• Project RISE Report
  • Preface
    • 0.1 Format of this report
    • 0.2 Skimmers, Swimmers, and Divers
    • 0.3 Searchable tables
    • 0.4 Audience for the current version of this report
    • 0.5 Project RISE Collaborative Structure
      • 0.5.1 Project RISE Timeline
    • 0.6 Acknowledgements
    • 0.7 Software
  • I EXECUTIVE SUMMARY
  • Executive Summary
    • 0.8 What is Project RISE?
      • 0.8.1 Project RISE Central Concepts
      • 0.8.2 Project RISE Goals
    • 0.9 Data Types and Methods
      • 0.9.1 Sample overview
    • 0.10 A Ritual Lens and Project RISE
      • 0.10.1 Replacement, Conflict, and Complementarity
      • 0.10.2 Most Rituals are Motivated by health promotion or risk aversion
    • 0.11 What does it mean to be in between?: The under-appreciated role of liminality
    • 0.12 Dai – ASHA Comparison
    • 0.13 ASHA Efficacy in Behavior Change
      • 0.13.1 ASHA Efficacy and Issues of Reach
    • 0.14 Emerging Insights and Implications
  • II INTRODUCTION
  • 1 Topic and Place
    • 1.1 Purpose
    • 1.2 Brief Overview of the ASHA Program
    • 1.3 Bihar
      • 1.3.1 Bihar Health Care System
  • 2 Rationale
    • 2.1 Project RISE Purpose and Motivation
      • 2.1.1 Project RISE data streams
    • 2.2 Project RISE in the Context of Previous Research into CHW Programs
      • 2.2.1 Community Health Worker (CHW) Research
      • 2.2.2 CHWs and India
      • 2.2.3 Social and behavior change communication (SBCC) in the CHW health context
    • 2.3 Why Ritual?
    • 2.4 Rituals and Extrinsic vs Intrinsic Motivators
      • 2.4.1 Ritual-Based Behavior Change
    • 2.5 The COVID-19 Pandemic and Project RISE
    • 2.6 Organizing Concepts
      • 2.6.1 A Nested-Social Ecology
      • 2.6.2 Insights hiding in plain sight
    • 2.7 Setting the Stage for Project RISE Analysis
      • 2.7.1 RISE Big Three
      • 2.7.2 Synthetic Outputs
  • III DATA STREAMS
  • 3 Qualitative Part 1: Focus Group Discussions and Key Informant Interviews
    • 3.1 Purpose and Procedure
    • 3.2 Perinatal ritual
      • 3.2.1 Chhati
    • 3.3 Food & diet
    • 3.4 Perception of CHW and Dai
    • 3.5 Chapter Discussion
      • 3.5.1 ASHA’s role prioritization and expectations from the system
    • 3.6 Chapter take-aways
  • 4 Qualitative Part 2: Extended discussions, ASHA interviews, focal follows, and participant observation
    • 4.1 Purpose and Approach
    • 4.2 Data Excerpts from Ethnographically Derived Qualitative Fieldwork
      • 4.2.1 Coded Summary of Ethnographic Findings
      • 4.2.2 Excerpts from ethnographic case studies
    • 4.3 Key themes from the Ethnographic Methods
      • 4.3.1 Support
      • 4.3.2 Doubly powerless
      • 4.3.3 Being in Between
      • 4.3.4 Motivation
    • 4.4 Chapter Discussion
    • 4.5 Chapter take-aways
  • 5 Qualitative Part 3: Interviewing the Interviewers
    • 5.1 Purpose and Procedure
    • 5.2 Table of Responses
    • 5.3 Chapter Discussion
    • 5.4 Chapter take-aways
  • 6 Quantitative Part 1: Sample Overview and Description of ASHA’s Role
    • 6.1 Purpose and Procedure
    • 6.2 Survey context and methods
      • 6.2.1 Existing descriptive summaries
    • 6.3 Sample characteristics & ASHA-Mother comparison
    • 6.4 Perception of ASHAs
    • 6.5 ASHA Workload and Remuneration
      • 6.5.1 Challenges of Workload
      • 6.5.2 Incentives and ASHA Motivation
      • 6.5.3 ASHA Support
    • 6.6 Chapter take-aways
  • 7 Quantitative Part 2: Behavioral Overview
    • 7.1 Purpose
    • 7.2 The Behaviors
      • 7.2.1 Variation in the coded behaviors
    • 7.3 ASHA Training and Experience Change ASHA’s own Maternal Behavior
      • 7.3.1 ASHA Respect with Time as an ASHA
    • 7.4 An ASHA Interaction Score
      • 7.4.1 Effects of ASHA Interaction on Perinatal Behaviors
    • 7.5 ASHA Interaction and Overall Uptake of Biomedical Behavior
      • 7.5.1 Component parts of ASHA Interaction Score
      • 7.5.2 Factors Predicting Greater ASHA Interaction Scores
    • 7.6 Do ASHA - Beneficiary Differences Impact Service?
    • 7.7 Chapter take-aways
