4.5 Chapter take-aways

In this chapter we extended the qualitative research efforts described in Chapter 3 to gain deeper perspectives on ASHA social dynamics and some of the key themes that emerged from the FGDs and KIIs.

ASHAs report that they view themselves as part of a community of frontline workers. They describe consulting each other for advice and suggestions for how to navigate complex situations. For example, ASHAs mentioned consulting each other about paperwork required by facilitators and supervisors. Their interactions with other ASHAs are positive overall, but not without some conflict. For example, there is clear disapproval and conflict over violating norms regarding recruitment of beneficiaries outside of their own catchment areas (but such conflicts are probably rare, overall).

ASHAs also reported challenges associated with beneficiaries moving from their marital to their natal homes prior to birth. This can have the effect of disrupting service delivery and prevent beneficiaries from building long-term trusted relationships with ASHAs.

The incentive structure imposed by the health systems may impair an ASHA’s ability to organize their service delivery in ways that would maximize efficiency. For example, ASHA reported that the timing of their visits are dictated by discrete incentivized behaviors, rather than being determined by critical points of potential influence in the perinatal journey. Some also described an inability to organize their own time, and instead often have priorities dictated by superiors on short notice. One consequence of this is that ASHAs visit families at inopportune times. For example, ASHAs report visiting families shortly after birth, a stressful time to provide health care information, and often too late to effectively impact behavior. Visiting during the pregnancy, particularly early on in the pregnancy could potentially provide the ASHA an opportunity to build a trusted relationship with her beneficiaries and to educate and influence multiple target behaviors during the same visit, rather than only the behavior being incentivized.

Support:

ASHA’s families provide extensive professional and personal support. ASHA’s report that their family members’ support is essential for them to fulfill their job duties. For example, their husbands help with paperwork and transportation, and their daughters and MILs provide help with childcare and domestic chores.

Embeddedness and Liminality:

These ethnographic observations provide many examples of how being a member of the communities they serves impacts ASHA job performance. For example, ASHAs describe a sense of personal responsibility to the community as a core motivation for their jobs. ASHAs indicate strong senses of obligation to promote the health of women and children in their communities. They indicate persistence in the face of sporadic and delayed payment. They describe feeling a sense of pride in their work, and indicate awareness of community appreciation. For example, ASHAs discussed the fact that beneficiaries reach out to them to seek out information and resources, and thus they do not have to rely exclusively on reaching out to beneficiaries themselves. Beneficiaries value the services ASHAs provide to such an extent that they would protest if an ASHA tried to quit. ASHAs reported viewing the role of an ASHA as a gateway to more highly skilled health occupations (e.g., ANM).

Many ASHAs reported the need to carefully and diplomatically navigate complex challenges with multiple stakeholders. For example, ASHAs described a need to handle controversial topics with care and sensitivity in order to ensure community acceptance. ASHAs also appreciate the vital role they play in providing beneficiaries with access to the health care system. For example, several ASHAs discussed the fact that beneficiaries reach out to them to help them navigate health infrastructure and services.

ASHAs also describe challenges associated with fulfilling their job responsibilities as well as meeting the needs of their families. ASHAs are women who are raising their own children, and have substantial domestic responsibilities. They also lack the age-related status of older women, and thus must carefully negotiate domestic responsibilities with their families. A source of tension for ASHAs is to be perceived as competent mothers and leaders of a household while also being good community healthcare workers.