12.5 ASHAs are primary influencers

Many of our 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 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 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 8 shows the influence of several different types of potential influencer on perinatal behavior and finds that ASHAs have the strongest positive influence (8.7) 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 8.6, Figure 8.4).

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 specific 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 earliest 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.

12.5.1 Limitations in Reach

While the ASHAs are effective, there are numerous cases of limited reach and to improve their impact it may be necessary to identify barriers to contact or access. Quite a few of the mothers surveyed did not receive a home visit during pregnancy (~22%). The number of women going a full trimester without an ASHA visit decreases from the first to the third trimesters (412 did not receive a visit in the first trimester, 210 did not in the second, and 164 did not in the third).

Many women did not receive a post-natal care (PNC) visits during the first week after birth. Of the 1200 women surveyed, 632 (52.7%) did not receive a postpartum home visit in the first week after birth.

The official guidance to ASHAs regarding home visits is more specific postpartum than it is during pregnancy. ASHA guidance does not seem to specify a target number of ANC visits, recommending instead to build community rapport and meet with mothers and families anywhere that seems logical or convenient. The guidelines indicate that home visits with pregnant women should occur regularly, but does not specify a schedule or target number. In contrast, there are specific guidelines for PNC visits. ASHAs are instructed to meet with mothers and their newborns five times in the first 28 days after delivery, and once every two weeks from the 42nd day until the child is two years old (http://nhm.gov.in/images/pdf/communitisation/asha/book-no-6.pdf.).

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.

The survey also asks mothers about visits with the ASHA outside of the home or if the ASHA sends her messages through a family member. We found that 46% of recent mothers said they had a health-related visit with an ASHA outside of their home and 39% said they received health-related advice that an ASHA delivered to them via a close relative. Moreover, 23% said yes to both of these questions. These alternative routes may be an important method for ASHA messaging.

Of the 260 mothers who did not receive a home visit during pregnancy, 81 met with the ASHA outside of their homes, leaving 179 (14.9%) with no direct ASHA contact during pregnancy. Lastly, we also ask mothers if they received health related messages from their ASHA that was sent through a family member, of which 468 (39%) did. However, there were still 155 (12.9%) recent mothers who did not receive a home visit, meet with an ASHA outside of their homes, or receive health messaging from the ASAH via a family member.

In sum, many women received just one visit during pregnancy (12.8%), or no visits at all (21.8%), and the other means of making contact (visits out of the home or messaging through a relative) still left many mothers out of the ASHA’s reach for messaging and services. Perhaps it is more critical to identify factors that limit ASHA reach and coverage than it is to focus on her personal efficacy in extending services.

12.5.2 Program vs Person

The general descriptions of ASHA – mother contacts make it clear that high ASHA efficacy has the problem of limitations in reach. For example, just over 20% of the mothers surveyed did not receive a home visit during pregnancy. ASHA guidelines do not specify a target number of visits during pregnancy but they do stipulate that visits should occur. A recent analysis of ASHA performance in Uttar Pradesh by Smittenaar et al. (2020) suggested that ASHAs should visit an expectant mother “as soon as possible after learning she is pregnant and 4–6 times over the course of the pregnancy.” This suggestion seems reasonable and if taken as a target median number of visits would require an increase of 1 to 3 visits per pregnancy in this sample.

To disentangle the factors that might lead to high efficacy, on the one hand, and insufficient reach, on the other, we think it is important to distinguish between the ASHA-as-person and the ASHA program. As individuals, ASHAs have high efficacy, but efficacy that could be better leveraged or enhanced with support and training. As a program, there may be certain factors that limit or constrain the ASHA workforce. For instance, transportation is a commonly mentioned difficulty of the job. ASHA catchment areas are based on approximate population estimates and may vary considerably from one ASHA to another. This variation in catchment-size could inadvertently lead to some households being more difficult to reach than others. Another job-related factor for the ASHA is monthly or seasonal variation in the number of pregnant women within a catchment. In our data for 400 ASHAs, the number of pregnant women in a catchment area at the time of the survey varied from 0 to 41 (most had from 5 to 11) and likely varies quasi-randomly (by season or chance) during the year, which could cause sudden jumps and reductions in workload that are beyond the ASHA’s control.

Another factor that affects ASHA reach is a common practice whereby mothers move back to their natal households to give birth, so they can be near their parents and immediate families. This indirectly affects ASHAs because expectant mothers are more likely to be acquainted with the ASHA’s near their husband’s family home.

ASHA programs also routinely add duties to what ASHAs are asked to do in their communities. Examples of this include conducting households surveys for some other government health initiative (outside of typical ASHA duties) or assisting with drug administrations or camps/workshops on special topics. ASHAs report that polio vaccination rounds are especially cumbersome and may conflict with their local duties. The number of additional tasks that ASHAs are asked to assist with likely increases during the pandemic.

The question then becomes how to increase the number of ASHA-mother contacts, given how valuable such contacts are for increasing the uptake health behaviors? Timely ANC registration may be especially important to encourage because of previous findings that ASHA - mother interactions that begin early and often lead to more uptake in other behaviors (Smittenar et al., 2020). This points to a cascading effect that happens as women associate recommended health behaviors with ASHAs that are more likely to adopt several, such that seemingly distinct behaviors seem inter-connected.


Schaaf, Marta, Caitlin Warthin, Lynn Freedman, and Stephanie M. Topp. 2020. “The Community Health Worker as Service Extender, Cultural Broker and Social Change Agent: A Critical Interpretive Synthesis of Roles, Intent and Accountability.” BMJ Global Health 5 (6). https://doi.org/10.1136/bmjgh-2020-002296.