4.2 Data Excerpts from Ethnographically Derived Qualitative Fieldwork

4.2.1 Coded Summary of Ethnographic Findings

Naturally, these extended qualitative efforts generated a wealth of observations. To aid the reader in exploring them, a subset of key observations were coded to facilitate comparison with the other data streams. The following table contains these coded observations in searchable form.

Two general codes were added to the observations:

  • Implication: meaning a broad category for the aspect of ASHA engagement that the observation pertains to. The terms used here include: Motivation, recruitment, support, challenges, disrespect, appreciation, and conflict.

  • Spheres: meaning the nested spheres of interaction we use as a framework to describe the ASHA world (as explained in (Fig. 2.1)). The spheres are:

  • 1: Self and family (of the ASHA, i.e., ASHA-as-mother, ASHA-as-individual)

  • 2: Beneficiaries, the mothers to whom the ASHA provides services

  • 3: Community, the broader community to which ASHAs and beneficiaries belong

  • 4: The health care system, interactions with other health workers, hospitals and hospital staff, and ASHA training

Table 4.1: Searchable table of ethnographic observations

In the table above, a general search on the term ‘help’ reveals several instances of ASHAs reporting on the value of familial support in completing their duties in addition to a couple of observations of trials faced by the ASHA, like not being able to help a child get to an exam. A more extensive listing of ways that ASHAs receive support can be viewed by typing ‘Support’ into the search column above Implication. A potentially important observation for understanding the pressures an ASHA feels was coded as both Motivation and Challenge in the table: the importance to ASHAs of being perceived as competent and successful leaders of healthy and well-functioning households. This speaks some of the ‘betweenness’ of the role, as well as ways that being a CHW can perhaps bring types of pressure not immediately evident to those accustomed to office-based work environments.

4.2.2 Excerpts from ethnographic case studies

The ethnographic case-studies give deep insight into an ASHA’s day-to-day experiences. We chose a few exemplary excerpts to include here, but interested readers are encouraged to explore the full case-studies document, see Appendix A. Excerpt 1: Competing demands and difficult incentives

SMA05 [An ASHA identifier] says that sometimes women arrive just the night before their deliver from her in-laws with low Hb [hemoglobin] and swollen limbs. When this happens ASHAs are yelled at for not giving them IFA tablets and not having checkups done and the women are referred to sadar hospital and then to DMCH and if the work doesn’t happen then eventually to a private hospital. Women in this critical state prefer to go to a private hospital instead of traveling the distance to DMCH in Darbhanga. She says she hasn’t gone to Darbhanga but has gone to the private hospital with pregnant mothers. She says that some of these women have an Hb count of 4 and if the woman has to undergo delivery with that [such low Hb], even god can’t save her. On these cases, the patient is scared and doesn’t let go of the ASHA even if she goes to a private hospital. Sometimes looking at the patient’s condition, the private hospitals ask for huge amounts (as high as INR 50,000). The patients expect ASHAs to negotiate with the hospital in such cases [difficult situation!]. The doctors at the private hospital then tell ASHAs to take the responsibility for such cases. The ASHA sees this as a threat/warning (word “dhamki” was used by the respondent). She reiterates what she was told at the PHC when the woman was taken there with a low Hb count- the MOIC said “do you only get such patients?” In response, the ASHA told him that she had just come down the previous night. The doctor then said, “she will need blood and if we do the delivery here and something happens to her, would you (take the fall and) hang yourself in your house?” The patient was then taken to Sadar hospital from where they were referred to DMCH as there was no blood in their bank. She says that they finally decided to go to a private hospital. She says that for her it’s okay because ASHAs get incentives when the delivery happens at private institutions also. She says that two units of blood were given to the mother each costing INR 4500 - the mother went out of consciousness right after the child was born when the second unit was given- this would not have been possible at Sadar as there was no blood in their bank. Though it is written that the patient will receive blood if need be, it is never available in government hospitals.

Take-home message

  • Example of ASHA betweenness in multiple ways. She is not just connecting woman to health care, but navigating public and private health care systems, neither world to which she belongs.
  • Because the ASHA is part of the community, she bares responsibilities to beneficiaries in ways that other health professionals do not.
  • Example of a real job challenge - both the decision of which hospital to use but the costs and the reaction of the doctor. Excerpt 2: Challenges of Household and YouTube

ASHA (SMA05) tells RA about her interaction with a family who were visited earlier by the research team (family visited on 01/03/19). She says that on her seventh visit after delivery, the family behaved badly with her. They told her to keep her advice to herself as they are aware of the measures they are supposed to take after delivery. They said that they got their information through Youtube videos. ASHA says they were nice in the presence of the research team but the family (and the mother) was rude to her despite being less educated than herself. She says it’s not the caste (as they belonged to the same caste as the ASHA) but their financial status in the village that determines how they behave with the ASHA. She says that she is hurt by the incident and that she only visits them because it is her job to but now she should stop going back to that family. She again adds that if she stops her visits, the family will then complain about how they are not benefited by the ASHA and Anganwadi workers at all. However, when they need information about events like vaccination camp dates they turn to the ASHA - after the incident, the mother approached her requesting she lets them know about upcoming vaccination dates.

