0.14 Emerging Insights and Implications

The Project RISE data set and a great deal of analysis and co-design led to the identification of four insights that harness this ritual framework to improve ASHA motivation and performance. Combined with a ritual framework and the key guiding ritually-derived concepts of lived experience, connectedness, and embededness, these insights will be explored for service-oriented tools to assist the ASHA in her role:

  1. ASHA embeddedness raises unique tensions that affect her motivation and performance.

  2. ASHA interactions are impactful but access is missing during critical time periods.

  3. The Perinatal Journey is shaped by complex inter-connections of behaviors and motivations.

  4. ASHAs are the primary influencer for some behaviors, and only one among many for others.

Across the dynamics and results we observed, we identified a common goal – to help resolve ASHA tensions that emerge due to her liminal role between the health system and community. This led to a few general points. First, seek ways to resolve personal and familiar tensions related to her job. Second, help her build strong networks with other community influencers to resolve tensions within the community and to solidify or facilitate trust that can lead to new messaging opportunities. Third, build strong networks with other CHWs and health-system actors to resolve tensions related to the health system and to ensure more peer-to-peer support and awareness of the behavioral change components of ASHA work. Fourth, to use all these insights to facilitate a shift from service extenders to cultural facilitators. This can be done by helping ASHAs invest in relational strengths associated with embeddedness, resolve tensions associated with liminality by leveraging connectedness and lived experience, and to improve access to beneficiaries.

Suggested ways to implement a ritual approach came directly from ASHAs in remote co-design sessions conducted via Whatsapp (details in Chapter 10). ASHAs have valuable lived-experience and whenthat can be levereged to identify solutions to some of the problems they or the system faces. Current protocols and trainings tend to overlook this key and valuable aspect of the ASHA as an ‘embedded’ health worker.

To work around periods of the perinatal journey when ASHA access is limited, ritual-based interventions may want to facilitate interactions that occur early and often. Opportunity areas include marriage or time before the first pregnancy so the ASHA can deliver messages especially pertinent to the times when she has less access (early pregnancy and first few days postpartum). This is a chance to build rapport but also to begin health education earlier, so the mother is informed about practices before the window of access for the ASHA is more restricted. The relationship with the Dai is another opportunity area. Perhaps this could be leveraged as part of a homecoming ritual involving the Dai, family, and ASHA.

Another factor interfering with ASHA access at critical points is the common practice of mothers returning to their maternal homes to give birth. This is only a potential issue because the mother is more likely to have some relationship and familiarity with the ASHA near her husband’s family’s home but may not be familiar with the ASHA near her own mother’s home. For this reason we suggest a ritual to facilitate an ASHA to ASHA transition ASHAs near the parental home help connect engaged girls to the new ASHAs in their in-law’s village.

Most of the following Report focuses on the raw data and its analysis that leads not just these four opportunity areas but many empirical findings as well. The specific design process used to move from the datastreams to these opportunity areas is summarized in Chapter 10).