2.2 Project RISE in the Context of Previous Research into CHW Programs

While many studies have sought to evaluate and improve the performance of ASHAs and other CHWs, sustainable gains have been somewhat elusive and seem hampered by insufficient quantity and/or quality of interactions with beneficiaries. Because previous outcome-oriented approaches to evaluating CHW efficacy have yielded mixed results, there is a need to focus on intrinsic motivations and lived experiences of CHWs (RISE 2018).

To set the stage for Project RISE’s rationale and approach that views lived experience and intrinsic motivators as necessary components of sustained behavioral change interventions for CHW programs, we briefly review some recent research on CHWs in general, CHWs in India, and how this research overlaps with the Social and Behavioral Change Communication (SBCC) community.

2.2.1 Community Health Worker (CHW) Research

Here we briefly review CHW research in general with the intent of identifying trends and findings in past studies as well as demonstrating how Project RISE differs from, or adds nuance to, existing research.

CHW programs are common around the world, especially in rural and low-resource areas (Liu et al. 2011), but exist in high income settings as well.

Overall, CHW programs have positive effects on health behavior (Exemplars 2020). For example, CHW efforts in Mozambique helped lower the prevalence of childhood under-nutrition by 30%. In Pakistan, Neonatal mortality has gone down by 28%. In the countries of Bangladesh, Malawi, and India, maternal mortality has been reduced by 37%. However, most countries with CHW programs are lagging behind MDGs (Prachitha, Dhume, and Subramanian 2019) and most efforts designed to make sustainable improvements in CHW performance have had mixed and/or short-lasting results.

As such, numerous efforts have been made to evaluate these programs for efficacy and means of improvement. Here we briefly summarize some of the findings that seem especially relevant to Project RISE.

Across evaluations of CHW programs, a recurring finding is that there is little consensus on how to effectively make interventions that unambiguously and sustainably improve CHW performance. Put another way, there is a lot of discussion about what does not work, and relatively few definitive suggestions about what does work. Notably, little is known about best practices for designing effective interventions for CHWs. Most of the previous efforts focus on extrinsic motivators (e.g., financial incentives) and a direct outcome, like a percent increase in compliance for a target behavior. These tendencies contribute to the Project RISE motivation to include a broader set of behaviors and sources of influence in the same analysis, and especially to the need for a more complete perspective on CHW motivation.

Studies of extrinsic motivation often focus on the incentive (payment) system. CHW incentive systems are highly variable, from volunteer, to salaried, to those who are paid incentives for certain behaviors, as is the case for ASHAs in Bihar. Studies have focused on how variation in incentives affects variation in performance or if payment plans are predictive of which behaviors CHWs are most likely to impact.

A review of healthworker motivations by Okello and Gilson (2015) extends this finding in making the crucial point that most studies focus on external factors, but that intrinsic factors are perhaps more important for understanding health worker motivation and behavior. Intrinsic factors are also much less commonly studied. Trust between community members and CHWs is extremely important as is a feeling of fulfillment for the CHW. They suggest that the following motivational factors contribute to fostering trusting relationships: respect; recognition, appreciation, and rewards; supervision; teamwork; management support; autonomy; communication, feedback and openness; whereas staff shortages and resource inadequacy can damage trust. These factors likely affect many of the ASHAs in Bihar.

In another extensive review of incentives and motivation, in part motivated by a recent WHO guidance document on CHW programs (reviewed below), Ormel et al. (2019, 10) found that: “intrinsic motivational factors are important to and experienced by both types of CHWs, yet for many salaried CHWs, they do not compensate for the de-motivation derived from the perceived low level of financial reward.”

Trust was also emphasized as a key factor for facilitating good relationships between CHWs and communities in a study by (Kok et al. 2017); “Sometimes, constrained relationships between CHWs and the health sector resulted in weaker relationships between CHWs and communities.” They also noted that poverty combined with irregular or uncertain payments has a negative effect on CHW-community relationships, which is certainly a dynamic that could affect ASHAs in Bihar. Another finding was that clearly defined tasks had positive effect on community trust (Kok et al. 2017).

