0.13 ASHA Efficacy in Behavior Change
Part of understanding the ASHA’s role in beneficiary communities is understanding her efficacy in increasing the frequency of biomedically desirable behaviors.
Some previous studies have found that ASHAs have neutral or negative effects on beneficiary health behavior or knowledge Lyngdoh et al. (2018). While we do find some evidence for limited contact (discussed below), our overall finding is that ASHAs have a strong positive effect on influencing behavioral uptake in the biomedically desirable direction. Our findings include comparison to a range of other possible sources of influence.
Our qualitative and quantitative datastreams made it clear that ASHAs are respected and thought of highly in their communities. The various lines of support for ASHAs having strong positive influence on the uptake of biomedically recommended behaviors are found in a few different places in the main body of the Report. We briefly list them here, along with links where one can find more detail:
This ASHA interaction 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 (Table 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 relevant behavior using a more complex statistical approach that included interactions and controls, we also found that ASHA’s effect was consistently strong and positive (Section 8.6, Figure 8.4).
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. 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 analyses and datastreams we see a strong positive effect of ASHAs on beneficiaries. Furthermore, the questionnaire to mothers did not prompt Mothers on who to name as influencers, and yet ASHAs were often named in association with behaviors not directly associated with the ASHA program, such as whether or not to abstain from sexual intercourse during pregnancy, or to avoid cereal-based foods the first week postpartum, or to avoid doing heavy work during pregnancy. That said, the ASHAs were typically the most frequently named source of influence for incentivized behaviors like institutional delivery (but still second to Family) or ANC registration. ASHAs were the most named for timely initiation of breast feeding and feeding colostrum.
0.13.1 ASHA Efficacy and Issues of Reach
While we found that ASHAs seem to be extremely effective at raising the probabilities that mothers practice healthy perinatal behaviors, we also found that this efficacy may lack sufficient reach. About 22% (260 of 1200) of the mothers in our sample did not receive an ASHA home visit during pregnancy. Of these, quite a few either visited with the ASHA outside of the home or received a message from the ASHA via a family member, but 13% of mothers did not receive any of these forms of contact during pregnancy.
While some of this lack in reach could be related to ASHA motivation, there are programmatic factors to consider as well. We suggest that in evaluating ASHA efficacy, it is important to distinguish between the ASHA program and individual ASHAs as a workforce. For instance, many structural or program issues may affect the ASHA’s reach:
the size of catchment area can vary by ASHA, with some having to cover more ground. Difficulties with transportation are frequently mentioned by ASHAs as a challenge.
the number of pregnant woman per month can change with seasonal or random factors such that the workload is not constant. This could lead to sudden jumps in workload. In our data on 400 ASHAs, the number of pregnant women in a catchment area varied from 0 to 41.
many mothers, especially for their first birth, move back to their natal households for birth. This brings them closer to immediate family but they may have a relationship with the ASHA in the catchment of their husband’s family’s area (i.e., nearer to the marital household) and not know the one for their mother’s household.
ASHAs are often asked to complete non-routine health assignments, like household surveys or support for other programs like drug administration or family planning camps. These can be conflicting with their own duties and/or cumbersome in nature.