What they know about their work, barriers, and challenges faced by the community health workers while performing their multiple roles: mixed method study in India

INTRODUCTION

In the glimpse of past experiences, National Health Policy, National Population Policy, Millennium Development Goals and feedback of National Maternity Benefit Scheme, Ministry of Health and Family Welfare, the union government had decided to launch a new initiative; the National Rural Health Mission (NRHM).¹ It is one of the core initiatives to bridge the gap between healthcare delivery system to the community. The key component in achieving the objective is by ASHA ACTIVIST-a honorary volunteer from the community itself with minimum qualifications and trained to be the link volunteer for making the community meet its health needs to the health care delivery.² The generalize meaning of the word “ASHA” is; “accredited” means recognized by the community, “social” means she is from the same community, by the community and for the community, “health activist” means she has to spread awareness for health concerns and promotes change in health-related practices.³ To be an ASHA there are certain criteria and requirement to be match with, such as resident of the village with the age group of 25 to 45 years- married/widow/divorcee. She must have effective communication skills and leadership quality. The important function of ASHA is to be reaching out to the community when they need her. Along with the qualities, she should be a literate with a formal education up to 8^th class.⁴

ASHA works as a fountainhead of government and its health related services and programmes in her respective village and as the first port of call for health-related demands of the community.⁵ Her job responsibilities are three-fold, such as the role of a link-worker (facilitating access to healthcare facilities and accompanying women and children), that of a community health worker (depot-holder for selected essential medicines and responsible for treatment of minor ailments), and of a health activist (creating health awareness and mobilizing the community for change in health status).⁶

The success of NRHM largely depends on ASHAs’ performance as they are considered as the grass root level workers. The national guidelines stipulate that ASHA receives 23 days of training in the first year and 12 days of training every subsequent year thereafter. The training curriculum aims to impart the knowledge, skills and attitudes required of an ASHA to effectively perform their roles and responsibilities.⁹ She is accountable for delivering the existing health services to the community along with promoting good health practices.⁴ Hence, for effective service delivery ASHAs need to have a sound awareness and perception about their roles and responsibilities.¹⁰ Since ASHA programme is being implemented in 2005, there have been numerous studies evaluating the ASHA programme.¹¹

However, India with the wide range of cultural and economic background with the unequal distribution of healthcare services and programme and ASHA is crucial in achieving the aim and objective set under NRHM.¹² Reviews mentioned above reported several gaps linkage between the demand and supply side and also revels the latent importance of facing problems in their roles and responsibilities. In a broad sense we know that majority part of health care delivery is depends on community health worker, if they have partial knowledge and any sorts of barriers or challenges then it may impact in their performance level. Since it’s been fifteen years of journey they passed, it is needed to weigh up their knowledge and barriers, and challenges they are facing. If we will have in-depth information about their current knowledge and situation then it could help the oversee to fill the gap hence, current study has been designed to assess the overall knowledge of the ASHA workers, barriers and challenges faced during delivering healthcare among the community.

METHODS

Design, settings, participants and ethical consideration

A mixed method study was conducted in Narsan block Haridwar District, Uttarakhand State, India.

The quantitative approach was to measure the overall knowledge assessment related to the work performing by ASHA whereas the qualitative approach was used for in-depth interviews with the ASHAs regarding the barriers and challenges they are facing while performing their duties.

This study was conducted among selected ASHA workers of 12 selected PHC and one CHC. Quantitative data was collected among NHM appointed ASHA workers, present on the day of interview. The inclusion criteria for the both approaches were ASHA should have completed at least 1 year of service and willing to participate in the study. A purposeful sampling was done for both the approaches. Prior to data collection written informed consent was taken from the ASHAs and participants were given identification numbers to conceal their identities. Participants were informed of their rights to terminate the interview at any time and to skip any questions or topics that they did not wish to answer. Ethical approval was provided by the ethical review committee at AIPH (ERC protocol number 2018-38).