  • 8 Quantitative Part 3: Influencers and Reasons
    • 8.1 Purpose and procedure
    • 8.2 Influencer Counts/Percentages
      • 8.2.1 How to Interpret These Figures
      • 8.2.2 Influencers, percent association for each behavior
      • 8.2.3 The “other” influencer category
    • 8.3 Quantifying Influencer Effects
      • 8.3.1 Methods for Building Statistical Model of Health Behavior
    • 8.4 Results from ‘The Big Model’
      • 8.4.1 Biomedical Behaviors
      • 8.4.2 Neutral Behaviors
      • 8.4.3 Neutral Behaviors and being in between
    • 8.5 Overall Influencer Effects
    • 8.6 The Perinatal Journey by 1000 (38) Bar Graphs
      • 8.6.1 Early pregnancy
      • 8.6.2 During Pregnancy
      • 8.6.3 Near Delivery
      • 8.6.4 Post-Partum
    • 8.7 Reasoning
    • 8.8 Chapter take-aways
  • 9 Vignettes
    • 9.1 Purpose and Overview
      • 9.1.1 ASHA-Mother Vignettes
      • 9.1.2 ASHA-only Vignettes
    • 9.2 The Vignette Data and Coding
      • 9.2.1 Vignettes and Questions
      • 9.2.2 Vignette Raw Data
    • 9.3 Summary and Implications of the Results
      • 9.3.1 ASHAs knowlege as agent of behavioral change
      • 9.3.2 Potential areas identified to target for service delivery improvement
    • 9.4 ASHA-Mother Vignettes Results
      • 9.4.1 Across-vignette analyses
      • 9.4.2 Question 1
      • 9.4.3 Question 3
      • 9.4.4 Question 2
      • 9.4.5 Question 4
      • 9.4.6 Question 5
      • 9.4.7 Effects of Vignette
    • 9.5 Individual Vignette Descriptions
      • 9.5.1 Colostrum
      • 9.5.2 IFA Tablets
      • 9.5.3 Exclusive Breastfeeding
      • 9.5.4 Vaccine-Pregnancy
      • 9.5.5 Vaccines-Infancy
      • 9.5.6 Institutional Delivery
      • 9.5.7 Family Planning No Children
      • 9.5.8 Family Planning
    • 9.6 ASHA-Only Conflict Vignettes
      • 9.6.1 Conflict between recommendation and own history.
      • 9.6.2 Conflict between maternal duties and ASHA duties.
      • 9.6.3 Mother not respecting ASHA nor her recommendations
      • 9.6.4 Mother disagrees about best practices.
      • 9.6.5 An ASHA does work on another ASHAs territory
      • 9.6.6 Doctor is rude to a Mother for not doing recommended practice
      • 9.6.7 Doctor is rude to ASHA
      • 9.6.8 ASHA has too many duties simultaneously
    • 9.7 Chapter take-aways
  • IV DESIGN
  • 10 Design Thinking and the Human Centered Design (HCD) approach in Project RISE
    • 10.1 Introduction to Design Thinking and Human-Centered Design
      • 10.1.1 What is HCD?
      • 10.1.2 Relevance of HCD in public health
      • 10.1.3 What is the value that HCD brings to Project RISE?
    • 10.2 Overview of the design phases
    • 10.3 Phase I. Discovery: Understanding the Present
      • 10.3.1 Purpose and Process
      • 10.3.2 Defining Research Objectives
      • 10.3.3 Mixed method research and data collection
      • 10.3.4 Mixed Method Analysis
      • 10.3.5 Data Synthesis through Four Domains
      • 10.3.6 Four Opportunity Areas
    • 10.4 Ritualization Strategy Framework
      • 10.4.1 Four Elements to Ritualize Behaviours
    • 10.5 Phase II. Define - Creating a Vision
      • 10.5.1 Purpose and process
    • 10.6 From opportunity areas to Design Drivers
    • 10.7 Design Lab: from insights to action
    • 10.8 HMW Themes: Expert feedback
    • 10.9 Prioritizing HMW Theme directions for co-design
    • 10.10 Phase III: Create - Drafting a Path to Future
      • 10.10.1 4.1 Purpose and Process
    • 10.11 Co-design for HMW Theme 1B
      • 10.11.1 Objectives and Recruitment The main goals of the first set of co-design sessions in December 2020 was:
      • 10.11.2 Remote Co-design considerations
      • 10.11.3 Synthesis
    • 10.12 Co-design for HMW Theme 1A
      • 10.12.1 Objectives and Recruitment
      • 10.12.2 Lessons Learned
      • 10.12.3 Synthesis
      • 10.12.4 Emerging Ideas
    • 10.13 Ideation and concepts
      • 10.13.1 9 Concepts
    • 10.14 Prototyping the Future Family Tool
      • 10.14.1 Selection, Objectives & Recruitment The main considerations for prototyping were:
