9.3 Summary and Implications of the Results

9.3.1 ASHAs knowlege as agent of behavioral change

Overall, ASHAs see themselves as agents of behavior change who promote adherence to biomedical practices. Most ASHAs believe they are respected in the community and by the medical system. Most also recognize that the conflicts described in the vignettes do happen, but feel that they are not very common.

ASHAs like their role and view themselves and the ASHA program as successful. Mothers and ASHAs agree about best practices as well as about the causes and solutions to conflicts. ASHAs have more specific health knowledge than their beneficiaries, but they share similar explanations for recommended behaviors.

9.3.2 Potential areas identified to target for service delivery improvement

Potential areas of improvement are also revealed by analysis of the vignette data.

Inspecting beliefs about how behaviors benefit health reveals some gaps in ASHA knowledge that could be filled with training. For example, ASHAs are widely aware of the benefits of the iron in IFA tablets, but seem unaware of the benefits of folic acid to prevent neural and spinal birth defects. This would be a powerful motivator for increasing uptake of IFA during pregnancy. ASHAs and Mothers recognize that knowledge gaps on the part of the mother are not the main reason for lack of compliance with recommended behaviors. Rather, social dynamics within the family can be the primary barrier. Critically, the most common strategy ASHAs report to overcome these barriers is to simply persist in explaining the health benefits of the recommended practice. This suggests that equipping ASHAs with more persuasive tools concerning the family social dynamics could be a benefit.

Mothers report many common concerns, such as miscarriage, during their pregnancies. A common theme mentioned to convince mothers to engage in the recommended behavior was for ASHAs to target their direct and specific concern rather than focus on the general health benefits of the practice.

ASHAs see Mothers as having more autonomy in their decision-making than the Mothers see themselves having. In comparing responses across vignettes, the Mothers give more decision-making power to their mothers-in-law. In addition, when there is a conflict between Mothers and members of her family about performing an ASHA recommended practice, the family sees it as the job of a Mother to make amends. Likewise, when there are negative social interactions with Mothers at the hospital, ASHAs reported that this can have longstanding negative effects between Mothers and the ASHA, in addition to reducing the desire of a Mother to return to the hospital for future medical services. The ASHAs did not have many solutions for dealing with these problems that would seem to be a comfort to Mothers.

Unless prompted, ASHAs rarely reported that they should seek help from other ASHAs when there is some form of conflict with families. However, the vast majority said it would be good to seek help when asked directly. Supporting ASHA-to-ASHA communication would be important to establish new norms in the health sphere, ultimately benefiting performance. Perhaps establishing this norm and encouraging discussion of best approaches to opposing family dynamics could be a targeted area of improvement.

ASHAs rely on their own family for support with their responsibilities (also often seen in our qualitative data). ASHAs prioritize their duties as ASHAs over their current duties as a mother, which causes minor consequences to their own children (i.e. missing a meal or some school). The reasons for ASHAs prioritizing their positions as CHWs is primarily because it is their responsibility, not because of the incentivization of their position. This is another key motivator seen in other data streams.