Data collection and analysis

A structured close-ended questionnaire was used in quantitative method and it began with assessing the demographic profile followed by their overall knowledge on the roles and responsibilities assigned to them. The qualitative data were collected till the information were saturated, total 16 ASHAs worker were purposefully selected for in-depth interview and the interviews were lasted for an average 40-50 minutes. A self-designed semi-structured questionnaire IDI guide was used with focus to mainly on the theme- duties, barriers and challenges faced by them while performing their multiple roles. Data were collected from the month of May 2018 to August 2018. In Quantitative approach descriptive statistics was used and data analysis was performed by using SPSS version 16. For the qualitative approach all interviews were collected by the female trained interviewer and digitally recorded, the translated from the local language to finally the translation were checked for the quality by all team members. Then codes and categories were generated as matched to the theme. Content analysis was done and disagreeing opinions on the contents of a theme were discussed and resolved by our team.

RESULTS

The socio-demographic profile of ASHA workers is depicted in Table 1. Mean age±SD of ASHAs was 35.85±6.7 years. Maximum 31 (56.4%) belonged to age group of 25-35 years. 47 (85.5%) were Hindu and 8 (14.5%) ASHAs belonged to Muslim community. Majority (61.8%) of ASHAs were educated up to or above senior secondary school and most of them were married (96.4%). 16 (29.1%) belonged to scheduled caste, 16 (29.1%) to other backward classes and 21 (38.2%) to general category. Majority (87.3%) were catering to a population of 1000-2000. Mean±SD population catered was 1891.85±384.27.

Knowledge on ANC and PNC

Majority of ASHAs were aware about the importance of Antenatal Care, 78% of ASHAs were know about that total ideal ANC visits are 4. About 73% of ASHA were know the importance of iron and calcium supplement during pregnancy but only 23% of them knows that iron should not be taken with milk product. Also 91% had the knowledge about the importance of colostrum milk, whereas all of them were know about the exclusive breast feeding up to 6 months. Majority of ASHAs (87%) knows about the 6 months post-natal care and 3 postnatal check-ups and 69% of them aware about the problems related to breast feeding.

Knowledge on child health

All of the ASHAs were having the utmost knowledge about the ideal birth weight of baby and immunization schedule and about 79% of the study participants were aware about the contraindications of immunization. Majority 52% of the ASHAs were aware about the birth defects of child. In case of knowledge assessment on diarrhoea, majority 76%, 69% and 47% of them aware about the symptoms, treatment and zinc supplementations during diarrhoea respectively.

Knowledge on programmes

Almost all the ASHAs were aware about different programmes launched by the Government of India but except maternal and child health programme they don’t have detailed and in-depth knowledge about the other programme like mental health and non-communicable diseases programme. About HIV/AIDS programme 52% of them were aware the main causes and route of HIV infection. They were also fully trained on identification of TB cases and 67% of them elaborated about the sign and symptoms of TB and 70% of the participants told about the referral system.

Knowledge on roles and responsibilities

Almost all ASHAs were aware about the basic sanitation and they know that prevention is better than cure and about 55% of them told that hand washing is the single most effective way to prevent numbers of diseases. Only 33% of them were able to name all the records available which need to be filled. Majority 83% ASHAs were aware about the fact that they need to send the children to Anganwadi centre. From the all-study participants, 70% know about the importance of nutrition. Majority 69% of the ASHAs knows about the importance of birth preparedness and family involvement in child birth, almost 73% of the ASHAs are creating awareness in mobilizing community for seeking appropriate and accurate care form the health centres. About 63% of the ASHAs were aware about their roles and responsibilities in providing directly observed treatment short course (DOTS) under revised National Tuberculosis Control Programme. Around 64% of the study participants able to correctly name the items, which are stored in depot and almost all the ASHAs, know that they are also responsible as a depot holder.

Knowledge on integrated work with Anganwadi worker

Almost all the ASHAs knew that they have different kinds of integrated work with the AW, while asking about the organizing health day, 74% of the ASHA workers told that in integrate way they are organizing once a health day monthly and rest are organizing twice a month. For creating awareness 32% of ASHAs, with the help of Anganwadi worker (AWW), are doing IEC activities quarterly once. Majority (71%) knew about mobilizing pregnant mothers and infants for nutrition supplements with the help of AWW.

