2.7 Setting the Stage for Project RISE Analysis

In these two opening chapters we have presented the Project RISE philosophy of data-driven behavioral change. Several approaches to CHW research and behavior change support key aspects of Project RISE’s approach. Certainly there is wide agreement that to understand CHW performance and motivation, we need more data, greater attention to intrinsic factors, greater attention to CHW connections to communities, and we need approaches that go beyond linear connections between payment systems and a narrow range of outcomes.

As a consequence of using a ritual lens to examine the complexity of inputs and drivers that affect ASHAs in Bihar, we identified three critical implications.

2.7.1 RISE Big Three

Lived experience - to understand how an ASHA might affect change in behavior it is important to understand her connection to it. ASHA’s are also mothers and like all of us they draw from their own experiences and perceptions, which in turn are passed through the perspective gained from training and work experience. Rituals identify how people make sense of the world, how they delineate life stages and groups, and contribute to a sense of trust. Because the ASHA is a connector, her lived experience with perinatal ritual and behavior provides a key vantage point on how she grows into her role as a cultural broker and also how she might view some types of behavior as more responsive to change than others. 

Connectedness - behaviors do not exist in isolation. Many behaviors that might be seen as simple outcomes of a behavioral change intervention are in fact parts of constellations of inter-related behaviors and beliefs. In order to diagnose an effective strategy, these connections need to be documented and understood. Doing so may identify opportunity areas as well as barriers that need to be understood and planned around. Opportunities because sometimes adjacent behaviors or beliefs may be more readily nudged or altered than a target behavior, thus providing a window for intervention. Or we may find that some behaviors are much more difficult to alter than others and therefore present obstacles to work around.     

Embeddedness - by definition, community healthcare workers are from the communities where they work. This embeddedness is over-looked in terms of the constraints and opportunities it presents for understanding CHW motivation and behavior. Embeddedness can lead to unforeseen tensions between health workers and beneficiaries [e.g., quadrants figure]. ASHAs must adhere to many of the same norms of the mothers they are influencing and these likely place constraints on they type and content of messaging that can be leveraged for persuasive argument. 

2.7.2 Synthetic Outputs

Between this Introduction and the synthesis chapters at the end of the report are several chapters that each report a different analysis of a main RISE datastream. These data chapters are focused on methods and empirical results. The main synthetic outputs, drawing from all of the datastreams, include: A Ritualization Tool

A ritualization tool leverages the Project RISE perspective as a way to diagnose how behaviors connect, who influences them, and what degree of normative resistance there might be in cases where a behavior needs to be directly changed, as opposed to introduced. The tool will be useful for the design of research strategies and for the process of intervention design. It will identify blindspots as well as opportunities to nudge behaviors or find opportunity areas for affecting change. The tool itself will exist as a product outside of this report, so that it can be readily adopted to other behavior change scenarios, but the rationale and process for building it a description of its content are presented in the last section of this report.

While the ritualization framework is built from Project RISE data, it is designed to guide other behavior change initiatives in other contexts.

We first started thinking about this framework (ritual tool/taxonomy/etc) after comparing the behaviors affected by ASHAs and Dais, noting that ASHAs were ‘outside’ the household, in concept and in behaviors influenced by them, and that Dais were ‘inside’ the household. This came initially from the FGD/KII results but received a lot of support from the quantitative data too.

From there, we gradually built two organizing concepts for the tool: ritual taxonomy and ritual friction. A ritual taxonomy is used to diagnose ritual (or cultural or normative) viscosity, or the settings where behavior interventions will likely encounter more or less resistance and where that resistance might come from.

A ritual taxonomy: A ritual taxonomy is an organized description and categorization of the rituals documented by Project RISE during the perinatal journey. The description should include the nature of the behavior/practice, where it occurs, the culturally associated ‘why’ it occurs, the influencers associated with it, and the broader beliefs that it is connected to. This should build on the Project RISE emphases of connectedness and systemic view of ‘influence.’ One example of this, discussed in detail in later chapters, is the connections between concealing the pregnancy and ANC registration. Side-by-side these seem quite different but they have an important link. The cultural/normative drivers for concealing are so strong and pervasive that they exist in most cultures of the world. One should not blame a woman for wanting to conceal her pregnancy until she feels comfortable sharing the news, and we also empathize with the ASHA that this natural tendency to conceal prevents access for messaging and in turn uptake of some key behaviors at a critical time. For instance, the earlier ANC registration happens, the more likely a woman is to complete her full IFA regimen, which most women do not do. The key influencers associated with concealing a pregnancy are different than those with ANC registration or IFA (indeed, hardly anyone influences concealing the pregnancy because it is so pervasive and normal).

A goal of the ritualization tool is to formalize and extend this way of thinking to include the broader suite of behaviors that Project RISE is studying. Ideally, a ritual taxonomy would identify the following factors:

  1. function or functions of the ritual/behavior/belief

  2. influencers, those who inform the woman about the behavior and especially those who affect the probability that she actually does or doesn’t do it

  3. obstacles that may stem from other behaviors/practices that are connected to it or perhaps a physical distancing that occurs due to the ritual that makes messaging difficult

  4. how the practice is transmitted, meaning identifying if it is learned from parents/neighbors, if it is sacred/religious, or derived from other source

Ritual friction:

Ritual friction is a measure of resistance that incorporates beliefs and values of culture and norms. In some cases, ritual could make cultural system have less friction toward a new idea or practice. A cultural setting with high friction is one that connects to lots of reinforcing meanings and beliefs or is widely practiced, or is key to showing your affiliation to an important group. Basically, these are hard to change because they are highly valued, connected to multiple value systems, or are strongly influenced by important cultural figures. If we are introducing a behavior that is similar to one that people already like to do and does not conflict with any core values, then the friction is low (and the behavior relatively easier to change). If we are introducing a behavior that is tied to many core beliefs and must actually displace or re-align some of those beliefs, then friction is high. In Project RISE there may be some cases where we are confronting both impurity and evil eye and tightly held values. Numerous Facts, Figures, Descriptions, and other Findings about Perinatal Behavior in Bihar

Project RISE has made every endeavor to be well-informed and the mixed-methods research approach was the vehicle for doing so. In what follows we present a wealth of data and information that covers qualitative data (e.g., focus group discussions), borrows from ethnography, vignettes as used in psychology, questionnaires that collect extensive and detailed quantitative information, vignettes, and the capstone method of interviewing the interviewers who collected much of the data.

Over the course of the next seven chapters in the Data Streams Section, we make every effort to present a clear and accurate depiction of a complex suite of behaviors and beliefs. Some readers (skimmers and swimmers) may want to skip to the synthesis. Note that each chapter has an abstract and labels ‘take-home messages’ as ways to aid the reader in a hurry.

Next, we turn to the data…