      • 10.14.2 How the Future Family tool works
      • 10.14.3 Prototyping results
    • 10.15 Ritualization Intervention System
    • 10.16 Chapter take home messages
    • 10.17 Annex - external resources
  • V SYNTHESIS
  • 11 Ritual Narrative
    • 11.1 Purpose and Procedure
    • 11.2 Background
    • 11.3 The Narrative
      • 11.3.1 Pre-Pregnancy
      • 11.3.2 First Trimester
      • 11.3.3 The Second Trimester
      • 11.3.4 Third Trimester
      • 11.3.5 Labor
      • 11.3.6 Delivery and Early Postpartum
    • 11.4 Postscript
  • 12 Discussion
    • 12.1 A Ritual Lens: Most rituals are intended to promote health or avoid risk
      • 12.1.1 Different belief systems often coexist, and may even complement each other
      • 12.1.2 Rituals and behavior change
    • 12.2 ASHAs are effective service extenders but this overshadows their potential as cultural facilitators
    • 12.3 Liminality and the Foundation of the ASHA Program
      • 12.3.1 ASHA is a connector between systems
    • 12.4 Mixed Methods Case Study: From concealing the pregnancy to IFA tablets
    • 12.5 ASHAs are primary influencers
      • 12.5.1 Limitations in Reach
      • 12.5.2 Program vs Person
    • 12.6 Tensions and Liminality
    • 12.7 Closing Thoughts
  • Appendix
  • A Ethnographic Documents
    • A.1 Case Studies
      • A.1.1 Family Planning Day with SMA01
      • A.1.2 Family Planning Day with SMA02
      • A.1.3 Interview with SMT01
      • A.1.4 Home Based Newborn Care (HBNC) with SMA04
      • A.1.5 Home Based Newborn Care (HBNC) with SMA04
      • A.1.6 Home Based Newborn Care (HBNC) with SMA05
      • A.1.7 Ante-natal Care (ANC) Day with SMA05
      • A.1.8 Interview with Dai
      • A.1.9 Monthly Meeting of Satmalpur ASHAs and SMF03 & Delivery with SMA10 at PHC
      • A.1.10 Interview with SMA10’s Beneficiary (Delivery Case)
      • A.1.11 Interview with PHC Mamtas
      • A.1.12 Interview with SMA01’s Husband
      • A.1.13 Interview with SMA11 (Infant Mortality Case)
      • A.1.14 Interview with ANM, SMF01 & SMA01 (Infant Mortality Case)
      • A.1.15 Interview with ASHA (SMA01) (Call recording)
      • A.1.16 ANM & Facilitators Monthly Meeting with MOIC, BHM & BCM
  • B Appendix B: Vignette Supplementary Analysis
    • B.1 ASHA-Mother Vignettes
    • B.2 Effects of Vignette
      • B.2.1 Question 1: Why did the mother choose/not choose to follow her ASHA’s recommendation?
      • B.2.2 Question 3: What do you think the ASHA said/could have said to persuade the mother to do the recommended behavior?
      • B.2.3 Question 2A:Who makes the decision? 2B: Why does this person make the decision?
      • B.2.4 Question 4: Was there any conflict between the mother and her ASHA/family member?
      • B.2.5 Question 5A: What should the person communicate to resolve the conflict? 5B: Who initiaties the resolution?
    • B.3 Individual Vignette Descriptions
      • B.3.1 Colostrum
      • B.3.2 IFA Tablets
      • B.3.3 Exclusive Breastfeeding
      • B.3.4 Vaccine-Pregnancy
      • B.3.5 Vaccines-Infancy
      • B.3.6 Institutional Delivery
      • B.3.7 Family Planning No Children
      • B.3.8 Family Planning
    • B.4 ASHA-Only Conflict Vignettes
      • B.4.1 Conflict between recommendation and own history.
      • B.4.2 Conflict between maternal duties and ASHA duties.
      • B.4.3 Beneficiary not respecting ASHA nor her recommendations
      • B.4.4 Beneficiary disagrees about best practices.
      • B.4.5 An ASHA does work on another ASHAs territory
      • B.4.6 Doctor is rude to beneficiary for not doing recommended practice
      • B.4.7 Doctor is rude to ASHA
      • B.4.8 ASHA has too many duties simultaneously
  • References
  • PROJECT RISE GITHUB LINK

Bridging the gap between service extension and cultural facilitation among ASHAs

10.17 Annex - external resources

RISE Miro Board

RISE Miro IDEAS

RISE Future Family Tool Timeline

RISE Future Family Tool Blank

RISE Rituals Templates - Filled examples

RISE Rituals Templates - Blank

Ritualization Strategy Framework Guide