Qualitative findings

The core thematic areas could be represented as personal, psychological, economic, social and environmental factors on the basis of their stimulation over the job of ASHAs in community health betterment.

Personal factors

The feeling of being able to do something by their own and not getting dependant on family income was clearly seen on their faces while answering. They were satisfied that as women in this society they are no more financially dominated. The families are also supporting them to work, as they stated. They are confident and happy about being self-dependant.

“I can remember when I came to this village for the first time after my marriage with Rajesh Ji. He used to give me some money for my personal expenses, hiding from my in laws. Ha..Ha..Ha! (She laughed remembering this) But now I can earn by my own and contributing in family expenses and study of my children. I am feeling confident.” (Translated) (IDI, ASHA).

“After his death (talking about her late husband), I was scattered thinking about the future of me and my children. Then I got this chance to become ASHA and this helped me in establishing myself financially and more than that I was able to divert my mind from the sorrow. I am running my home and looking after the requirements of my sons. I am stable now.” (Translated) (IDI, ASHA).

“We are self-satisfied and the feeling of being capable gives pleasure.”

At the same time family responsibilities are acting as barriers for the ASHAs while they are not being able to spare enough time to their families due to uncertain timings of their work. The working hours are not fixed, which is influencing their interest.

“Most of the time it happens, and we hear from our family members that what is the value of working for the community when you are not there for your family when we need you here with us.”

“My sister-in-law’s baby shower was next day, and I had to attain one case. I returned from the CHC and everyone looked at me like I am faking in the name of my job responsibilities to avoid my family responsibilities. It hurts (Got sad stating this).” (Translated) (IDI, ASHA)

Psychological factors

The psychological factors are nothing but most of the stressors. They stated of being overloaded with work and performance fear is too there. Some of the situations in their work lead them to drain completely psychologically.

“Look madam, after all we are humans only and not machines. All most all the Government programs are dependent upon us more or less. Beside our daily job of household visits, we accomplish them too in given time. How we will manage then!”

“Competition of being appreciated and awarded, creating a lot of fear in my mind. I don’t want to be criticized by my villagers for not being able to carry forward my village’s name.” (Translated) (IDI, ASHA).

Economic factors

All most all ASHAs stated their concern about the incentives they are getting. There is work incentive which is negligible in comparison to their job performance. Provisions of incentives are also there but that’s also depending upon case load. Work is getting influence by the amount they are getting.

“I used to ask for money before but now I can purchase gifts for my husband on our anniversaries with my income. I am earning. What can be better than that!” (Translated) (IDI, ASHA).

“I am getting half of the money in comparison to my other ASHA friends, as more people living there in their villages and they are getting more cases.” (Translated) (IDI, ASHA)

“They are asking us to get involved in most of the health programme and we are happily giving our best. But we are not getting a satisfactory amount for the same. Sometime all of our involvement is free of cost.”

“Sometimes it feels like what’s the value of working day and night if getting this much only.”

“Some of the doctors are referring cases to have delivery operation in the private hospitals and clinics, from where they can get extra money. And what about us? By this act we are just losing our incentives.”

Social factors

They are feeling dignified with the respect they are getting from the community members. Their work is giving opportunity to them to earn respect and appreciation from the fellow villagers. The other side of the coin indicating lack of recognition and poor amount respect they are getting then they deserve.

“We are feeling dignified as people started addressing us when they need medical help for different health issues and it feels really good when they come to me for solving their health-related concerns.”

“The hospital staffs behave like we are nothing in front of them. They will ask us to bring tea, snacks etc and we do the same but where is the respect and affection for us?”

“I faced this many time as of now. The hospital people will attain my cases according to their wish. Seeing the pain of the mother I used to run after them requesting but they ignored and said it’s normal to have labour pain. This I don’t like personally Madam.”

