Factors influencing the performance of accredited social health activists in district Sirmour, Himachal Pradesh

INTRODUCTION

In India, the health care system is rendering multitude of care to communities through health care personnel for promoting and maintaining health.¹ According to WHO, community health workers (CHWs) are integral members of the communities who carry out certain activities and are supported by the health system.² Among all CHWs, accredited social health activists (ASHAs) are playing an important role in delivering health care services in community area with their full participation and accountability.³ Although the general norm of selection of ASHA is 1 per 1000 population but in tribal, hilly and desert areas the norm could be relaxed according to needs.⁴ So, it is the responsibility of the states to select ASHAs and train them for 23 days spread over a span of 7 days followed by 4 rounds of 4 days each.⁵

National rural health mission, 2005 (NHM, 2013) aimed to provide an effective health care to the rural population through its key strategy of selection of ASHAs at grass root level.⁶ National health policy, 2017 highlighted universal health coverage through increase in utilization of Public Health facilities and by strengthening the health care delivery services at grass root level.⁷ Global conference on primary health care, 2018 also emphasized on primary health care which has a critical role for universal health coverage.⁸ This scenario in India is bleak and NHM is trying to achieve this goal.⁹ Recently, WHO on world health day, 2019 focused on “universal health coverage: everyone everywhere” which can be achieved through CHWs at peripheral level.¹⁰ So, target of the present study was to assess the performance of ASHAs and factors influencing their performance.

METHODS

The researcher used quantitative approach and non-experimental exploratory research design to perform the study. This study was conducted in district Sirmour of Himachal Pradesh. There are total 6 blocks in district Sirmour out of which 4 blocks were selected randomly. Out of each block, main centers were approached and then from each main center, disproportionate stratified sampling technique was used to draw out the required samples. Here, the first stage was random selection of blocks; second stage was final selection of samples from the main health centers with disproportionate stratified sampling technique, thus making a multi-stage sampling.

The sample size of the study was 228 which was estimated using the formula:

n=NZ²P(1-P)/d²(N-1)+P(1-P)

Where N=602, P=0.80 (from previous studies), d (margin for random error=0.05, at 95% significance level) and the ASHAs were selected following the exclusion and inclusion criteria. Data collection was done through structured interview. The tool consisted of four sections. Section A consisted of seven items related to socio-demographic data such as age, education, marital status, type of family, family monthly income, work experience and population covered where as section B contained fifteen dichotomous questions for assessing the level of performance. Section C and section D consisted of 14 dichotomous questions and 1 contingency question for assessing the individual and environment factors influencing the performance of ASHAs. The tool was validated by experts from various departments and reliability was found using the inter-rater reliability method applying Kappa’s formula:

k=Po - Pc / 1 – Pc

Where, k=kappa, Po=proportion of units in which raters agreed and Pc=proportion of units in which agreement bychance is expected).

The reliability of the tool was 0.96 which is highly reliable. Informed written consent was taken from all participants. The confidentiality and anonymity of participants were maintained as well. Data was analyzed using descriptive and inferential statistics i.e. frequency, percentage and Chi Square.

RESULTS

Most of the ASHAs i.e. 38.6% were in the age of 36-40 years, 39.5% were having secondary education and 11.8% ASHAs had middle education (Table 1). Majority of the ASHAs i.e. 91.2% were married and 0.9% ASHAs was single. Almost half of the ASHAs i.e. 48.2% were living in a joint family while 8.8% were living in an extended family respectively. About half of ASHAs i.e. 43% were having family income in between Rs. 5001-10000 and 5.7% had Rs. 15001-20000 monthly income. Almost all ASHAs i.e. 96.1% had 4 years of work experience and only 3.9% ASHAs had 2 years of work experience. Around three-fourth of the ASHAs i.e. 71.5% were covering population of 501-1000 and 6.2% ASHAs were covering population above 1500. 61.4% ASHAs had average performance followed by 38.6% of them had good level of performance (Figure 1). 23.2% ASHAs were having health problems and only 7.5% ASHAs had missed their duties due to health problems (Table 2). Where 7.5% ASHAs were having family problems only 1.8% ASHAs was not supported by their family. 6.1% ASHAs were not satisfied with their job, maximum i.e. 85.5% ASHAs had insufficiency in incentives, 16.7% ASHAs had work stress and 34.6% ASHAs had difficulty in work due to superstitious believes of the community.

More than two-third of ASHAs i.e. 69.3% did not get sufficient materials for their work and 23.7% ASHAs opined that their work distribution was not equal (Table 3). Only 8.8% ASHAs told that penalty was given to them for not completing their work on time. More than half i.e. 59.6% ASHAs had faced problems due to distance or transport and other half i.e. 49.1% faced problems due to weather (Table 3). The diagram depicts that the performance of 100% ASHAs are influenced by irregular availability of resources, 96.10% by inadequate provision of incentives, 76.3% by lack of safety and 48.2% due to difficulty in motivating people (Figure 2).

