How female community health workers navigate work challenges and why there are still gaps in their performance: a look at female community health workers in maternal and child health in two Indian districts through a reciprocal determinism framework

Abstract Background Accredited Social Health Activists (ASHAs) are community health workers tasked to deliver health prevention in communities and link them with the health care sector. This paper examines the social, cultural, and institutional influences that either facilitate or impede ASHAs’ abilities to deliver services effectively through the lens of the reciprocal determinism framework of social cognitive theory. Methods We conducted 98 semi-structured, in-depth interviews with ASHAs (n = 49) and their family members (n = 49) in Gurdaspur and Mewat districts. Data were analyzed by comparing and contrasting codes leading to the identification of patterns which were explained with the help of a theoretical framework. Results We found that while the work of ASHAs led to some positive health changes in the community, thus providing them with a sense of self-worth and motivation, community norms and beliefs as well as health system attitudes and practices limited their capacity as community health workers. Conclusion We outline potential mechanisms for improving ASHA capacity such as improved sensitization about religious, cultural, and gender norms; enhanced communication skills; and sensitization and advocating their work with health and state officials

The Mixed Nature of Incentives of Community Health Workers: Lessons from a Qualitative Study in Two Districts in India

Incentives play an important role in motivating community health workers (CHWs). In India, accredited social health activists (ASHAs) are female CHWs who provide a range of services, including those specific to reproductive, maternal, neonatal, child, and adolescent health. Qualitative interviews were conducted with 49 ASHAs and one of their family members (husband, mother-in-law, sister-in-law, or son) from Gurdarspur and Mewat districts to explore the role of family, community, and health system in supporting ASHAs in their work. Thematic analysis revealed that incentives were both empowering and a source of distress for ASHAs and their families. Earning income and contributing to the household’s financial wellbeing inspired a sense of financial independence and self-confidence for ASHAs, especially with respect to relations with their husbands and parents-in-law. In spite of the empowering effects of the incentives, they were a cause of distress. Low incentive rates relative to the level of effort required to complete ASHA responsibilities, compounded by irregular and incomplete payment, put pressure on families. ASHAs dedicated much of their time and own resources to perform their duties, drawing them away from their household responsibilities. Communication around incentives from supervisors may have led ASHAs to prioritize and promote those services that yielded higher incentives, as opposed to focusing on the most appropriate services for the client. ASHAs and their families maintained hope that their positions would eventually bring in a regular salary, which contributed to retention of ASHAs. Incentives, therefore, are both motivating and inspiring as well as a cause dissatisfaction among ASHAs and their families. Recommendations include revising the incentive scheme to be responsive to the time and effort required to complete tasks and the out-of-pocket costs incurred while working as an ASHA; improve communication to ASHAs on incentives and responsibilities; and ensure timely and complete payment of incentives to ASHAs. The findings from this study contribute to the existing literature on incentivized CHW programs and help throw added light on the role incentives play in family dynamics which affects performance of CHW

The cost-effectiveness of three methods of disseminating information to improve medical male circumcision in Uganda.

Uganda is working to increase voluntary medical male circumcision (VMMC) to prevent HIV infection. To support VMMC quality improvement, this study compared three methods of disseminating information to facilities on how to improve VMMC quality: M-providing a written manual; MH-providing the manual plus a handover meeting in which clinicians shared advice on implementing key changes and participated in group discussion; and MHC-manual, handover meeting, and three site visits to the facility in which a coach provided individualized guidance and mentoring on improvement. We determined the different effects these had on compliance with indicators of quality of care.This controlled pre-post intervention study randomized health facility groups to receive M, MH, or MHC. Observations of VMMCs performance determined compliance with quality indicators. Intervention costs per patient receiving VMMC were used in a decision-tree cost-effectiveness model to calculate the incremental cost per additional patient treated to compliance with indicators of informed consent, history taking, anesthesia administration, and post-operative instructions.The most intensive method (MHC) cost $28.83 per patient and produced the biggest gains in history taking (35$1.13 per patient) was most efficient because it produced small gains for a very low cost. The handover meeting (MH) was the most expensive among the three interventions but did not have a corresponding positive effect on quality.Health workers in facilities that received the VMMC improvement manual and participated in the handover meeting and coaching visits showed more improvement in VMMC quality indicators than those in the other two intervention groups. Providing the manual alone cost the least but was also the least effective in achieving improvements. The MHC intervention is recommended for broader implementation to improve VMMC quality in Uganda

Comparison of changed in quality indicators from the three interventions.

<p>Comparison of changed in quality indicators from the three interventions.</p

Differences in indicators between pre- and post-intervention periods, costs and cost-effectiveness of the three interventions compared to no intervention.

<p>Differences in indicators between pre- and post-intervention periods, costs and cost-effectiveness of the three interventions compared to no intervention.</p