Role of information, education, and communication in enrollment of health insurance: A case of Nepal

Background Most of the studies have indicated that various programmes were failing due to lack of appropriate information, education, and communication [IEC] to the target audiences. But still unanswered that which methods or means of communication could be the most powerful for changing behaviour, decision making,and or desired action. The paper aims to assess the effects of IEC on the enrollment of health insurance in Nepal. Methods A cross-sectional study, with randomly selected 810 [405 enrolled and 405 not-enrolled] households, was conducted at Baglung and Kailali districts of Nepal in 2018 using pretested structured interview tool. Background characteristics of family and respondents, and exposure to the means of communication were independent variables; and enrollment of health insurance was the dependent variable. Univariate, bivariate, and multivariate analyses were done to interpret the data. Results Data show that socio-demographics and exposure to communication were associated with the enrollment of health insurance. Demographic characteristics of the respondents and households particularly household head, age, wealth status, ability to feed the family, and presence of chronic diseases in the family were significantly associated with the enrollment of health insurance. Similarly, exposure to communication and media such as knowledge on health insurance and contribution amount of health insurance, having health insurance related books or guidelines, participation in training and workshop, discussion with peers and neighbours, exposure to health insurance related messages from radio and television, seen hoarding board, newspaper, and health insurance related pamphlet, brochure, and posters were significantly associated with enrollment in health insurance. Knowledge about health insurance and contribution amount, having health insurance related books and guidelines, and discussion with peers and neighbours appeared to be the positive and significant predictors for enrollment in

health insurance scheme.

Conclusion Communication and interaction with peers and neighbours about health
insurance scheme of the government could lead to higher participation in health insurance programme. It would be better to incorporate this strategy while planning policies and interventions on health insurance. also declared basic health services as one of the fundamental rights of the citizen (2).However, the GoN has allocated less than three percent of its total budget for health sector (3) which is said to be insufficient to meet the targets of global agenda of good health and wellbeing for all and constitutional provision of right to healthcare. Therefore, appropriate and sustainable financing for health is needed to meet the targets and agendas. The GoN has formulated Health Insurance Act [HIA] 2017 to ascertain the financial sustainability for health care(3,4) through Health Insurance [HI] programme was already introduced as Social Health Security [SHS] in 2016 under the provision of Development Board Act 1956 in Kailali, Baglung and Ilam Districts in initial phase (5).
Health Insurance Programme [HIP] is relatively a new programme for Nepalese people. So, it has obviously both opportunity and challenge to implement. An opportunity in the sense of new service to the people and challenge in the sense that people may or may not participate in the HIP since they may not have adequate and correct information about it.
A survey conducted in Kailali District shows that only nine percent people had good knowledge about HI (6). Department of Health Services shows about only eight percent population were enrolled in HIP as of November, 2018 from 36 districts but less than three [2.4] percent population were enrolled in Baglung and Kailali Districts, and majority did not renewed their scheme (3,5). This may be happening because of inadequate information, education, and communication [IEC] activities. Inadequate IEC leads to poor enrollment, lower retention, and fewer renewal as well.
The HIP in Nepalese context requires proper sensitization and information to the targeted population in mass level. Various interventions such as sensitization, awareness, orientation, and training shall be conducted for mass enrollment (7,8). However, it is still unanswered which method would be more appropriate to get people informed about HIP.
Health Insurance Board [HIB] has set three tiers of communication strategy at policy level, community level and household level but the strategy is yet to be validated (9). IEC may be a single term but has several meanings. It is a combination of strategies, methods and approaches that enables a person to adopt a dynamic role in improving quality of life through healthy conducts (10). IEC is not only limited to the process of changing behaviour but also a process of political, social and economic transformation. Adequate IEC approaches can encourage and support to follow up for positive behaviour change (11). IEC creates awareness, increases knowledge, changes attitude, and moves people towards change and continues their behaviours to adopt new innovation (12 (17). Gathering all people in the main stream of IEC is a difficult task.
It does not only change the behaviour but develops culture and civilization. It is a process of transforming innovations, ideas, opinions and new trends (18).
IEC informs, inspires, motivates, enables, and empowers people for making decision towards the healthy way by making changes in terms of knowledge, attitudes, and beliefs (19). Communication is a power for decision making for behaviour change. It makes individuals positive, motivating, encouraging, and supportive for understanding (20). IEC consists several methods, approaches, and interventions but it is neither evaluated nor assessed which method and approach would be better for behaviour change in relation to enrollment in health insurance in the context of Nepal. So the article aims to assess the effects of information, education, and communication on enrollment in health insurance.

Research approach and design
The study used cross-sectional survey design, was a retrospective study, and household was the unit of study.

Study field/area
The study was undertaken in Baglung and Kailali Districts of Nepal. Baglung is located at hill in mid-western part and Kailali is situated in Terai and south-western part of Nepal.
HIB initiated HIP at these districts in initial phase however it has been expanded at 36 Districts as of November, 2018 (3).

Population and sample
All households residing in Baglung and Kailali Districts were the population of the study.
There were two types of sample: enrolled and non-enrolled. Sample size was calculated by using Daniel's formula (21,22). for enrolled family and the same size was determined for non-enrolled household. List of households was obtained from HIB district offices and household unit was randomly selected for enrolled sample. The proximal household of enrolled household, which was not enrolled in HIP, was selected as non-enrolled sample.

Data collection tool
Interview schedule [IS]was used for research tool. It was pretested and modified for validation prior to administration. The IS had eight sections: family profile, sociodemographic characters, HI related questions, IEC related questions, public service announcement related questions, Health Belief Model Related questions, perception regarding HI, and household's assets and wealth status. The IS was 14 pages and normally required 25 minutes to fill up.

