health (2012) 12(1):252.
doi:10.1186/1471-2458-12-252
9. Hadi A. Promoting health knowledge through micro-credit programmes:
experience of BRAC in Bangladesh. Health Promot Int (2001) 16(3):21927.
doi:10.1093/heapro/16.3.219
10. DeLoach SB, Lamanna E. Measuring the impact of microfinance on
child health outcomes in Indonesia. World Dev (2011) 39(10):180819.
doi:10.1016/j.worlddev.2011.04.009
11. Van Rooyen C, Stewart R, de Wet T. The impact of microfinance in sub-Saharan
Africa: a systematic review of the evidence. World Dev (2012) 40(11):224962.
doi:10.1016/j.worlddev.2012.03.012

1. Ofori-Adjei AB. Microfinance: an alternative means of healthcare financing

for the poor. Ghana Med J (2007) 41(4):1934.
2. Organization WH. World Health Report 2005: Make Every Mother and Child
Count. Geneva: World Health Organization (2005). 2005 p.
3. Saha S. More health for the money: an analytical framework for access to
health care through microfinance and savings groups. Community Dev J
(2014) 49(4):61830. doi:10.1093/cdj/bsu037
4. Haq M, Hoque M, Pathan S. Regulation of microfinance institutions in Asia: a
comparative analysis. Int Rev Bus Res Paper (2008) 4(4):42150.
5. Wagstaff A. The Millennium Development Goals for Health: Rising to the
Challenges. World Bank Publications (2004).
6. Leatherman S, Metcalfe M, Geissler K, Dunford C. Integrating microfinance
and health strategies: examining the evidence to inform policy and practice.
Health Policy Plan (2012) 27(2):85101. doi:10.1093/heapol/czr014

655
656
657
658
659
660
661
662
663
664
665
666
667
668

612

669

613

670

Frontiers in Public Health|www.frontiersin.org

January 2016|Volume 3|Article 289

Q14

Dhungana et al.

671
672
673
Q15
Q16
Q17

674
675
676
677
678

Q18

679
680
681
682
683
684
685
686
687
688
689
690
691
692
693
694

Perceived Usefulness of a Microfinance Intervention on Health Awareness and Practices in Nepal

12. Saha S, Annear PL. Overcoming access barriers to health services through
membership-based microfinance organizations: a review of evidence from
South Asia. WHO South East Asia J Public Health (2014) 3(2):125.
13. Neupane HP. Advancing Inclusive Financial System in the Next Decade: A Case
of Nepal.
14. Bank NR. Banking and Financial Statistics. Various Issues Kathmandu (2009).
15. Dhungana BR. The Status of Financial Inclusion in Nepal (2015).
16. Pun L, Dhakal N, Pyakurel G. Reaching the unreached: case of MEDEP
modality for micro-finance service delivery in Nepal. A Paper Presented in
Microfinance Summit in Nepal (2010). p. 146.
17. Dhakal NH. Microfinance for achieving millennium development goals in
Nepal. Agr Credit Bi Annu J (2004) 37.
18. Bhatta G. Small is indeed beautiful but: the context of microcredit strategies in Nepal. Pol Stud J (2001) 29(2):28395. doi:10.1111/j.1541-0072.2001.
tb02092.x
19. Aoki C, Pradhan PK. Impact of Microfinance Services on Socio-Economic
Empowerment of the Womens Group in Nepal. Geography of Governance:
Dynamics for Local Development (2013). 1 p.
20. Tull DS, Albaum GS. Survey Research: A Decisional Approach. Intext
Educational Publishers (1973).
21. Khanal V, Adhikari M, Sauer K, Zhao Y. Factors associated with the introduction of prelacteal feeds in Nepal: findings from the Nepal demographic and
health survey 2011. Int Breastfeed J (2013) 8(1):9. doi:10.1186/1746-4358-8-9
22. Zhang J, Kai FY. Whats the relative risk?: a method of correcting the odds
ratio in cohort studies of common outcomes. JAMA (1998) 280(19):16901.
doi:10.1001/jama.280.19.1690
23. Arole M, Arole R. A Comprehensive Rural Health Project in Jamkhed (India)
(1975).

24. Rosato M, Laverack G, Grabman LH, Tripathy P, Nair N, Mwansambo C, etal.

Community participation: lessons for maternal, newborn, and child health.
Lancet (2008) 372(9642):96271. doi:10.1016/S0140-6736(08)61406-3
25. Schurmann AT, Johnston HB. The group-lending model and social closure:
microcredit, exclusion, and health in Bangladesh. J Health Popul Nutr (2009)
27(4):518. doi:10.3329/jhpn.v27i4.3400
26. Littlefield E, Morduch J, Hashemi S. Is microfinance an effective strategy to reach the millennium development goals? Focus Note (2003)
24(2003):111.
27. Dohn AL, Chvez A, Dohn MN, Saturria L, Pimentel C. Changes in health
indicators related to health promotion and microcredit programs in the
Dominican Republic. Rev Panam Salud Publica (2004) 15(3):18593.
doi:10.1590/S1020-49892004000300007
28. Amin R, Shah NM, Becker S. Socioeconomic factors differentiating maternal
and child health-seeking behavior in rural Bangladesh: a cross-sectional
analysis. Int J Equity Health (2010) 9(9):112. doi:10.1186/1475-9276-9-9

728
729
730
731
732
733
734
735
736
737
738
739
740
741

Conflict of Interest Statement: The authors declare that the research was con- 742
ducted in the absence of any commercial or financial relationships that could be 743
construed as a potential conflict of interest.
744

Copyright 2016 Dhungana, Singh, Acharya, Gautam and Paudyal. This is

an open-access article distributed under the terms of the Creative Commons
Attribution License (CC BY). The use, distribution or reproduction in other forums
is permitted, provided the original author(s) or licensor are credited and that the
original publication in this journal is cited, in accordance with accepted academic
practice. No use, distribution or reproduction is permitted which does not comply
with these terms.

745
746
747
748
749
750
751

695

752

696

753

697

754

698

755

699

756

700

757

701

758

702

759

703

760

704

761

705

762

706

763

707

764

708

765

709

766

710

767

711

768

712

769

713

770

714

771

715

772

716

773

717

774

718

775

719

776

720

777

721

778

722

779

723

780

724

781

725

782

726

783

727

784

Frontiers in Public Health|www.frontiersin.org

January 2016|Volume 3|Article 289