Association of level of performance of ASHAs with their socio-demographic variables

Education, income and population coverage by ASHAs was statistical significantly associated with level of performance of ASHAs at the level of p<0.05 level of significance (Table 4).

DISCUSSION

Demographic profile of ASHAs

In the present study, 38.6% ASHAs were in the age group of 36-40 years and 11% ASHAs were till the age of 30 years. A study done by Das et al in Singur, West Bengal also found that 33.93% ASHAs were in the age group of 36-40 years and 9% were in the age of 30 years or less.¹¹ The current study has shown that 39.5% ASHAs were having secondary education. A study done by Gohel et al in Jamnagar of Gujarat too had similar results i.e. 37.93% ASHAs were having secondary education.¹² Another study done by Choudhury et al also found that 34.02% ASHAs had secondary education.¹³ In the existing study, 91% of ASHAs were married and the study done by Das et al also found that 94% of ASHA workers were married.¹¹ The present study revealed that 76.8% of ASHAs were having family income above Rs. 5000. A study by Shet et al in Karnataka also showed that 88% ASHAs had family income above Rs. 5000.¹⁴ The present study found that 3.9% ASHAs had 2 years experience and 96.1% had 4 years experience. A study done by Gopalan et al in Orissa had shown that 17.10% ASHAs had less than 2 years experience and 82.90% had experience in between 2-4 years.¹⁵ In the current study only 5.3% were covering population in between 1501-2000 and the study conducted by Shet et al also unfolded that only 9% ASHAs covered population in between 1501-2000.¹⁴

Performance of ASHAs

The current study revealed that only 38.6% ASHAs had good performance and 61.4% had average performance. A study concluded by Fathima et al in Karnataka also found that 40-60% ASHAs had moderate performance.¹⁶ Another study conducted by Baghel et al in Bilaspur, Chattisgarh found that 56.4% ASHAs create awareness on health determinants and 70.2% do postnatal visit but in the current study only 20.2% ASHAs create awareness on health determinants and 100% goes for postnatal visit.¹⁷ The study done by Fathima et al in Karnataka unfolded that 88.1% ASHAs counsel women on all aspects of pregnancy and 96.3% accompany women during delivery while in the current study only 11% counsel pregnant women and 100% accompany women during delivery.¹⁶

*Significant at the level of p <0.05

Individual factors influencing the performance of ASHAs

In the current study, the individual factors positively influencing the performance of ASHAs were family support, good relationship with family members, job satisfaction, interest in work, community support, providing beneficial services to community, appreciation from community people and community people’s participation. A study done by George in Delhi also found that support from family members, improved self-identity, job satisfaction and a sense of social responsibility, social recognition and status conferred by the community were the factors positively influencing the performance of ASHAs. ¹⁸

The creating hindrance individual factors were presence of health problems, family problems, insufficient incentives, work stress and superstitious believes of community people. A study done by Guha et al in Wardha, Maharashtra showed that work load, inadequate and delayed incentives negatively influenced their performance.¹⁹ Another study carried out by Baghel et al also found that hurdles in receiving incentives influence the performance of ASHAs.¹⁷

Work environment factors influencing the performance of ASHAs

A study completed in Chattisgarh found that that the following factors influence the work performance of ASHAs knowledge and practice on MCH services, training sessions, support from health staff, drug kit re-filling and hurdles in receiving incentives.¹⁷ The present study also found that low incentives and lack of training are influencing the performance of ASHAs. Another study conducted by Saprii et al in Manipur revealed that ASHAs experience small and irregular monetary incentives. Similar finding was shown in the current study too.²⁰ A study carried out in Uttar Pradesh revealed that ASHAs cover more population that their estimated population and motivation, incentive and stress level has association with their performance level.¹² The present study also found that 27.3% had population above 1000 and there was a positive association of performance with incentives and difficulty in motivation.

CONCLUSION

Current study concluded that the level of performance was influenced by individual, work environment factors and many other factors. Hence, the study recommended that initiatives should be taken at administrative levels to improve the performance of ASHAs and the factors creating issues in their performance should be solved out.

ACKNOWLEDGEMENTS

Authors would like to thank the chief medical officer and ASHA coordinator of district Sirmour, Himachal Pradesh for permitting to conduct the research study and providing the necessary data. Authors are also very grateful to all the medical officers for extending their helping hands during the research study. A special thanks to all the ASHA workers for participating in the study.

Lastly, the authors take a heavy gratitude to thank the members of the research committee, Eternal university for their constant guide and support all through the way.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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