An extensive review of CHW programs by Schaaf et al. (2020) focused on the ways CHWs act as a ‘bridge’ between communities and the health care system. This important point is very much reinforced by Project RISE. They summarize three ways that the literature has characterized this bridging function:

  1. Service extender: a service has difficulty reaching a segment of a population, and the CHW extends the reach of the service

  2. Cultural broker: sometimes the CHW addresses cultural differences or mistrust. This can happen in two pretty different ways. One is to distill biomedical information for beneficiaries in culturally appropriate ways. Another is to communicate the needs of the community to a health care system that may seem foreign or inaccessible.

  3. Social-change agent: here, the authors focus on the CHW as a community mobilizer, someone who socially engages the community and helps facilitate social-change movements. The second ‘A’ in ASHA is for ‘activist’ but certainly this kind of ‘bridge’ function is not a function typically fulfilled by the ASHAs in Bihar. In some ways, the definition of ‘social change agent’ as used by these authors, which included the term ‘liberator’ was a bit more specialized than implied by the task. However, at times ASHAs certainly strive to achieve changes in behavior.

In many ways, the ASHA program focuses on service extender role but less so on the other two. That is, ASHAs extend the reach of the health care system by bringing service to beneficiaries (or beneficiaries to services) and less so on reporting back to the health care system about the needs of the communities or on developing a platform for social change. The discussion in this review Schaaf et al. (2020) is quite broad and encompasses many types of CHW programs, so we would make some adjustments for the ASHA case, but we certainly augment the finding that CHWs (ASHAs) are focally a bridge and that there are different ways to accomplish this function. Notably, an aspect missing from the ‘social change agent’ bridge function is one of being a persuasive extender of health care services. That is, we suggest that another key type of bridge function might be a combination of all three of these factors, as there are times when CHWs extend services but encounter cultural differences and must become persuasive social change agents to convince someone to change their behavior. Project RISE will also develop a taxonomy of behaviors that helps diagnose the kind of tensions and associated tools that ASHAs need as they serve as a bridge. The WHO guidance document on CHW programs

The World Health Organization (WHO) made a thorough review of CHW programs in an attempt to identify common features leading to better performing programs (World Health Organization 2018). This resulted in 18 recommendations. Each of these is accompanied by a rating for the certainty of the evidence that supports the recommendation. Only one of the 18 recommendations is rated as having ‘moderate’ support whereas the remaining 17 are ‘low’ or ‘very low.’ That so many recommendations had low empirical support points to a need for more studies on the subject. These gaps in certainty and scope for their 18 recommendations led to what is probably the most robust directive of the report: to do more work on CHW programs to understand what underlies performance.

Across the 18 recommendations CHW motivation does not occur, but improving community engagement does. The report mentions motivation, but as a desirable trait to have in individuals that CHW programs recruit. That is, a motivated CHW would be preferable to recruit over an unmotivated one. They also found that some general non-monetary incentives could be important for CHW motivation, including: “respect, trust, recognition, and [sic] opportunities for personal growth, learning, and career advancement,” which are factors that could be addressed by Project RISE.

In general, studies have emphasized the role of personal motivation in remuneration and incentive systems and stressed the importance of community involvement. Very little has been done on intrinsic motivators or use of community rituals as way to facilitate CHW - beneficiary connections.

2.2.2 CHWs and India

Here we focus on CHW program research based specifically in India.

The ASHA program in India is the world’s largest CHW program and of course many studies have also been conducted to examine it specifically (Smittenaar et al. 2020). One such study surveyed 2208 recent mothers in Uttar Pradesh and found that increased contact with CHWs4 led to increased awareness for requirements for ANC visits, IFA tablets during pregnancy, and tetanus injections (Lyngdoh et al. 2018). The only health behaviors that went up in frequency with CHW interaction were tetanus injections and timely initiation of breast feeding. Their overall finding was that knowledge and practice of key behaviors was low among beneficiaries and that most did not improve with frequency of CHW interaction. In setting up the study the authors note that India is behind schedule for Millennium Development Goals for infant mortality and the maternal mortality ratio and that CHWs are used in many places to ‘fill the gap’ between actual and desired health levels. Given their findings, they see a lot of room for improvement and encourage finding new ways to improve the quality of CHW care.

