12.4 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. However, many of an ASHA’s positive effects occur more as a service extender and less as a cultural facilitator (or ‘behavior change agent,’ sensu Schaaf et al. (2020)). From the perspective of behavior change, we also want to know if some behaviors are essentially low-hanging-fruit to the ASHA in terms of potential to have major impacts on uptake, whereas others might be more difficult to reach and require more of the tools of a cultural facilitator. 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.
Several lines of evidence show that ASHAs are effective at increasing the uptake of recommended behaviors among mothers. For instance, in Chapter (ref?)(quant2) 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 (ref?)(fig:plotmakehealthscore)). This measure is indirect, in that it totals the number of health behaviors adopted, and finds a correlation with the number of contacts reported across a range of possible contacts and services. From a different perspective (and using different questions), Chapter (ref?)(quant3) shows the influence of several different types of potential influencer on perinatal behavior and finds that ASHAs have the strongest positive influence ((ref?)(tab:tabrankinfluencers)) on the uptake of recommended behaviors. We also looked at the ASHA’s effect on individual behaviors (as opposed to an overall effect) and found that she was consistently among the strongest positive influencers (Section (ref?)(thousgraphs), Figure (ref?)(fig:plotmomprobs)).
Furthermore, the general association between ASHAs are recommended health behavior is highly pervasive and general. While many studies of ASHA efficacy focus on specific links between contacts of a certain type, like home visits during pregnancy, and a specfic outcome, like institutional delivery, we also think its important to look at the association between ASHAs and a general pattern of uptake. ASHAs seem to be highly salient in the minds of Bihari mothers, for a range of behaviors. While our study is not longitudinal, there is some evidence that this general salience might have increased with time of the ASHA program. The first line of evidence for this is simple deduction: before the ASHA program there could not have been an association between ASHAs and health behavior; in the earliers months or years of the program, the association would have been small or infrequent, with the possibility to increase in time as more women had experiences with ASHAs helping to connect them to services. Secondly, we have evidence in the qualitative data that the ASHA role has grown in time and that the association has become more positive (Chapter 3). Third, data on the ASHA’s own births suggests that the association between ASHAs and engaging with recommended practice increased with the program.
While the ASHAs are effective, there are numerous cases of limited reach and to improve their impact it may be necessary to identify these remaining barriers to contact. Quite a few of the women surveyed did not receive a home visit during pregnancy (~22%). In terms of medical contact outside of the home, just under half of the mothers surveyed (~48%) had the four recommended checkups. Of course, if we look across services, we find that mothers may be less likely to take them the more ‘bundled’ the evaluation becomes. For instance, if we compare the ‘Full ANC’ takeup of Kumar et al, which is defined as 100 or more IFA doses, at least one tetanus injection, and four or more ANC checkups, we find that only about 23% of mothers reported adopting all three of these behaviors. [Note how similar our uptake levels are to this paper]