Project RISE Report
Preface
0.1
Format of this report
0.2
Skimmers, Swimmers, and Divers
0.3
Searchable tables
0.4
Audience for the current version of this report
0.5
Project RISE Collaborative Structure
0.5.1
Project RISE Timeline
0.6
Acknowledgements
0.7
Software
I EXECUTIVE SUMMARY
Executive Summary
0.8
What is Project RISE?
0.8.1
Project RISE Central Concepts
0.8.2
Project RISE Goals
0.9
Data Types and Methods
0.9.1
Sample overview
0.10
A Ritual Lens and Project RISE
0.10.1
Replacement, Conflict, and Complementarity
0.10.2
Most Rituals are Motivated by health promotion or risk aversion
0.11
What does it mean to be in between?: The under-appreciated role of liminality
0.12
Dai – ASHA Comparison
0.13
ASHA Efficacy in Behavior Change
0.13.1
ASHA Efficacy and Issues of Reach
0.14
Emerging Insights and Implications
II INTRODUCTION
1
Topic and Place
1.1
Purpose
1.2
Brief Overview of the ASHA Program
1.3
Bihar
1.3.1
Bihar Health Care System
2
Rationale
2.1
Project RISE Purpose and Motivation
2.1.1
Project RISE data streams
2.2
Project RISE in the Context of Previous Research into CHW Programs
2.2.1
Community Health Worker (CHW) Research
2.2.2
CHWs and India
2.2.3
Social and behavior change communication (SBCC) in the CHW health context
2.3
Why Ritual?
2.4
Rituals and Extrinsic vs Intrinsic Motivators
2.4.1
Ritual-Based Behavior Change
2.5
The COVID-19 Pandemic and Project RISE
2.6
Organizing Concepts
2.6.1
A Nested-Social Ecology
2.6.2
Insights hiding in plain sight
2.7
Setting the Stage for Project RISE Analysis
2.7.1
RISE Big Three
2.7.2
Synthetic Outputs
III DATA STREAMS
3
Qualitative Part 1: Focus Group Discussions and Key Informant Interviews
3.1
Purpose and Procedure
3.2
Perinatal ritual
3.2.1
Chhati
3.3
Food & diet
3.4
Perception of CHW and Dai
3.5
Chapter Discussion
3.5.1
ASHA’s role prioritization and expectations from the system
3.6
Chapter take-aways
4
Qualitative Part 2: Extended discussions, ASHA interviews, focal follows, and participant observation
4.1
Purpose and Approach
4.2
Data Excerpts from Ethnographically Derived Qualitative Fieldwork
4.2.1
Coded Summary of Ethnographic Findings
4.2.2
Excerpts from ethnographic case studies
4.3
Key themes from the Ethnographic Methods
4.3.1
Support
4.3.2
Doubly powerless
4.3.3
Being in Between
4.3.4
Motivation
4.4
Chapter Discussion
4.5
Chapter take-aways
5
Qualitative Part 3: Interviewing the Interviewers
5.1
Purpose and Procedure
5.2
Table of Responses
5.3
Chapter Discussion
5.4
Chapter take-aways
6
Quantitative Part 1: Sample Overview and Description of ASHA’s Role
6.1
Purpose and Procedure
6.2
Survey context and methods
6.2.1
Existing descriptive summaries
6.3
Sample characteristics & ASHA-Mother comparison
6.4
Perception of ASHAs
6.5
ASHA Workload and Remuneration
6.5.1
Challenges of Workload
6.5.2
Incentives and ASHA Motivation
6.5.3
ASHA Support
6.6
Chapter take-aways
7
Quantitative Part 2: Behavioral Overview
7.1
Purpose
7.2
The Behaviors
7.2.1
Variation in the coded behaviors
7.3
ASHA Training and Experience Change ASHA’s own Maternal Behavior
7.3.1
ASHA Respect with Time as an ASHA
7.4
An ASHA Interaction Score
7.4.1
Effects of ASHA Interaction on Perinatal Behaviors
7.5
ASHA Interaction and Overall Uptake of Biomedical Behavior
7.5.1
Component parts of ASHA Interaction Score
7.5.2
Factors Predicting Greater ASHA Interaction Scores
7.6
Do ASHA - Beneficiary Differences Impact Service?
