9.1 Purpose and Overview

To complement the quantitative survey tool, we presented a series of vignettes to both Mothers and ASHAs that described conflicts about recommended biomedical practices informed by our qualitative data. Vignettes are short scenarios presented to Mothers and ASHAs as third person situations that they in turn react to. Respondents reason through scenarios about fictional people in circumstances similar to what they have experienced. These vignettes allow us to gather information on the underlying reasons for certain beliefs and behaviors, and especially what kinds of arguments are seen as requiring active persuasion or if barriers to affecting the reasoning process exist. We probe the reasoning process by altering the decisions made by the characters in the vignettes and ask respondents for corresponding justifications.

We did two types of vignettes. The first were given to both Mothers and ASHAs and involve reacting to the decision of another mother in the community. The second were given just to ASHAs and involve depictions of other ASHAs in scenarios concerning potential conflicts that ASHAs might face carrying out their duties.

We give overviews for each of these two types of vignettes, then we present the raw data from the study, then a summary of overarching themes, and lastly a discussion.

9.1.1 ASHA-Mother Vignettes

Mothers and ASHAs were presented with eight vignettes, each of which depicted a hypothetical situation about a specific interaction between an ASHA and a mother. Each participant then answered six questions responding to the hypothetical situation in each vignette. These questions intend to reveal nuances related to perceptions, values, and social norms. Additionally, the situations depicted in the vignettes were further sub-divided into two conditions. In one, the mother in the vignette responds consistently with the biomedical recommendation (i.e., she does the recommended behavior, called the ‘consistent’ condition) and in the other she responds inconsistently (she does not do the recommended behavior, called the ‘inconsistent’ condition).

The exact text of the vignettes is presented in the next section. The eight behaviors in them are:

  1. colostrum feeding
  2. taking IFA tablets
  3. exclusive breastfeeding
  4. institutional delivery
  5. family planning before any children
  6. family planning after already having children
  7. vaccinating during pregnancy
  8. vaccinating the infant.

In the ‘consistent’ condition, the mother follows the ASHAs recommendation to participate in the behavior. In the ‘inconsistent,’ the mother does not follow the recommendation of the ASHA. Participants were then asked questions for each vignette that covered six key themes. The following are the broad forms of each of these six questions, the exact text of each question is in the next section.

  1. Why did the mother choose/not choose to follow her ASHA’s recommendation?
  2. Who typically makes this decision?
  3. What do you think the ASHA could/should have said to persuade the mother to do the recommended behavior?
  4. Was there any conflict between the mother and her ASHA/family member?
  5. How is that conflict resolved? Who initiates the resolution?
  6. When should mothers be told about the recommendation on the perinatal journey?

9.1.2 ASHA-only Vignettes

In the second type of vignettes, ASHAs were presented with eight vignettes designed around possible scenarios ASHAs may encounter in their roles. These were hypothetical situations about an ASHA involved in a conflict with a Mother. Here, the exact number of questions varied slightly between vignettes, depending on what was appropriate for that vignette. In addition, there was only a single condition with a more open-ended outcome for the ASHA to answer, rather than react to different decisions.

The eight ASHA-only vignettes targeted different sources of conflict:

  1. conflict between an ASHA’s own history and current recommendations
  2. conflict between an ASHA’s work duties and current duties as a mother
  3. a Mother who disrespects an ASHA
  4. a Mother disagreeing with the recommended practice
  5. a conflict with other ASHAs
  6. a doctor being rude to mothers
  7. doctors being rude an ASHA
  8. an ASHA having too many responsibilities

The questions had the following forms, made appropriate for the specific vignette context:

  1. How should the ASHA in the vignette handle this conflict?
  2. Should the ASHA discuss with other ASHAs how to handle this conflict?
  3. How common is the form of conflict?
  4. Why would this form of conflict arise?
  5. How frequently have you had to deal with this conflict yourself?

In addition, further questions were asked that were specific to each vignette. We detail them on the next few pages. The appendix has the complete set of all vignettes and questions in full.