ASHA programme in India
India’s Accredited Social Health Activist (ASHA) programme was launched by the National Rural Health Mission (NRHM) (now known as the National Health Mission (NHM)) in 2005, in line with its policy of community engagement to ensure people’s participation in health.
One ASHA is responsible for conducting health promotion activities for 1000 people in a village. ASHAs are recruited from the community based on leadership and communication skills and have at minimum an eighth grade education. This education requirement is relaxed in areas where women are unqualified. Women between 25 and 45 years are preferred. The responsibilities of ASHAs include functioning as a “health care facilitator, service provider, and health activist” [
1].
ASHAs’ activities in reproductive, maternal, neonatal, and child health (RMNCH) include motivating and escorting women to access antenatal care (ANC) and facility-based delivery, providing post-natal care, promoting and facilitating use of birth spacing methods, immunizations, and counseling about pregnancy-related issues including anemia management. Additionally, ASHAs distribute iron tablets, sanitary napkins, contraceptives, and pregnancy kits. They also maintain pregnancy registration records and hold village-level health meetings [
1].
CHW programmes, globally, have been shown to be effective in certain areas of maternal and child health including promotion of uptake of breastfeeding and immunization, essential newborn care, health education, and reduction in child morbidity and mortality [
2,
3]. Home visits for neonatal care by CHWs reduce infant and neonatal deaths and stillbirths in resource-limited settings [
4,
5]. Despite this, there are barriers to CHW performance.
A Cochrane Review identified organizational, social, and interpersonal factors that either facilitated or impeded CHW programmes [
6]. While community acceptance of CHWs and organizational support were important for the success of CHW programmes, barriers to CHW programme success were related to the relationship with beneficiaries and the health system, prevailing socio-cultural conditions, and institutional factors. Notably, socio-cultural norms that restrict movement of female CHWs and govern acceptable male-female communications have been identified as a barrier to doing their jobs successfully [
7‐
10]. Interpersonal barriers include fear of blame if interventions were unsuccessful, inability to meet expected needs of the community, and lack of understanding of benefits that prevented community members from using contraception [
11] or having a facility-based delivery [
12]. Institutional barriers include limited supplies [
8,
13,
14], excessive paper work [
15], and limited support from a rigid and hierarchical health system [
16‐
18].
While the literature on obstacles CHWs face is extensive, their responses to these obstacles have not been scrutinized with the exception of several studies. CHW communication skills play an important role in overcoming barriers related to community perceptions and beliefs [
19‐
23]. In India, female community-based workers in an urban slum were found to negotiate their relationship with other women by emphasizing common experiences, characteristics, and forming friendships [
20]. In India, an evaluation of the ASHA programme in 16 states highlighted gaps in technical skills of ASHAs, and their inability to cover marginalized populations [
24]. Although context-specific barriers have been identified in studies of ASHAs [
17,
18,
25] that may explain why their performance is still low, what remains to be known is whether ASHAs can appropriately address these barriers and the strategies they employ to resolve these and perform as health workers.
The current study examines the influences of ASHA workers’ environments on their role as health workers and how they respond to these in the course of performing their duties. We have based our conceptual framework on Bandura’s reciprocal determinism which posits that people’s actions are determined by goals, self-efficacy, outcome expectations, and perceived facilitators, and social and structural impediments [
26]. Self-efficacy is an individual’s belief in one’s ability to succeed in a specific task or situation. It is important for behavior change as it provides motivation to overcome barriers and evokes feelings of empowerment to enact change [
27]. In explaining worker motivation, Franco and others developed a conceptual framework, from which we additionally borrowed, which lays down internal factors such as self-concept, external factors such as cultural influences, as well as organizational systems and structures that determine worker motivation [
28]. In this framework, culture and community influence internal motivational factors such that an individual frames her actions against what is possible and expected, and the consequences of going against cultural norms [
29]. Furthermore, organizational support structures and processes influence a worker’s ability to perform [
28].