Investigating violence against _Accredited Social Health Activists_ (ASHAs): a mixed methods study from rural North Karnataka, India

# Background Accredited Social Health Activists (ASHAs) are female community health workers who primarily work to improve local reproductive, maternal, neonatal, and child health across India. As ASHAs often hail from patriarchal environments and are positioned at the bottom of the healthcare hierarchy, they are vulnerable to experiencing different forms of violence from the various individuals that they interact with. There is a gap in knowledge about the violence ASHAs experience. The purpose of this study was to assess the working condition of ASHAs, the extent and types of violence they experienced, and the corresponding perpetrators of this violence in two districts of Northern Karnataka. # Methods Using a mixed methods approach, we first surveyed 396 ASHAs to characterize their experiences of violence. We then conducted in-depth interviews with 16 ASHAs to elaborate on survey findings. Data was analyzed using quantitative prevalence statistics and qualitative thematic analysis. # Results The majority of ASHAs reported economic (88%) or emotional violence (73%), while many ASHAs reported sexual (32%) or physical violence (26%). ASHAs reported high levels of economic violence from their beneficiaries and their beneficiaries’ families (64%), emotional violence from their co-workers (44%), and physical and sexual violence from their husbands (17% and 12% respectively). Mixed methods findings revealed that violence was often rooted from their low positioning on the healthcare hierarchy, a lack of respect from community members, and limited autonomy at home. # Conclusions Evidence from this study suggests that violence perpetrated against ASHAs is highly prevalent, diverse in forms, and often arises from the ASHA’s immediate circles. Interventions aiming to decrease violence against ASHA workers requires multi-level approach, with collaborative components empowering ASHAs, sensitizing ASHA families and co-workers, implementing regulations at the health facility level, and increasing community-wide respect for ASHAs and their role in the health care

Integrative approach to lifestyle management: Implications for public health research & practice in the context of SDG-3

In the last 100 years, the communicable diseases have been replaced by non-communicable diseases as the leading cause of deaths across the world. Periodically, the communicable disease outbreaks continue to pose a challenge to the public health systems. Change in human behaviors and lifestyles are recognized as risk factors for the public health challenges we face today, which significantly affect wellbeing and quality of life. Healthy lifestyles are critical to not only controlling diseases, but also to promote good health and wellbeing. Modern Medicine has provided evidence-based approaches to lifestyle management, but there are challenges to implementing them effectively. The traditional disciplines such as Ayurveda, Yoga and Meditation are showing promise as complementary approaches to further community wellbeing. A new perspective and a model is proposed by the author called ‘Integrative Lifestyle” which is informed by the evidence in the space of modern and traditional approaches to lifestyle management. The article describes the elements of the model, highlights the emerging evidence and implications for public health practice and research. The efforts by Government of India and its collaborators to promote integrative approaches is worthy of emulation and should be backed by sufficient investments into implementation research and population wide scale up for accelerating SDG-3 outcomes related to health and wellbeing

A commentary on cancer prevention and control in India: Priorities for realizing SDGs

Abstract In India, cancers along with cardiovascular diseases contribute to significant mortality and morbidity. With less than 10 years remaining towards achieving Sustainable development Goals (SDGs), public health systems in India need to be critically assessed and strengthened, for addressing non‐communicable diseases (NCDs) in general and cancers in particular. Our Commentary address the public health response to cancer prevention and control, with specific pointers based on emerging evidence. The relevant issues are stratified as: emphasis on the critical appraisal of national programs, strengthening primary health care (PHC) systems, enhancing focus on client and community centricity, exploring integrative approaches to cancer management and stepping up implementation and multidisciplinary research. Ongoing surveillance is essential to assess the current and future trends of cancer as well as the outcomes of prevention and treatment measures. For revitalizing comprehensive PHC, much depends on our epidemiological capacity and surveillance systems which impart information for local planning. It is imperative to address the cultural barriers and societal norms, which limit the acceptability and participation in screening programs. SDG 3 has ushered the wellbeing agenda at an opportune time. There is a compelling need to conduct research on an integrated approach (ayurveda complimenting allopathic medication) for the treatment of cancer. The unique challenges posed by the rise in NCD morbidity in LMIC, requires horizontal integration of the health systems with new services focused on cancer control

Influence of integrated community- and facility-based interventions on select maternal and neonatal outcomes in Northern Karnataka, India: Lessons for implementation and measurement

Background: Sukshema project provided technical assistance to National Health Mission of government of Karnataka to improve maternal, newborn and child health (MNCH) outcomes in eight districts of Karnataka between 2009 and 2015. The project designed tools, processes and provided mentoring to frontline workers, community structures, and facilities to improve demand generation and quality of MNCH services. Objectives: To assess over time changes in selected MNCH care indicators among women who had delivered in the past 2 months in Bagalkot and Koppal districts. Methods: An innovative strategy was designed to collect routine monitoring data, namely community behavior tracking survey using mobile technology. The catchment area of an Accredited Social Health Activist (ASHA) was the primary sampling unit, and in each district 200, ASHA areas were selected. Women from these selected ASHA areas were interviewed and information collected on various MNCH care outcomes. Multivariate logistic regression was used to assess changes in selected MNCH care indicators. Results: Gradual increase was noticed in institutional delivery, hospital stay for 48 or more hours, initiation of breastfeeding within 1 hour and continuum of MNCH care. Forty-eight hours stay and initiation of breastfeeding improved marginally possibly due to health systems and cultural norms. Conclusions: Results indicated that the interventions were successful in changing the critical MNCH care indicators and hence have potential for replication in similar high priority district settings

Availability and distribution of emergency obstetric care services in Karnataka State, South India: access and equity considerations.

BACKGROUND: As part of efforts to reduce maternal deaths in Karnataka state, India, there has been a concerted effort to increase institutional deliveries. However, little is known about the quality of care in these healthcare facilities. We investigated the availability and distribution of emergency obstetric care (EmOC) services in eight northern districts of Karnataka state in south India. METHODS & FINDINGS: We undertook a cross-sectional study of 444 government and 422 private health facilities, functional 24-hours-a-day 7-days-a-week. EmOC availability and distribution were evaluated for 8 districts and 42 taluks (sub-districts) during the year 2010, based on a combination of self-reporting, record review and direct observation. Overall, the availability of EmOC services at the sub-state level [EmOC = 5.9/500,000; comprehensive EmOC (CEmOC) = 4.5/500,000 and basic EmOC (BEmOC) = 1.4/500,000] was seen to meet the benchmark. These services however were largely located in the private sector (90% of CEmOC and 70% of BemOC facilities). Thirty six percent of private facilities and six percent of government facilities were EmOC centres. Although half of eight districts had a sufficient number of EmOC facilities and all eight districts had a sufficient number of CEmOC facilities, only two-fifths of the 42 taluks had a sufficient number of EmOC facilities. With the private facilities being largely located in select towns only, the 'non-headquarter' taluks and 'backward' taluks suffered from a marked lack of coverage of these services. Spatial mapping further helped identify the clustering of a large number of contiguous taluks without adequate government EmOC facilities in northeastern Karnataka. CONCLUSIONS: In conclusion, disaggregating information on emergency obstetric care service availability at district and subdistrict levels is critical for health policy and planning in the Indian setting. Reducing maternal deaths will require greater attention by the government in addressing inequities in the distribution of emergency obstetric care services

Geographic distribution of government and private BEmOC facilities in 42 taluks of northern Karnataka, 2010.

<p>A. Government sector EmOC. B. Private sector EmOC. BEmOC = Basic Emergency Obstetric Care.</p