7.7
Chapter take-aways
8
Quantitative Part 3: Influencers and Reasons
8.1
Purpose and procedure
8.2
Influencer Counts/Percentages
8.2.1
How to Interpret These Figures
8.2.2
Influencers, percent association for each behavior
8.2.3
The “other” influencer category
8.3
Quantifying Influencer Effects
8.3.1
Methods for Building Statistical Model of Health Behavior
8.4
Results from ‘The Big Model’
8.4.1
Biomedical Behaviors
8.4.2
Neutral Behaviors
8.4.3
Neutral Behaviors and being in between
8.5
Overall Influencer Effects
8.6
The Perinatal Journey by 1000 (38) Bar Graphs
8.6.1
Early pregnancy
8.6.2
During Pregnancy
8.6.3
Near Delivery
8.6.4
Post-Partum
8.7
Reasoning
8.8
Chapter take-aways
9
Vignettes
9.1
Purpose and Overview
9.1.1
ASHA-Mother Vignettes
9.1.2
ASHA-only Vignettes
9.2
The Vignette Data and Coding
9.2.1
Vignettes and Questions
9.2.2
Vignette Raw Data
9.3
Summary and Implications of the Results
9.3.1
ASHAs knowlege as agent of behavioral change
9.3.2
Potential areas identified to target for service delivery improvement
9.4
ASHA-Mother Vignettes Results
9.4.1
Across-vignette analyses
9.4.2
Question 1
9.4.3
Question 3
9.4.4
Question 2
9.4.5
Question 4
9.4.6
Question 5
9.4.7
Effects of Vignette
9.5
Individual Vignette Descriptions
9.5.1
Colostrum
9.5.2
IFA Tablets
9.5.3
Exclusive Breastfeeding
9.5.4
Vaccine-Pregnancy
9.5.5
Vaccines-Infancy
9.5.6
Institutional Delivery
9.5.7
Family Planning No Children
9.5.8
Family Planning
9.6
ASHA-Only Conflict Vignettes
9.6.1
Conflict between recommendation and own history.
9.6.2
Conflict between maternal duties and ASHA duties.
9.6.3
Mother not respecting ASHA nor her recommendations
9.6.4
Mother disagrees about best practices.
9.6.5
An ASHA does work on another ASHAs territory
9.6.6
Doctor is rude to a Mother for not doing recommended practice
9.6.7
Doctor is rude to ASHA
9.6.8
ASHA has too many duties simultaneously
9.7
Chapter take-aways
IV DESIGN
10
Design Thinking and the Human Centered Design (HCD) approach in Project RISE
10.1
Introduction to Design Thinking and Human-Centered Design
10.1.1
What is HCD?
10.1.2
Relevance of HCD in public health
10.1.3
What is the value that HCD brings to Project RISE?
10.2
Overview of the design phases
10.3
Phase I. Discovery: Understanding the Present
10.3.1
Purpose and Process
10.3.2
Defining Research Objectives
10.3.3
Mixed method research and data collection
10.3.4
Mixed Method Analysis
10.3.5
Data Synthesis through Four Domains
10.3.6
Four Opportunity Areas
10.4
Ritualization Strategy Framework
10.4.1
Four Elements to Ritualize Behaviours
10.5
Phase II. Define - Creating a Vision
10.5.1
Purpose and process
10.6
From opportunity areas to Design Drivers
10.7
Design Lab: from insights to action
10.8
HMW Themes: Expert feedback
10.9
Prioritizing HMW Theme directions for co-design
10.10
Phase III: Create - Drafting a Path to Future
10.10.1
4.1 Purpose and Process
10.11
Co-design for HMW Theme 1B
10.11.1
Objectives and Recruitment The main goals of the first set of co-design sessions in December 2020 was:
10.11.2
Remote Co-design considerations
10.11.3
Synthesis
10.12
Co-design for HMW Theme 1A
10.12.1
Objectives and Recruitment
10.12.2
Lessons Learned
10.12.3
Synthesis
10.12.4
Emerging Ideas
10.13
Ideation and concepts
10.13.1
9 Concepts
10.14
Prototyping the Future Family Tool
10.14.1
