8.8 Chapter take-aways

In this third of the quantitative chapters, we take a close look at the role of different influencers on affecting perinatal behaviors and the stated reasons associated with behavior. A key premise of the Project RISE rationale is that behaviors do not exist in isolation; they are connected to broader constellations of related behaviors, sets of beliefs, and sources of influence. This premise shaped the design of our survey such that we could link uptake of several behaviors to specific sources of influence and reasoning.

Opportunity areas include leveraging the connections ASHAs have with other health influencers to maximize the uptake of recommended behaviors and avoidance on non-recommended behaviors.


Our data reveal complex patterns of behavioral influence. The behaviors we studied vary substantially in a number of respects. First, some behaviors are associated with many influencers while others are associated with very few. ASHAs, ANMs, and government doctors influence the uptake of biomedically recommended behaviors and avoidance of non-recommended behaviors but have little or no influence on neutral behaviors (concerning traditional health practices and the involvement of Dais). This is noteworthy for several reasons. First, some of the neutral practices, such as rituals like Chhathi, have the potential to be leveraged as health-educational opportunities. This would require cooperating with Dais and family members who are the primary influencers for those behaviors.

Opportunity areas include providing ASHAs with targeted training on best practices for addressing behaviorally specific concerns, rather than exclusively discussing the health benefits of particular behaviors.

Embeddedness and Liminality:

We found beneficiaries frequently named ASHAs as sources of influence for biomedically recommended behaviors, and did so more frequently than ASHAs did when discussing their most recent pregnancies. This likely reflects the increased access to ASHAs in recent years, our beneficiaries have given birth within the last two years, much more recently than most ASHAs in our sample. Family and friends are mentioned most often for neutral behaviors, particularly for rituals such as Chhathi, for both beneficiaries and mothers. In general, biomedically non-recommended behaviors are also associated with, family and friends, with the exception of applying ointment to the cord stump and bathing within 24 hours, which are associated with a wider range of influencers (including Dais and RMPs). Notably, some behaviors are normative, for example, concealing early pregnancy and having a Dai attend birth are both very common behaviors, but not associated with a named influencer. Note that our analyses differentiated between mentions and effects, where mentions are how often a particular influencer was verbally or conceptually associated with a behavior and effects are the probabilities of actually doing each behavior.

We calculated each influencer’s effect on the probability that a beneficiary and an ASHA indicated that they had personally engaged in health-related behaviors. We found strong evidence that ASHAs are among the primary influencers of biomedically-recommended behaviors. Both ASHAs and government doctors strongly influence ANC early registration, institutional birth, TIBF, and colostrum feeding. ASHAs, government doctors, and ANMs are also the primary influencers of IFA tablets. Notably, ASHAs also strongly influence decisions not to engage in biomedically non-recommended behaviors. For example, ASHAs strongly influence decisions not to apply ointment to the cord stump and not to bath the infant in the first 24 hours. They also influence decisions not to fast while pregnant, not to avoid eating cereal after birth, and to limit physically taxing work while pregnant. Notably, government doctors, ANMs, and media also have a very strong influence on engaging in recommended behaviors and avoiding non-recommended behaviors (although the percent of women naming these sources of influence is relatively low).

Among ASHAs, training, media, government doctors, ANMs, ASHAs, and private clinics all had a strong influence on engaging in recommended behaviors and avoiding non-recommended behaviors.

Neutral behaviors were analyzed separately. Our analyses revealed that a different set of influencers impact decision making for these behaviors, for both beneficiaries and ASHAs. For example, the primary influencers of abstaining from sex, avoiding the market, celebrating Chhathi, isolating after birth, and consulting a Dai (before, during, and after pregnancy) were Dais, family, and friends. ASHAs, ANMs, and government doctors have very little influence on any of these behaviors.

The ASHA has the strongest positive effect on uptake of biomedically recommended behaviors and avoidance of non-recommended behaviors. We documented a nearly six-fold increase in the odds of following biomedical advice relative to those who did not identify an influencer, followed by the government doctor, then the ANM, and then the private clinic. The only influencer with an overall negative effect on these behaviors was the RMP. Older women and those higher in parity were progressively less likely to comply with biomedical advice than lower parity, younger women.

We find strong evidence of the nature of the ASHAs role being in between worlds. Notably, ASHAs have the strongest positive impact on the uptake of recommended biomedical behaviors and avoidance of non-recommended behaviors in our sample of 1200 mothers. ASHA has less influence on neutral behaviors, but actively participates in these, both during her own pregnancies and by attending the Chhathi ceremonies of her beneficiaries and interacting with Dais. Moreover, the ASHA is often a ‘middle influencer’ on neutral behaviors, having more influence than influencers actually in the medical system like doctors, and less influence than household influencers like the Dai or the family. ASHAs engage in the same perinatal health behaviors during their own pregnancies as their beneficiaries and identify roughly the same influencers. ASHAs have knowledge of these behaviors, and the local influencers that impact these behaviors that could be leveraged in health-promoting ways. This could mean that ASHAs require training in how to recruit other influencers to promote positive health outcomes, or at least in how to adopt and use messaging that is greatly different from their own lived experience, if necessary.

Opportunity areas include providing ASHAs with targeted training on best practices for collaborating with other health influencers, such as Dais and family members.