Another study looked at the effects of payment schedules on the performance of ASHAs and AWWs in four states of India (Andhra Pradesh, Chhattisgarh, Odisha (Orissa), and Uttar Pradesh) (Koehn et al. 2020). Because ASHAs are paid incentives for particular behaviors and AWWs are paid a salary, the authors sought to identify if any differences in effectiveness of each type of CHW would be predicted by these differences in payment schedule. They essentially assumed that if interactions with AWWs were associated with a higher proportion of women self-reporting that they engaged in healthy behavior that this improved effectiveness would have been ‘caused’ by the difference in payment system. For our purposes, we emphasize their finding that women who had been visited by an ASHA were significantly less likely to have engaged in several health behaviors, and were more likely to have engaged if they had been visited by an AWW. They also suggest that ASHAs had better performance with paid services than with unpaid services. Their findings that ASHAs may have an overall negative effect on uptake of recommended health behaviors is worrisome, but is certainly one that can be examined with Project RISE data and one to keep an eye out for in terms of evaluating the influence of ASHAs on health behaviors in Bihar. We further note that this paper is ‘recent,’ published in 2020, and focuses almost exclusively on financial reward as the primary driver of CHW efficacy, again indicating the novelty and ambitious uniqueness of Project RISE’s emphasis on intrinsic factors and ritual.

Note further that both of these recent studies found mixed (Lyngdoh et al. 2018) or negative (Koehn et al. 2020) evidence that ASHAs were increasing the health levels of their beneficiaries.

A study by Kosec et al. (2015) also focused on the relationship between outcome and incentive, specifically in Bihar (Bhojpur district). They make a distinction between information-oriented services and product-oriented services. Information-oriented services are those that require the transmission of guidelines and knowledge from CHW to beneficiary, which includes behaviors like the recommended best practices for pregnancy care or nutritional advice. Product-oriented services are those that have a direct uptake of a good or service, like an immunization or the delivery and consumption of a supplement. This distinction in service types, between information-oriented and product-oriented, could be useful for distinguishing different types of messaging or anticipating the nature of resistance to a service initiative that an ASHA might face.

Further, product-oriented services are reported by more households as being received and financial incentives improved performance, in terms of the number of houses that reported receiving the service (Kosec et al. 2015). They make the recommendation that program organizers should be “optimizing existing incentives for FLWs [CHWs] in national programs, helping FLWs [CHWs] better organize their work, and raising awareness among groups who are less likely to access services.” From Project RISE’s perspective, there is some potential to address the organization of work, but, more importantly, the areas of motivation and performance that were not addressed by this study, like motivation and individual experiences, are indicative of the major gaps between evaluation and CHW lived experience; gaps that Project RISE hopes to address.

A recent study by Smittenaar et al. (2020) has particular relevance for Project RISE because of using mixed-methods and focusing more on the ASHA’s experience and how she connects to beneficiaries. For instance, this aspect of their study’s rationale is very much in agreement with the RISE approach (Smittenaar et al. 2020)

“Most studies of CHWs are descriptive, for example, capturing CHWs’ level of clinical knowledge or the number of visits they make. Explanatory studies of the mechanisms by which CHWs achieve impact (or fail to) are needed. Such insights can be used to guide the development of CHW programs.”

They focused on ASHAs in Uttar Pradesh, India, a neighboring state to Bihar, and interviewed 5,469 recent mothers, 3,064 of their husbands, 3,626, of their mothers-in-law as well as 1,052 ASHAs.