Take-home message

  • Example of ASHA betweenness as ASHA navigates a challenging household.
  • While the quantitative data suggests that use of YouTube is low, this is almost surely a situation that will become more likely with time. It is likely that access to the internet and other forms of digital technology will increase, and at some point very rapidly.
  • Note observation that wealth, rather than caste, is boundary to respect of ASHA’s advice. Excerpt 3: The Dai and observations of breastfeeding practice

Dai refers to the family visited on March 1st and says that the baby needs to be suckling for proper milk production and that instead of breastfeeding the baby is often just given a bottle. She says the mother is lying about not producing enough milk and that sometimes due to the drugs the mother is on there might be some issue with the amount of milk produced but often it gets better if the child is made to suckle irrespective of whether there is milk or not. She says instead of having the child nursed by the mother, they give him baby formula. She says the same happened with their first child as well where the mother did not breastfeed (even on Chhathi) - she knows because the family used to call her for massages when the child got cramps in their neck (sikri) after the mother got back after delivery from Muzaffarpur. The Dai says nowadays the educated women refrain from breastfeeding as it is increasingly becoming a symbol of fashion among them.

Take-home message

  • Role of Dai is complex too. Here she is promoting the biomedical recommendation and is an ally to the ASHA.
  • No other datastream captured this key observation, that a notion of fashionable practice can be a barrier to recommended breastfeeding practice. Excerpt 4: Education doesn’t always align with uptake, and an example of an ASHA frustration

ASHA (SMA05) on one of her HBNC visits, goes to a second family with a visible power differential with the ASHA in terms of money, education and social status. The new mother is a graduate (same as ASHA) and the father is an MBA who has worked in metros. The family however strictly follows traditional practices even when they go against instructions given by ASHA (and hence modern medicine). The team walks into a room where the mother is seated on a bed. There’s a Dai sitting on the floor in a space next to the bed and waiting for her turn to begin her work of giving massages to the mother and the infant. The mother-in-law sitting by the door with the infant in her lap feeding it cow’s milk and the older sibling sitting next to her. The mother is not able to breastfeed the baby as she is not able to produce any milk [so the medical advice is to keep trying to breastfeed in this situation to encourage milk production, correct?]. The ASHA at the same times makes the mother listen to a recording of the benefits of breastfeeding and the steps to follow when there is no milk; according to the instructions the baby needs to be kept suckling to set about milk formation. At the same time, and on the contrary, the disinterested mother listens to the recording while the mother-in-law is feeding cow’s milk to the baby in the same room.

Take-home message

  • Example of ASHA betweenness as ASHA navigates a challenging household where wealth is perhaps again a barrier but in this case an educated family prefers traditional practices over biomedical ones.
  • A biomedical v traditional distinction seems evident in the way the ASHA reasons about the situation.
  • We need to understand more about what the ASHA does (and should do) in a situation where she must advise on a biomedical behavior that conflicts with a traditional behavior. If she does this without acknowledging it, how will the community view her?
  • The mother seems disinterested in the message. Excerpt 5: An interesting recruitment story

ASHA (SMA04) narrates an incident that led to her recruitment [so how this ASHA became an ASHA] - she mentions a case of a sick child in her family who was born at SBH Patori and was extremely weak and sickly after birth. The ASHA who was looking after their case was not doing a good job (she now works in a different area) and hardly made visits other than the day of delivery. She says she had gone to visit the family when the grandmother expressed her concern about her infant grandson. ASHA [ASHA SMA04, who is telling the story about before she became an ASHA] then took the child to a private hospital. The child was given medicines by the doctor there and after taking one dose they came back to the house. The child was only 20 days old at the time and the grandmother, to expedite the process, administered a much higher dose to the child than prescribed. The child’s health was falling drastically soon after, the family went to ASHA [SMA04, again, before being an ASHA] for help. By the time she got there, the child was hardly breathing. They took the child to BB Jha hospital in Samastipur where the doctor looked at the child and referred him to a different hospital. ASHA [SMA04, pre-ASHA] took the child in her arms and went to see the doctor again insisting they start his treatment. She told him that she will take the responsibility for whatever happens and nobody will blame the doctor. She kept insisting until the doctor agreed to start treatment for the child. He [the sick baby] was given two shots of viral - 100 ml each, the child started making gasping sounds after that, the doctor asked to have the child’s clothes changed. ASHA sat with the child all night and recorded the time of his bowel movements to keep a track of his progress. By morning the condition of the child was much better. At the time of discharge, the doctor congratulated ASHA in front of the family and gave her the credit of saving the child’s life. She was even offered a job at the hospital to which ASHA replied that she is not qualified enough for the job and her house is very far from this hospital, [so even if she could take the job] she would end up spending her entire salary on commute. She then told them that she will speak to her family and consider the offer again. The doctor then informed her about ASHA positions and recruitment and that she should apply for the same. After coming home, ASHA went to the PHC and inquired with the ANM. ANM said that there are ASHAs who are even less qualified than her and are doing good work. [And that’s how she became an ASHA]

Take-home message

  • The potential motivational impact of positive feedback from healthcare system.
  • A touching story of ASHA recruitment.