Background
The cluster randomized controlled trial
Context
ICDS, LHW duties and work environment
The intervention
The qualitative study
Participants
Village | LHW No. | Age | Education (years of education) | No. of 12–59 month children in village |
---|---|---|---|---|
FGD #1 | 1 | 42 | 12 | 49 |
2 | 35 | 9 | 11 | |
3 | 59 | 10 | 45 | |
4 | 42 | 10 | 44 | |
5 | 50 | 10 | 38 | |
6 | 38 | 10 | 45 | |
7 | 45 | 10 | 55 | |
8 | 54 | 15 | 43 | |
9 | 49 | 10 | 61 | |
FGD #2 | 1 | 35 | 9 | 11 |
2 | 42 | 10 | 44 | |
3 | 50 | 10 | 38 | |
4 | 38 | 10 | 45 | |
5 | 42 | 12 | 49 | |
FGD #3 | 1 | 45 | 10 | 55 |
2 | 54 | 15 | 43 | |
3 | 49 | 10 | 61 | |
4 | 26 | 10 | 19 | |
5 | 55 | 10 | 20 | |
Observations | 1 | 45 | 12 | 58 |
2 | 46 | 12 | 61 | |
3 | 47 | 10 | 60 | |
4 | 50 | 10 | 38 |
Methods
Data collection
Focus group discussions
Non-participant observations
Field notes
Analysis
Meaning unit | Code | Subtheme | Theme |
---|---|---|---|
‘We can’t tell too many things to them. We tell them slightly little more if we feel like they listen. If they show negligence or lethargy, we don’t bother too much about them. We tell what needs to be told and return. Some show interest, others may have less interest slightly because of their busy work or visiting some place or in a hurry. It is possible that they can’t give attention.’ | Challenging to retain mothers interest and attention | Variable mother LHW relationship | Interpersonal relationship with mothers |
Theme | Working conditions challenging intervention | |
---|---|---|
Subtheme | Position is one of responsibility, which they take seriously | Duties are extensive and varied; wide ranging tasks |
FGD1 | We have come here to do it, and now we will do it, how much ever the difficulty. | |
FGD2 | [Long discussion about the various logs, registers an diaries they maintain, involving maternal, child, and community health; registrations of births, deaths, and everything in between; educational responsibilities; official records; and account and book keeping] | |
FGD3 | Same comment as above, re: completion of registers, logs, and diaries | |
Field notes | LHWs clearly view their position and work with pride: this is evident in the way they dress and authoritative way they carry themselves. Most take their responsibilities seriously, with the intent of fulfilling them. | On a daily or weekly basis, LHWs perform, at a minimum: nonformal preschool activities, ration distribution, 1–2 meetings related to maternal and child health or related issues, home visits, meetings with or visits by supervisors, and completion of various registers. |
Ethics and consent to participate statement
Results
LHWs initial acceptance of the intervention changing over time
In the initial FGD, LHWs suggested ways to continue intervention work even after the trial was complete. However, such positive sentiments diminished in subsequent FGDs, as the trial progressed. Moreover, since the research team conducted point of care blood testing to detect anemia in children and actively sourced IFA supplies during supply shortfalls, LHWs expressed doubt about their ability to continue such activities after the trial was complete:‘Now that we are giving tablets and informing them about food, mothers can also understand... This makes both mothers and us happy. We will also get happy because we can improve children a bit’ (FGD #3, LHW 1)
‘We can give them information regularly. But what about tablets? Who gives all that? We explain them about food and nutrition benefits... If there is anaemia child what we do? We don’t have the facility to take care them... Blood test is also a big problem. How can we check a child of having anaemia?’ (FGD #2, LHW 8)
The waning of enthusiasm for the intervention from the first FGD to subsequent ones was also seen through comments on the number of forms the intervention required and confusion about how to correctly fill these. In a later FGD, LHWs described the forms as a burden but later after familiarization with this activity some found it more acceptable:‘We can say about diet. We can tell children to take something that is available at home. But about the tablet, we can provide only if you can provide it to us. Otherwise [we cannot continue]... And about testing, you have to conduct a blood test. Otherwise no.’ (FGD #3, LHW 1)
Initially, some LHWs thought that completing the data collection instruments was a relatively simple task but subsequently developed confusion about expectations. These LHWs expressed the following lack of clarity:‘We were unsure of how to work with these, this new additional burden. Already we had many books to write and now we were given a new one... we thought in the beginning [it is a burden], but now it’s nothing’ (FGD #2, LHW 8)
‘Should we write all the dates if we visit them 2-3 times in a day? ... Now we went for counselling. Then we visit them within a week. We visit them 5-6 times in a month. Is one date enough during those occasions?’ (FGD #3, LHW 1)
LHWs innovating and adapting the implementation protocol
‘[We do the counselling] when we are together, when we distribute rations. We tell them when all are together.’ (FGD #3, LHW 1)
This finding was corroborated by non-participant observations, which showed how LHWs found ways to incorporate the intervention tasks into their regular work. In addition, we observed that most LHWs did not use the supplementary material to help facilitate their education and counselling sessions but depended on their memory.‘Sometimes they did not come even when we call them. Sometimes we do not get opportunities to meet them even when we visit. Then we meet them at the ration. This meeting is inevitable for them, where we explain this thing.’ (FGD #3)
Precarious relationships with mothers in participating communities
