Readiness Among Female Community Health Volunteers to Deliver Community Based Tobacco Cessation Counseling in Rural Nepal: A Two-phase Mixed-methods Study

Tobacco cessation support is largely absent from health facilities in Nepal, particularly in rural areas. Female community health volunteers(FCHVs) serve communities across the country and could help extend cessation services, but it was unknown whether they can deliver tobacco cessation counseling. We evaluated their readiness to do so. Guided by the Health Belief Model, we conducted a two-phase mixed-methods evaluation with 28 volunteers in rural mid-Western Nepal. We held eight focus group discussions exploring the volunteers’ knowledge, confidence, and barriers to providing counseling, in two phases, eleven months apart. After the first phase we delivered a tobacco cessation training using lectures and role play, followed by a refresher training after the second phase, and we administered surveys before and after each training. We analyzed the qualitative data with deductive and inductive coding to identify themes, analyzed the surveys with descriptive statistics and Fisher’s exact test, and integrated the two sources to assess convergence and complementarity. The volunteers’ mean age was 48 years, one third had secondary education, and three quarters had served as volunteers for more than ten years. We identified five themes. In the first phase, volunteers had good knowledge of tobacco, its health effects, and cessation measures, recognized a role for themselves in counseling, and asked for regular training. In the second phase, their knowledge and confidence had improved, including trust that quitting is achievable, although some misconceptions and hesitation remained. They described personal, social, and policy-level barriers, such as community hesitation to engage in counseling, limited time, and easy access to tobacco products. Community receptivity to counseling improved over time, but the COVID-19 pandemic disrupted their efforts. Surveys showed that volunteers recognized their role and routinely provided counseling, while knowledge, confidence, and perceived barriers remained relatively stable across surveys; concerns about inadequate incentives and motivation rose from 25% to 57.1% between phases. The qualitative and survey findings converged and complemented each other, with the qualitative data providing depth and the surveys showing numerical trends. Female community health volunteers want to provide tobacco cessation counseling, showed good knowledge and confidence, and reported growing community receptivity, but they face several barriers. Qualitative findings suggest that training improved their knowledge and confidence. Policymakers should consider addressing system-level barriers, including training support and the availability of tobacco products, and integrating volunteers into cessation services. Before wider adoption, future studies should evaluate whether volunteer-led tobacco cessation counseling is clinically effective.