“We will do all the home visits, all the survey and other work, but the credit will always be given to the nurses, doctors and other officers. No one takes our name.”

Environmental factors

There are external factors categorised here as environmental factors here are environmental and geographical effects that are affecting the work of ASHAs. Poor road connectivity, hilly areas or a bad weather, its standing as a barrier only.

“It’s too stressful to manage things in the midnight or during bad weather.”

“There are areas with poor road connectivity. Most of the times the ambulance drivers refuse to cooperate. And if it’s raining, then there is not anyone to listen us.”

In our study it was observed that, where the personal factors, economic factors and social factors have both positive and negative effects on ASHAs, the psychological and environmental factors only de-motivating them in committing professional responsibilities.

DISCUSSION

The mean age group was 35.85. Majority 70 (46.67%) of the ASHA workers were in the age group of 25-35 years. Hence, the results showed that majority of the workers were young which may be strength for the programme to deliver the health services with more motivation and capacity building. Similar result was found by other studies.^6,4,13 Regarding the level of education, it is also found that most of the ASHA workers have completed primary school of education i.e. 91 (60.67%) followed by secondary education 48 (32%). Contrary to this finding, another research study revealed the percentage of ASHAs educated below 8th std as high as 32.8%.^7,14

In this study, 32% ASHAs were involved in IEC activities with the help of Anganwadi Workers. A study conducted in Uttarakhand, 79.2% reported spreading health awareness as one of their job responsibilities, a study in Orissa, reported that 48% of the ASHA knew that creating community awareness about various health determinants.^15,16

A study from Orissa reported that 81.3% of ASHA workers had knowledge about their responsibilities regarding counselling on antenatal care/postnatal care.¹⁶ In present study nearly 73% of ASHAs were know the importance of Iron and calcium supplement during pregnancy. Similar findings were found in a study that 100% knew about the IFA tablets to be taken during pregnancy.¹⁷ A study also found that majority (94.6%) of the ASHA workers were of the opinion that pregnant mothers should increase the food consumption and 90.9% were aware of the iron and calcium tablets to be consumed by the antenatal mothers.¹⁸

A study in Delhi found awareness of their role in distribution and intake of tablet IFA was known to 85.5% of ASHAs.¹⁹ In this study, 73% ASHAs create awareness in mobilizing community for seeking appropriate and accurate care from the health centres. Similar to this finding in Karnataka found 90% of the deliveries were hospital deliveries.¹⁹ A study in Rajasthan 71.46% were institutional delivery have been motivated by ASHAs.²⁰ In the present study, only 33% were able to name all the records available which need to be filled in. Supporting to the findings, a study found 17% ASHAs aware about birth and death registration.⁷ On the other hand, a study revealed that 100% ASHAs were aware and performing birth and death registration.³ In present study, all ASHAs had knowledge about new born care. Contrary to this a study from Karnataka reported only 38.8% had knowledge on neonatal care.²¹ In the present study, 91% of ASHA had knowledge about colostrum and its importance. A study reported that all the ASHA’s were aware of the importance of colostrum administration to the new-born.¹⁸ Another study found that 94.44% of ASHA had proper knowledge of the fact that pre-lacteal feeds need to be given.²²

In present study all ASHAs had knowledge about exclusive Breast feeding which is almost similar observations were made by a study from Orissa that 81.3% of ASHA workers had knowledge about their responsibilities regarding counselling on breastfeeding.¹⁶ Another study revealed that, 73.5% were aware of the duration of exclusive breastfeeding to be practiced by the lactating mother.¹⁴ In this study, all ASHA had knowledge on immunization schedule. A study also observed that 100% ASHAs were aware of her immunization responsibilities.¹³ A study in Gujarat found only 11.4% was working as mobilizers for immunization sessions.²³

CONCLUSION

In general, ASHAs are having adequate knowledge about their job responsibilities, there is more training needed about maintaining the records and documentation process. There is immediate need to overcome the barriers and challenges they are facing, which can hamper their performance level.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the ethical review committee at AIPH (ERC protocol number 2018-38)

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