9.6 ASHA-Only Conflict Vignettes
These vignettes described a conflict a fictional ASHA was experiencing. The questions asked the ASHA respondents how the character in the vignette should resolve the conflict, and asked ASHAs about their own experiences with conflicts like the one in the story. For these vignettes, because there were no experimental manipulations and only a single kind of respondent, we did conduct GLMMs analyses. Here, we quantify and describe the results. Each vignette describes a different potential conflict that ASHAs may experience. Further analyses of all ASHA-only conflict vignettes can be found in Appendix B.2.
9.6.1 Conflict between recommendation and own history.
When asked whether ASHAs should tell Mothers that they did not do something that they did not do themselves, the 85% said they should be honest about it. 15% said they should lie, and say they did in fact do this themselves. Zero ASHAs said they should only recommend things they did themselves. For the mothers who said they should be honest, 68% explained that times (social norms, knowledge, etc) have changed since they were young. 74% said it is important to tell Mothers to make better choices than they did themselves. When asked whether they should talk to other ASHAs about how to handle this kind of conflict, 75% of ASHAs said yes. However, we note that this question, which was asked for all eight vignettes was slightly misinterpreted. This question was trying to see if ASHAs had established social networks to discuss how best to do their job. The question was taken more as asking if they should get direct help resolving the conflict (or with their duties for other vignettes). When asked whether it is common to have to recommend something they did not do, 87% said it was. The table below shows the most common recommended practices that conflict with their own history.
9.6.2 Conflict between maternal duties and ASHA duties.
When asked what to prioritize, 66% of ASHAs said to prioritize ASHA duties. 11% prioritized maternal duties, and 23% rejected the premise by saying they would just figure out how to do it all regardless. 6% offered a novel strategy to be more efficient, e.g., communicating with Mothers with text message if there is not enough time for an in-person meeting. This suggests there is space to improve and help ASHAs have more time-saving strategies. 97% of ASHAs said they get help from their families when they are extremely busy. Getting help from other community members (19%) and other health care workers (29%) was not rare, but not nearly as frequent. The reason for prioritizing some duties over others would be because of the severity of the consequence of dropping a duty. For example, their own child might wait longer for one meal one day if her mother is prioritizing ASHA duties, but this is worth it if it means Mothers gives birth at a hospital rather than in the home. 83% said they would take help from other ASHAs. There was a mixed reports of how frequently this happens in their own lives, with the most common responses being between “frequently” and “never.” Only 10% said their own children become first. The most common explanation (46%) for why they prioritize ASHA duties, was that it is their responsibility, less common was money (19%).
9.6.3 Mother not respecting ASHA nor her recommendations
When asked how to handle this issue, 54% of ASHAs said it is important to persist in trying to persuade a Mother, and 37% suggested they need to explain health benefits. 3% suggest discussing social factors. This pattern resembles the ASHA-Mother vignette pattern of ASHAs under-discussing social issues regarding non-adherence. 34% said other ASHAs or health care workers should be asked for help. When directly asked if other ASHAs should be asked to help, 88% said yes. This suggests that many more ASHAs recognize how other ASHAs can help them rather than spontaneously think of the idea. This suggests they ASHAs helping each other can be further leveraged than it currently is. When asked how frequently this happens in their own lives, there was a range of experiences with 36% saying it is frequent, and 39% saying it is rare. When asked why this would happen, common responses are that something is wrong with the disrespecting Mother (e.g., she is uneducated; 35%), but it was more frequent to say it is because the ASHA was not doing a good enough job (48%). 15% suggested it is because Mothers think ASHAs don’t really care about them, they are just in it for the money.
9.6.4 Mother disagrees about best practices.
This vignette is similar to the previous. The previous vignette concerned the Mother not taking the ASHAs nutritional recommendations seriously, while here there is a specific practice that the Mother believes is important to do (treat infant’s navel with oil) that the ASHA recommends against. 84% would explain health risks/benefits, 63% said they would let mother know of potential infections. 26% of ASHAs said they would get family help or other healthcare worker help. 90% of ASHAs said she should talk to other ASHAs on how to deal with this issue 46% say it’s rare for mothers to disagree, but it happens, and 33% say it is frequent. Majority (85%) of ASHAs would persist to convince mother to do recommended practice, and 48% of ASHAs said they would compare new practice to old ritual to try to convince them.
9.6.5 An ASHA does work on another ASHAs territory
Here, it was instructive to compare how ASHAs discussed the character in the vignette, and discussing these conflicts in general, with their reporting of their own actions in this domain. The ASHAs suggested the vignette character should talk to the other ASHA 58% of the time, the Mother from the character’s territory 25% of the time, report the territory violating ASHA to a supervisor 60% of the time. All three of those numbers are lower when discussing their own history (46%, 12%, 38%, respectively). When discussing how often this happens, 41% of ASHAs said it is frequent, while only 5% say they do it frequently. Further, when asking why this happens, 40% say it is to help others when they do it, and 8% says it is to help themselves. However, when talking about other ASHAs these numbers are 10% to help others, and 25% to help themselves. This suggests some shaping their answers about themselves to what they would perceive as the normative response about. This shows the value of the vignette 3rd person perspective. When asked if ASHAs should get help from others about this issue, similar to previous vignettes, 85% say yes.
9.6.6 Doctor is rude to a Mother for not doing recommended practice
When asked how to handle this situation, 85% say they would tell the Mother the doctor was right to yell at them because it is their fault for not complying. Any discussion of comforting the mother was more rare. 46% of ASHAs said it is frequent, but only 2% say it is frequent with their own beneficiaries. Importantly 53% said it affects the Mothers desire to return to the hospital, and only 16% say it has no effect on the Mother. Given the primary response from ASHAs is to tell Mothers the harsh treatment, perhaps this opens a door for a different response that would not hurt their desire to return to the hospital as much. Further 70% say it has a negative effect on the Mother-ASHA relationship. Further suggesting there is room for improving these interactions. Similar to other vignettes 80% said when asked directly ASHAs should get help from others concerning this situation, but only 6% volunteered this strategy before being directly asked.
9.6.7 Doctor is rude to ASHA
90% of the ASHAs said the doctor is right to be rude when the ASHA is not successful in her duties. 88% said this has a negative effect on the relationship with the Mother, with 63% saying the Mother loses respect for the ASHA. On how to handle this situation, the most frequent responses are to apologize to the doctor (32%), and to do a better job in the future (52%). It is not clear how this will help repair the relationship with the Mother. Similar to the previous vignette, ASHA claim this is a frequent occurrence (46% say so), but it is more rare them to experience (only 3% say it is frequent). Similar to all previous vignettes, 75% say they should get help from other ASHAs. When asked overall, do ASHAs receive sufficient respect, the majority say yes (67%).
9.6.8 ASHA has too many duties simultaneously
This vignette described a scenario wherein an ASHA needed to give out a new round of vaccines to the community, but also had hospital births to help with. There was an even split between which to prioritize, 43% said vaccines; 48% said births. 36% offered solutions for more efficient delivery of services, such as gather all the mothers in one place to make vaccinations faster. They generally saw major consequences for missing either duty (over 50% for both), but few suggested they should enlist the health of other health care workers (12% for births; 26% for vaccines). However, 90% said they should get help when asked directly, more frequent than any other vignette. When asked which duties in their own lives are most likely to conflict with others, it is taking a Mother to the a clinic for a checkup or delivery. This suggests a system for having other ASHAs cover duties when one has to go to a clinic could be beneficial. 54% did suggest that they would ask for help from others in their own lives, much more than what they recommended for the vignette character.