Data collection procedure
After completing all administrative procedure: ethical approval was received from Nepal to analyse the data.

Ethical consideration
NHRC reviewed and approved the study proposal on 15 th Feb, 2018. We followed National Ethical Guidelines for Health Research in Nepal and Standard Operating Procedure (23) and Ethical Compliance Checklist prepared by American Psychological Association (24) throughout the research process.

Characteristics of respondents and households
Of the total 810 respondents, 70 and 30 percent were from Kailali and Baglung respectively. They were drawn as per the proportional distribution of sample based on the national population and household census 2011 (25). Out of them, more than one fourth [26%] were from rural area. More than half of the respondents [51%] were female. Among them, two third [66%] were the household heads. More than 92 percent were literate, more than half of them had basic and secondary level of education, and 12 percent had bachelor or higher level of education. Forty-one percent household belonged to nuclear family. Fifty-six percent of the total households had upto five members in the family, 42 percent households had six to 10 members and nearly two percent had more than 10 members in the family. Different nine types of household assets and dwelling were assessed to categorize wealth status in three equal class. So, the wealth status of the people comprised one third each of the rich, middle and poor households. Nearly two third [66%] of the respondents had knowledge about contribution amount for HI. Seventeen percent of them had HI related books or guidelines. However, only five percent had participated in training and discussion related to HI.  percent respectively less likely to enroll in HI compared to those who did not.  (12,(26)(27)(28). IEC materials were useful tool for promoting suitable eye awareness and also a powerful for social change in Madhurai, India (29). Similarly, it was observed that IEC and contraceptive uses were significantly associated beyond the visits of medical and family planning officers which was experienced in Indonesia (30). A study from Gambia shows that mass media was effective and feasible means to make change in maternal health service utilization and care (31).
Similar observation seemed in India that IEC approaches appeared appropriate for consuming low salt diet to control hypertension (32) however flip chart seemed ineffective for food hygiene and food safety (33). IEC could be useful not only for making changes in behaviour but also for preparedness, response and mitigation for disaster that may save lives and resources (34).
Different audiences may be motivated from different mode of communication. Arroz (2017) states that Radio, dramas, lectures, posters and pamphlet, and folk programmes could considered as synergetic approaches but not replace one another (35). There was a significant difference between the respondents who listened HI message from radio and enrollment in HI compared to those who did not. The similar result was observed in Liberia that the women who listened radio spots were encouraged to care their child and visit health facilities of their babies appear with fever (36).
The study shows that educational level of respondents was not significantly associated with the enrollment in HI but knowledge on HI was significantly associated with the enrollment in HI. A study from Nigeria shows that educational level of the participants was significantly associated with the awareness of national health insurance scheme (37). So it does not always mean that educational status is equal to HI literacy as well as enrollment.
Another study from Columbia suggested that integrated approaches that are Radio, TV and interpersonal communication with health workers/volunteers were effective for seeking treatment for malaria (38). Another study from Odisha, India shows that drugs adherence to IEC was significantly higher in receiving Artemisinin combination therapyin experiment group compared to control (39). Therefore, it can be concluded that IEC is an effective means to adopt an innovation or change in desired behaviour.
The study shows that nearly two third of the respondents, who interacted with peer or neighbours were enrolled compared to 39 percent of those who did not interact that was statistically significant. In the same way interaction with peers or neighbours was a positive significant predictor for enrollment in HI. Various empirical studies support the argument. Information and counselling from neighbours or peers make significant changes in behaviour modification. Not only a good behaviour but health destructive behaviours also influenced by peers (40). Peer teaching or coaching enhances relationship, reciprocal understanding, and development to achieve the targeted behaviour (41) besides these peer assessment improves students' learning outcomes with progressive attitudes (42).
Not only that, the peering approach appears also successful in peer to peer fiscal planning and educational programmes (43).
The peer teaching method supports to develop in-depth and mutual understanding, cooperative and collaborative learning environment and also ensures self-assessment and monitoring of progress (44). Peering approach seems more effective specially for adolescents with high risk background. It connects with positive towards peer-to-peer relationship and they should be guided in supporting one-another in promoting healthy behaviour (45). The approach has been recognized as an effective and valuable approach so can be incorporated into different setting using various methods and approaches (46) which might be fastest, cheapest, efficient, and beneficial approach and can be utilized social as well as cognitive field (47).
The peering or neighbouring approach leads productive social interaction, responsiveness, co-operation and positive attitudes and social harmony. It supports learning environment and encouraging participation in interaction (48). A systematic review shows that adolescents and sexuality health education had improved in knowledge, attitude and intentions by peer leading approach (49). Peer mediated approach also leads to positive changes in social behaviour of person having learning disabilities (50). Another experimental study shows that peer education significantly increased knowledge and practice of mental health of adolescents girls (51).
Peers support in three different ways: first, social; second, informational; and lastly, personal or folk, facts and feelings respectively which are interconnected with interpersonal skills. From the biomedical point of view on breastfeeding, peer to peer [P2P] approach is women centred, related to their own experiences, considering women as change agent from their own experiences and able to cope cultural constrains therefore recommended for P2P approach (52). From the result of this study and empirical evidences from other studies show that P2P or neighbouring approach is more convenient, efficient and effective way to change or modification of the behaviour.

Conclusion
From the data of the study and empirical evidences from other studies, it can be concluded that knowledge about HI and contribution amount seem major predictors for enrolment. Similarly, HI related books, guidelines and Hoarding Board can support for mass participation. The existing ways of message dissemination through Radio, TV, newspaper, poster and pamphlet seem less effective for enrolment. It should be reevaluated for disseminating message to public awareness or it should be modified. But, interaction with peer or neighbour seemed a positive and significant predictor for enrollment in HI. Therefore, policy maker should think of these facts while planning for the interventions.