12.2 ASHA Efficacy
Many of results from the qualitative investigations (see Chapters 3 to 5) demonstrate that ASHA services are respected, well-received, and lead directly to increases in the uptake of biomedically recommended behaviors. Interestingly, it may be that many of an ASHA’s positive effects occur as a service extender and less so as a social-change agent (sensu Schaaf et al. (2020)). In that sense, the inquisitive reader could wonder if there are some behaviors that represent an equivalent of low-hanging-fruit to the ASHA in terms of potential to have major impacts on uptake, and others that are more difficult to reach and require a shift from service-extender to social-change agent. To understand where friction points may lie between ASHA’s potential to affect change and ASHA’s current effect on change, we first take an overall look at her efficacy.
From the qualitative data we have numerous accounts of ASHA’s work being highly respected and trusted. For most health-related questions she is considered a good source of information and women report that they appreciate her service.
From analysis of the quantitative data we have several lines of evidence regarding ASHA efficacy.
In Chapter 7 we calculated an ASHA interaction score and found that it was positively associated with the number of health behaviors adopted by Mothers in the sample (Figure 7.10).
This ASHA health score was also predictive of individual behaviors when controlling for basic demographic factors such that increased ASHA interaction had large effects on the odds that women give birth in a hospital, have early ANC registration, take IFA tablets, and feed colostrum (among others, see Table 7.7).
In Chapter 8 we examined the influence of several different types of potential influencer on perinatal behavior. ASHAs have the strongest positive influence (8.7) on the odds that women engage in behaviors consistent with biomedical recommendations of the influencers we considered.
When the effects of influencers was modeled for each biomedically influential behavior using a more complex structure including interactions and controls, we also found that ASHA’s effect was consistently strong and positive (8.6, Figure 8.4, more about this in the next section).
Another set of analysis examined how the experience and training of being an ASHA affected the ASHA’s own incorporation of the biomedically recommended behaviors into her personal lived experience as a mother. Similar to how behaviors differ between Mothers and ASHAs, at the level of sample averages, time spent as an ASHA increased uptake of some behaviors dramatically, like ANC registration and Institutional Delivery, but had almost no effect on others, like concealing the pregnancy (Table 7.5).
Across these lines of evidence we see an extensive commitment to understand how the connections among influencers affect behavior and how an ASHA’s lived experience as an ASHA interacts with her lived experience as a Mother.