Selection, Objectives & Recruitment The main considerations for prototyping were:
10.14.2
How the Future Family tool works
10.14.3
Prototyping results
10.15
Ritualization Intervention System
10.16
Chapter take home messages
10.17
Annex - external resources
V SYNTHESIS
11
Ritual Narrative
11.1
Purpose and Procedure
11.2
Background
11.3
The Narrative
11.3.1
Pre-Pregnancy
11.3.2
First Trimester
11.3.3
The Second Trimester
11.3.4
Third Trimester
11.3.5
Labor
11.3.6
Delivery and Early Postpartum
11.4
Postscript
12
Discussion
12.1
A Ritual Lens: Most rituals are intended to promote health or avoid risk
12.1.1
Coexistence
12.1.2
Implications
12.2
ASHAs are effective service extenders but this overshadows their potential as cultural facilitators
12.2.1
Implications
12.3
Liminality and the Foundation of the ASHA Program
12.3.1
Understanding ASHA Positioning and Access
12.4
ASHAs are primary influencers
12.4.1
Limitations in Reach
12.5
Mixed Methods Case Study: From concealing the pregnancy to IFA tablets
12.6
Tensions from Liminality
12.7
Motivation
12.8
Guiding Principles
12.9
Conclusion
Appendix
A
Ethnographic Documents
A.1
Case Studies
A.1.1
Family Planning Day with SMA01
A.1.2
Family Planning Day with SMA02
A.1.3
Interview with SMT01
A.1.4
Home Based Newborn Care (HBNC) with SMA04
A.1.5
Home Based Newborn Care (HBNC) with SMA04
A.1.6
Home Based Newborn Care (HBNC) with SMA05
A.1.7
Ante-natal Care (ANC) Day with SMA05
A.1.8
Interview with Dai
A.1.9
Monthly Meeting of Satmalpur ASHAs and SMF03 & Delivery with SMA10 at PHC
A.1.10
Interview with SMA10’s Beneficiary (Delivery Case)
A.1.11
Interview with PHC Mamtas
A.1.12
Interview with SMA01’s Husband
A.1.13
Interview with SMA11 (Infant Mortality Case)
A.1.14
Interview with ANM, SMF01 & SMA01 (Infant Mortality Case)
A.1.15
Interview with ASHA (SMA01) (Call recording)
A.1.16
ANM & Facilitators Monthly Meeting with MOIC, BHM & BCM
B
Appendix B: Vignette Supplementary Analysis
B.1
ASHA-Mother Vignettes
B.2
Effects of Vignette
B.2.1
Question 1: Why did the mother choose/not choose to follow her ASHA’s recommendation?
B.2.2
Question 3: What do you think the ASHA said/could have said to persuade the mother to do the recommended behavior?
B.2.3
Question 2A:Who makes the decision? 2B: Why does this person make the decision?
B.2.4
Question 4: Was there any conflict between the mother and her ASHA/family member?
B.2.5
Question 5A: What should the person communicate to resolve the conflict? 5B: Who initiaties the resolution?
B.3
Individual Vignette Descriptions
B.3.1
Colostrum
B.3.2
IFA Tablets
B.3.3
Exclusive Breastfeeding
B.3.4
Vaccine-Pregnancy
B.3.5
Vaccines-Infancy
B.3.6
Institutional Delivery
B.3.7
Family Planning No Children
B.3.8
Family Planning
B.4
ASHA-Only Conflict Vignettes
B.4.1
Conflict between recommendation and own history.
B.4.2
Conflict between maternal duties and ASHA duties.
B.4.3
Beneficiary not respecting ASHA nor her recommendations
B.4.4
Beneficiary disagrees about best practices.
B.4.5
An ASHA does work on another ASHAs territory
B.4.6
Doctor is rude to beneficiary for not doing recommended practice
B.4.7
Doctor is rude to ASHA
B.4.8
ASHA has too many duties simultaneously
References
PROJECT RISE GITHUB LINK
A Ritual Lens Reveals the Importance of Embeddedness for Understanding Community Health Workers
12.7
Motivation