2.1 Project RISE Purpose and Motivation
The “RISE” in Project RISE signifies the goal of understanding and leveraging ritual to improve service-delivery and empower health workers.
More specifically, the purpose of Project RISE is to understand the rituals, motivations, and social dynamics of ASHAs and to use this knowledge to devise solutions for sustainable improvements in the frequency and quality of services to new and expectant mothers and women of reproductive age. The Project RISE approach entails keeping an open and intentionally assumption-free mind about the factors that motivate CHWs, in general, and to realize that behaviors do not exist in isolation but, rather, are part of complex systems that receive inputs from many sources with different systems of reasoning. Rituals can be leveraged as a gateway into these complex cultural systems (Legare et al. 2020). In designing an intervention that studies a single behavior, there is a risk of not seeing enough of the ‘forest’ to find solutions that either tweak individual behaviors or that address other issues that surround constellations of behaviors. Likewise, this ritual-oriented approach focuses on the ASHA’s lived experience, the behaviors and beliefs that guide her own decision-making, as a mother and as an ASHA. This entails sources of influence on behavior and the reasoning used to guide it.
Project RISE researches social, psychological, and environmental factors that are barriers or amplifiers to health-promoting behavior. We then use this information to design and pilot a set of service solutions to improve the quality of care among CHWs (RISE 2018).
Project RISE uses a mixed-methods approach. This means that we gather many types of data that provide vantages on ASHA behaviors, perception, and patterns in ways that can capture intrinsic motivations and the systems that influence behavior and belief. We explored the perspectives of both ASHAs and their communities (beneficiary population, other health and non-health influencers) throughout all project RISE data streams. In short, this approach helps to root our understanding of ASHA motivation in context.
The vehicle for this context, and for finding a kind of ‘glue’ that can link the complexities of social and psychological inputs to health behavior, is ritual. Rituals are socially stipulated normative behaviors. Rituals are practiced by all human societies and surround aspects of our hygiene, diet, and feelings about other individuals and groups (the concept of ritual is discussed in more detail, below).
In order to formulate a comprehensive assessment of ritual and ritualized behaviors practiced by ASHAs and their beneficiaries, Project RISE combines social scientific research with human-centered design, which in combination will be used to co-design and test solutions that target barriers to frequent and high-quality health service delivery. Human-centered design is a creative problem-solving process used across sectors, including increasingly in addressing complex health and development challenges in low-resource settings.
In line with this rationale, Project RISE seeks to achieve the following outcomes:
- understand (via thorough documentation and analysis) the motivations, rituals, and social dynamics surrounding service delivery of ASHAs
- use the research to co-design new service-based solutions that directly address the psychological, social, and cultural roots of the current suboptimal delivery of services among ASHAs and to test the service concepts to develop clear proofs of concept
- articulate a strategy for implementation and impact evaluation and disseminate key findings.
This Report covers the efforts made to reach these three aims, in general, but with particular emphasis on the empirical aspects of Project RISE. This includes discussion of the rationale and motivation for decisions of what data to record, and how, as well as overviews of the raw data and associated analyses. Much of this effort will fuel goal 3, above, as the analyses supplied herein will inform the findings that are disseminated both here and in other outlets (slide decks, publications, etc.) as well as undergird service-based solutions in outcome 2. In this sense, this Report is a Project Manual (it is a living document that covers the approach, methods, and outputs), a repository for Project data and resulting analysis, as well as a record of the Project’s motivations, rationale, and major findings.
The end goal of harnessing ritual as a tool to facilitate motivation, respect, community-CHW trust and involvement, is fundamental to the Project RISE approach.
By building on existing research and employing an innovative mix of research methodologies, Project RISE aims to generate new understanding of CHW behaviors, needs, and rituals (RISE 2018).
2.1.1 Project RISE data streams
Project RISE investigates a series of complex social topics (motivation, health behavior, ritual) with an applied objective to modify behavior and improve health. This requires a strong empirical foundation that includes accurate descriptions of health behaviors, community rituals, and beliefs, as well as the way influencers and cultural values shape health behavior. The Project RISE team realized that multiple data streams would be necessary to confront these challenges.
Our mixed-methods approach included qualitative and quantitative approaches.
| Qualitative | Quantitative |
|---|---|
| Ethnography | Survey/questionnaire |
| Focus group discussion | Behavioral Vignettes |
| Key informant interviews | |
| Design |
Ethnography: Ethnography is a collection of mostly qualitative methods used to observe and interact with a study’s participants. While there are many variations in ethnography, the goal is usually to emphasize depth over breadth, meaning intensive time spent with a few key informants as opposed to exhaustive surveys. In ethnography, smaller sample sizes are intentional; rather than quantify, they achieve depth and seek novel insights and nuanced perspectives. Ethnography is interested in capturing culture, or shared knowledge and common practices to identify key themes and issues, especially issues that were not previously recognized. The Project RISE ethnographic work was conducted by a trained cultural anthropologist and two research assistants who worked in the Samistpur district of Bihar for about six weeks.
Focus Group Discussions (FGDs): Focus group discussions are semi-structured group interviews with a small group of people with a shared background or experience. FGDs are usually intended to capture ideas, opinions, or beliefs about a topic. Project RISE conducted 40 FGDs; 20 with recent mothers and 20 with mothers-in-law.
Key Informant Interviews (KIIs): Key informant interviews are similar to FGDs but without the small-group format (they are with just one individual). For Project RISE, KIIs were conducted with influencers who could not readily be recruited into small groups. Project RISE conducted fifty KIIs; 12 with Accredited Social Health Activists (ASHAs), 11 with Anganwadi Workers (AWWs), 10 with Dais, 6 with Rural Medical Practitioners (RMPs), 5 with Pandits, and with 6 Mulanas.
Questionnaire: Extensive quantitative survey covering a wide range of demographic factors, health behaviors, perceptions of health system and health providers. Quantitative questionnaires were conducted with 400 ASHAs and 1200 recent mothers. The mothers were recruited from the catchment areas of the ASHAs we surveyed.
Behavioral Vignettes: short stories that include contextual information about a decision related to a key Project outcome. They allow researchers to manipulate contextual information and include follow-up questions. By controlling the content of vignettes, Project RISE could experimentally examine the impact of particular information on how participants reason and make judgments. One advantage of vignettes over survey questions is that they provide more context for participants to reason about and reflect on. The design of vignettes also allows for a first or third person perspective, which provides complementary insight. Vignettes were conducted with 291 mothers and 146 ASHAs, the majority of whom were the same individuals who completed the quantitative survey.
Design: Human-centered design research was also conducted in parallel to these other methods. These are primarily qualitative research methods, that include FGDs but also card-sorting, projective techniques and other activities centered on visualizing or giving form to knowledge to provide interviewees stimulus on which they can reflect as they respond. In the final stages of the Project, design-based methods will be brought back in to lead the co-design of prototypes for behavioral interventions. This involves input directly from ASHAs in Bihar.
These data streams are meant to complement each other as we build a synthetic picture. The qualitative discussions (FGDs and KIIs) and the ethnography were done in the early part of Project RISE in order to inform the content of an extensive quantitative survey and also to give deep personal perspectives and nuance. These efforts in turn informed the design of behavioral vignettes.
All of these efforts inform the human-centered design. Project RISE will design service-based solutions to improve quality and frequency of ASHA interactions with beneficiaries. This will involve a process of co-design of solutions with ASHAs and community representatives, then testing, refining, testing, and refining with the ultimate users of these until we have established several proofs-of-concept ready to be more formally piloted.