Their study shows that visits from ASHAs that occur early and often during pregnancy leads to greater uptake of a number of recommended health behaviors, including taking IFA tablets and having an institutional delivery. Likewise, during delivery 57% of women surveyed had an ASHA present for institutional births, and the presence of an ASHA resulted in “respectful care, early initiation of breastfeeding, and exclusive breastfeeding, but not with delayed bathing or clean cord care.”

They also looked at what kinds of messaging ASHAs used for each behavior and who in the household other than the mother might influence decisions about maternal care. These are both key aspects of the Project RISE study design in that we associate a ‘who’ and a ‘why’ for each behavior we included in our quantitative study. They found that the most common messaging used by ASHAs were financial arguments, such as -this service is free so might as well…- and that normative arguments like -everyone is doing this- were the least common. They also found that some behavioral counseling should be directed at the beneficiary (the mother), such as IFA tablets and getting checkups, but for other behaviors, such as institutional deliveries, the messaging should be directed to the husband or mother-in-law.

“Previous research often recommends that ASHAs improve their communication skills (Sudhinaraset et al. 2016), but specific recommendations are lacking or based on small qualitative samples. ASHA training gives general communication tips but lacks specific recommendations to influence households on key behaviors and rarely mentions involving other stakeholders within the household. We found that many ASHAs did not use many behavior-change messages that could have been effective in driving higher rates of ANC visits and ID Institutional Delivery. They need to learn when to apply different messages and which individuals in the households should be counseled to achieve greatest impact (which may or may not be the primary decision maker). Our findings suggest that on average, the ASHA should target the pregnant woman for messaging about IFA and checkups, the husband and MIL for ID Institutional Delivery, and the MIL regarding postnatal care behaviors. Cultural barriers can inhibit the ASHA from talking to the husband or MIL (Sudhinaraset et al. 2016), so supervision and peer-learning structures may support ASHAs in solving these challenges”

Project RISE extends this framework of considering multiple influencers, both within and outside the household, on maternal decision making as well as to learn more about other factors in the ASHA’s personal experience and background that shape her approach to interfacing with the community.

2.2.3 Social and behavior change communication (SBCC) in the CHW health context

The literature on social and behavior change communication (SBCC) is voluminous, with large bodies of work in both applied and academic settings. Here we wish to highlight how Project RISE fits into some current thinking on this complex topic (without providing an in depth review of all literature on the topic). SBCC approaches leverage ‘communication’ as a powerful means of human interaction with the goal of improving social dimensions of health5. These ‘social dimensions’ include norms, values, attitudes, beliefs, and culture, all of which are addressed by Project RISE in the context of community perception, ritual, and behavior as they relate to the perinatal journey and the ASHA’s endeavor to improve the uptake of healthy practices.

A recent USAID (USAID 2019) synthesis of SBCC interventions across the continent of Africa stressed the importance of community engagement and fostering a sense of trust between beneficiary and health worker. SBCC interventions that were ‘top down’ and did not include locals within the communities of interest were described as especially weak. Interventions that are ‘essentially dialogues’ with local communities were much more effective because they reinforced or established trust with system actors. The co-design process in the later stages of RISE facilitate a dialog between the designer of the interventions and the community.

The following abridged excerpt of this USAID review’s key findings (USAID 2019) helps set the stage for how aspects of Project RISE’s approach to behavior change builds on and complements some of these broader themes in the SBCC community:

“This summary of key findings highlights some of the SBCC good practices that hold the potential of helping to restore trust and/or reinforce trust between system actors and that improve and sustain social and behavior change outcomes.”

