4.4 Chapter Discussion
Goals of ethnography are often focused uncovering what people actually do, rather than just what they say that they do. It uses triangulation of various observations to understand alignment of perspectives and how they reinforce each other in nuanced ways that emphasize depth over breadth. In this way, sample sizes are often exemplary rather than representative.
Here and in many subsequent chapters we find suggestions of a generational effect, whereby younger women might be more receptive to ASHAs than older women. To the degree that this generally true, interventions and health initiatives might need to understand how it affects uptake in a community. To what extent do we need to understand generational effects in evaluating the role of ritual surrounding an ASHA’s experience? Perhaps as the ASHA program has been around, women have had more exposure to ASHAs and a general sense of trust and familiarity has accumulated. The ethnography did document more of these subtle tensions than the other data streams, in terms of the ways that changing times affect the ASHA and those around her. For instance, on ASHA’s husband works for a PHC courier service, but he suffers from filaria and went a whole year without being able to work (in 2001). As a result, the ASHA had to manage her household and children, as well as make a living for the family. When she considered becoming an ASHA, she was worried that her father-in-law would not allow her to consider the work because in her role she would speak with men. However, the nurse who told her about the ASHA opening then said she’d speak to the father-in-law, because they worked in the same hospital, and told him that he had to learn to move with time. It worked and she became an ASHA.
One of the ethnographically-derived findings suggested that ASHA catchments with higher fertility sub-groups, based on religion, may seem to have better performance metrics and that ASHAs are aware of this and view it as a kind of inflation. We will need to try to capture the degree that caste, religion, or other social boundaries change the dynamics of beneficiary service. Is it possible that some social factors affect other aspects of ASHA performance? For instance, the ethnographic effort also suggested that wealth gaps may be another boundary that could limit beneficiary-ASHA interaction. Do some ASHAs look down on sub-groups (by caste, religion, education, or wealth) that seem to have higher fertility norms or whom are less likely to adopt recommended behaviors?
The ethnographically-oriented qualitative observations suggests that ASHAs are doubly powerless; they are often powerless with families and also with facilities. This theme certainly requires more exploration in terms of the degree to which it is true, as ‘felt’ by ASHAs in their lived-experience vs partially based on an ‘outsider’ perspective, especially given that ASHA services are clearly appreciated.
Family support seems vital to providing ASHA assistance in ways that improve performance and motivation. Should the ritual lens used via human-centered design find ways that this can that be leveraged or encouraged in some formal or ritualized way?
Broader community connections are important as well. One ASHA especially emphasized the importance of a good relationship with her village head (Panchayat), because they are needed for signing important documents.
In the following chapters we will revisit these themes and how they shape the Project RISE design process.