Exploring barriers to sickle cell disease care in a lower-middle income country – A qualitative exploration of the Tharu perspective in rural Nepal

The indigenous Tharu ethnic group inhabiting the Terai (lowland) region of Nepal has been shown to have a high prevalence of sickle cell disease (SCD); specifically, previous studies have found a prevalence of 9.3% for sickle cell trait in this group. The lack of knowledge about SCD in this population is suspected to be a major barrier in preventing early intervention. This qualitative study aimed to conduct a needs assessment and identify themes relating to the local Tharu population's perceptions of SCD and its related care. Using snowball sampling for recruitment, 133 Tharu community members in the rural district of Dang met inclusion criteria. Researchers conducted 22 focus group discussions (FGDs) using semi-structured interviews in the local Tharu dialect, Nepali, Hindi, or English until topic saturation. A constant comparison analysis based off grounded theory was used for thematic analysis (NVivo 11™). Three major themes emerged that explored the Tharu community's views of SCD: the social implications of SCD, the importance of SCD education, and the role of positive interventions. Inequity and lack of access to healthcare services were also thought to contribute to the lack of SCD-specific care. Using participatory action-based research to empower underserved communities, we have identified major themes surrounding the lack of understanding and wish for enhanced SCD awareness and education within the Tharu community. Our research explores fundamental barriers that must be addressed to develop a sustainable, accessible, and comprehensive SCD care plan in the region.