  1. “Promoting a Sense of Self-Efficacy: Change comes about when people feel that they can accomplish and sustain it.”
  1. “Leveraging the Power of Praise: Praising individuals and communities for adopting new behaviors and practices that lead to positive results can increase overall impact.”
  1. “Branding the Messages: In creating a national brand for a SBCC intervention, campaign designers seek to foster a nationwide identification with the effort to achieve behavior change goals. A branding exercise helps to reinforce the essential SBCC activities undertaken at the community level and keeps communication partners and other advocates of behavior change”on message.””
  1. “Building upon Existing Values and Social Norms: When messages that advocate for broad social and behavior change draw upon existing social norms and values in communities, it is easier for communities and individuals to trust the message and the messenger and then to adopt new behaviors and practices.”
  1. “Capitalizing on Existing Networks: SBCC studies caution against viewing behavior as essentially individual, or within households analyzed as discrete units (intra-household). That is because this may unduly constrain one’s ability to understand behavior as collective and shaped through interhousehold influence at the community or local level. Influencing behavior change within existing social networks often means having insiders within these social networks—people who are trusted—buy into a proposed behavior as well as promoting and modeling it. Such insiders may be early adopters of the proposed behaviors, faith leaders, and/or positive deviants who have spontaneously practiced the desired behaviors.”
  1. “Learning from the Community through Formative Research: The community participation principle also applies to the formative research carried in the form of a dialogue out to help design SBCC interventions. The researcher listens to community members to identify and build on existing positive behaviors. The next step is to identify existing values, beliefs, and social norms that can often be used to advance the adoption of desired behaviors, and to encourage communities to identify barriers to change and ways to overcome them.”
  1. “Promoting Community Participation in SBCC Intervention and Service Delivery: When system actors—elected officials, appointed officials, service providers, etc.—work collaboratively or achieve shared leadership with a community, this can lead to better SBCC results and cost-effective, sustained transformations.”
  1. Extending Culturally-Effective Formats to the Broadcast Media: The use of traditional mass media (radio and TV) for the scale-up of behavior change in Africa has been ubiquitous. The vast literature shows that the general principles of community participation (using interactive formats such as call-in shows, interviews, and panel discussions) may have greater impact than unidirectional messaging, in part because of the cultural resonance of these interactive formats.”
  1. “Promoting Empathetic/Effective Interpersonal Communication: Top-down, unilateral messaging from system actors—public officials, health officials, etc.—are often ineffective, and in crisis communication can easily backfire. When system actors express empathy, concern, and compassion, the effectiveness of their communication is improved.”
  1. “Optimizing the Use of Community-Based Media: Local radio stations, whether community, religious, or commercial, typically have a strong impact on audiences because community members normally perceive a local station as their own, thus increasing the trust factor and giving credibility to the messages.”
  1. “Deploying Culturally Appropriate Communication Formats: The use of culturally appropriate motifs and methods can enhance the effectiveness of government-led SBCC efforts.”
  1. “Using Community Monitoring of Public Service Provision: A community participatory approach to monitoring has led to significant behavioral changes that improve educational and health outcomes, and active community monitoring/oversight improves the quality of service delivery. Further, it can also create conditions for improving citizen trust in government and enhancing the legitimacy of the state and its actors.”

Project RISE aims to improve the self-efficacy and empowerment felt by ASHAs (Point 1). Rituals can potentially facilitate self-empowerment and trust relationships, as can improvements in tools that reduce cumbersome features of a job or increase access to support systems.

Concepts of reward, praise, and status-elevation can accompany company community rituals (Point 2). It may also be the case that improved recognition, community standing, or even branding can change the nature of praise.

After a first round of synthesis and co-design, Project RISE has also stressed the importance of branding the role and message of ASHAs (Point 3). Ritual can be a part of this.

One of the Project RISE “Ritual-Based Behavior Change Principles” stresses the importance of capitalizing on existing behaviors and rituals (Point 4). Further, an awareness for possible tensions between new and existing beliefs, practices, or behaviors will be important in Project RISE design.

One of central premises of Project RISE’s philosophy is that behaviors do not exist in isolation (Point 5). Likewise, one of the key social functions of rituals is to facilitate social bonds. Some social networks are held together by ritualized behavior.

Likewise, mixed-methods approaches are central to the Project RISE research and co-design process (Point 6).