The perceived inattention or lack of interest on the part of the mothers was a source of frustration for LHWs. They discussed the mothers forgetting or ignoring instructions at length:‘They [the mothers] ask us to make it fast. They keep [checking] the time every hour. They have to work with their cows and calves, etc.’ ‘... they do not want to learn. They don’t have much patience for these things.’ (FGD #2, LHWs 3 & 8)
‘We can’t tell too many things to them. We tell them slightly little more if we feel like they listen. If they show negligence or lethargy, we don’t bother too much about them. We tell what needs to be told and return. Some show interest, others may have less interest slightly because of their busy work or visiting some place or in a hurry. It is possible that they can’t give attention’ (FGD #3, LHW 10)
Multiple roles complicating the relationship
LHWs play a multifaceted role in the community that possibly requires them to draw on their interpersonal skills, that could challenge uniform implementation of an intervention in the setting of a trial. The LHW-mother relationship seemed to evolve across time and possibly other contextual issues, such as religious backgrounds. However, the LHW-mother relationship seemed to also have potential for conflict particularly based on the expectations of mothers:‘[Relationship with mothers] is generally good. But sometimes if we ask them to pay the loan back then there is some misunderstanding. Later they may realize we tell them for their own good and they are fine.’ (FGD #1, LHW 8)
‘It is possible they appreciate you when you do good things; it is possible that they blame you when you fail.’ (FGD #2, LHW 6)
Status in the community as positively influencing mother-LHW relationships
LHWs also took pride in their work and perceived themselves as valuable contributors to the village community. This finding was supported by our field observation notes, where the researchers noted that the LHWs usually dressed in official government issued uniforms and handled distribution of nutrition rations to villagers with diligence and responsibility (Table 3). They seemed invested in the well being of the mothers and their children.‘We feel like each house is like our house... we talk to the people while going around and we become familiar with the people.’ (FGD #1, LHW 6)
‘When we see the children we feel happy’ (FDG #1, LHW 9)
One LHW felt that mothers appreciated them:‘If there is a problem at home, when we see the children we forget it.’ (FGD #1, LHW 1)
‘When they get to know they are pregnant, they run towards us!’ (FGD #2, LHW 6).
Working conditions challenging intervention delivery
Wide ranging services and high work burden
‘We have come here to do it, and now we will do it, however much the difficulty’
However, this perception seemed to change and in the later FGDs, LHWs did not appear to find the additional intervention related activities particularly burdensome since they reported completing tasks within their regular work hours. This was also confirmed during the non-participant observations. It is possible that LHWs found additional intervention activities that they could complete during the regular working day hours burdensome since it was not remunerated.‘We will do whatever needs to be done... we have come to that level’ (FGD #1, LHW 6)
Salary concerns
‘We are working more and getting less salary... we are not satisfied. If we get at least Rs. 10,000 [about twice what they currently earn], we would be happy.’
‘Our salaries are low. We don't get salaries proportionate to our work’ (FGD#2, LHW 3)
Job security concerns
These two obstacles prompted LHWs and their unions to make demands for improved salaries and benefits (salary protection, pensions, subsidized healthcare). As indicated in the field notes, a 3-week Karnataka state wide strike by the LHWs brought all trial related activities to a complete halt. During this period the research team stopped all research activity and paid heed to the LHW concerns.‘They have decided to privatise the whole sector. Privatisation means they give ADC responsibilities to a private institution. They planned to give whole authority to Coca-Cola company. There is a big difference when responsibility is shifted to the private institution from the government. We may not get salary promptly. They may give more work stress to us. We may attend without missing a day. We may not get casual leaves properly. We may face many problems. They... may expel any worker whenever they want.’ (FGD #2, LHW 8)
Inadequate employer support and recognition
‘We are asking them from the past four years to close the drainage pit, but we didn’t get any help from them’ (FGD #3, LHW 1)
The range in Gram Panchayat engagement was noted in our non-participant observations and field notes; in some villages, leaders stopped by to meet with the field research team or chat with the LHW, but in others, there was little or no communication. In the former, village leader involvement seemed to result from the LHW being highly engaged with the community with respect to the intervention. At the district supervisor level, LHWs sought a sympathetic understanding of their working conditions. One LHW complained about her difficulties in travelling for work:‘They will put the signature, but they will not help us’ (FGD #1, LHW 3)
Notably, several LHWs praised a retired district-level supervisor who had demonstrated compassion in terms of accommodating the needs of LHWs who were pregnant and required medical assistance.‘Sometimes I cry, for my legs hurt from walking that distance... Sometimes bus, auto, and bicycle also increase my body pain... I applied for a transfer many times, but no one listens or reads my request letters’ (FGD #2, LHW 8)