Project RISE won’t focus directly on actors like elected and appointed officials, but this broad point about collaboration and local support is important to keep in mind (Point 7), especially in terms of emphasizing the theme of local buy-in and community involvement.

There is some potential for Project RISE to leverage media on mobile device technology as some aspect of the design-intervention (Point 8).

For Project RISE, prompting empathetic and effective communication will be an important ideal goal to pursue (Point 9). The emphasis on empowering the ASHA directly reflects this recommendation to not use uni-lateral top-down messaging.

While community-based media may not be central to Project RISE (Point 10), general insights about the effectiveness of different types of messaging and their sources can be tangentially informative.

Project RISE hopes to incorporate a wide understanding of the ASHA’s personal experience, combined with community beliefs, rituals, and knowledge in part to use ‘culturally appropriate communication formats’ (Point 11).

Monitoring is not a central focus of Project RISE (Point 12), but understanding what makes for an effective system of engagement and self-correction could factor in tangentially. Moreover, we again see the emphasis on community involvement.

Another key SBCC concept comes from a recent text on the subject (Sunstein 2020). In many cases it is better to think about tweaking a behavior rather than changing it, and it may be better to focus on constellations of behaviors rather than study target behaviors in near isolation. Some behavioral change researchers have noted the importance of ‘nudging’ behaviors rather than attempting to coerce people into new behavioral patterns. Sunstein (2020) defines a behavioral nudge as follows: >A nudge is defined as an intervention, from either private or public institutions, that affects people’s behavior while fully maintaining their freedom of choice. A GPS device is a canonical example. It tells you what route to take and thus helps you get where you want to go – but you specify the destination, and you can reject its advice and take your own route if you prefer. A default rule is a nudge, so long as you can easily opt out. The same is true of warnings and disclosure of information.

This supports the Project RISE rationale of placing behaviors in context. Studying lived experiences and rituals provides opportunities to identify ‘nudges’ and can help avoid the pitfalls of studying single behaviors in isolation. In fact, rituals are often cultural nudges for a variety of behaviors. Rituals that mark the transition from one stage to another typically reinforce the behavioral expectations of the next phase (transition to adulthood, marriage, graduation). Rituals that mark group affiliation certain nudge the participants to conform with the behavioral expectations of the group they are joining.

Take-Home Messages: CHW and SBCC Research

Across the above discussions of CHW research and SBCC approaches to health-sector interventions, we emphasize the following main points:

  • Studies highlight the need to understand more about CHW motivation and that many of the existing recommendations are either of narrow scope or based on limited empirical support.

    • This further motivates Project RISE to study a broader set of behaviors and sources of influence in the same analysis
  • While the literature tends to emphasize monetary factors and outcomes, trust is the main exception. Trust has been repeatedly shown to have a big impact on CHW performance and on the connection between CHWs and communities. This same research has emphasized respect, recognition, and communication, which could all be enhanced with rituals that link CHWs to beneficiaries.

    • Trust can be hampered by payment systems.
  • While incentives have been over-emphasized in previous studies, which is part of the reason for emphasizing intrinsic motivators here, their role shouldn’t be ignored either. Perhaps extrinsic motivators can be understood from perspectives other than: reward -> behavior.

  • The Smittenaar et al. (2020) study has perhaps the most to offer Project RISE. They go beyond previous work by considering ASHA strategies and the roles of multiple influencers to a mother’s health decisions.

  • The WHO SBCC advice of engaging the community, facilitating trust, and having awareness for messaging platforms and context are among the valuable recommendations from this community.

  • Project RISE will leverage the power of ritual in ways that are consistent with many of the WHO report’s findings, but that also extend this research area into new areas.


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  1. For this study CHWs included: ANM auxiliary nurse midwives, ASHA accredited social health activist, AWW Anganwadi worker, and SS (Swasthya Sakhi)↩︎

  2. many SBCC organizations exist. here’s one: https://healthcommcapacity.org/about/why-social-and-behavior-change-communication/↩︎