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ORIGINAL ARTICLE |
https://doi.org/10.5005/jp-journals-10082-03130
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Qualitative Assessment of Accredited Social Health Activist (ASHA/Mitanin) Regarding their Roles and the Factors Influencing their Performance in Delivering Immunization Services for Children’s in Selected Villages of Raipur District, Chhattisgarh
1Department of Community Medicine, Chirayu Medical College, Bhopal, Madhya Pradesh, India
2,3HRM, IIM Raipur, Raipur, Chhattisgarh, India
4NGO, John Snow International, Raipur, Chhattisgarh, India
5WHO Office, Raipur, Chhattisgarh, India
Corresponding Author: Harshal Mendhe, Department of Community Medicine, Chirayu Medical College, Bhopal, Madhya Pradesh, India, Phone: +91 8788530346, e-mail: drharshalmendhe@gmail.com
How to cite this article: Mendhe H, Patil N, Saini D, Patil M, Phatale P. Qualitative Assessment of Accredited Social Health Activist (ASHA/Mitanin) Regarding their Roles and the Factors Influencing their Performance in Delivering Immunization Services for Children’s in Selected Villages of Raipur District, Chhattisgarh. J Basic Clin Appl Health Sci 2022;5(1):3–7.
Source of support: Nil
Conflict of interest: None
ABSTRACT
Background: The Government of India in 2005 started the ASHA program to enhance the health of the rural population. The ASHA (Accredited Social Health Activist) was the important link person between the health system and the community. She supports various national programs along with the childhood immunization service. The study was conducted to know her role and the factors which influence their performance while delivering the immunization services.
Methodology: A qualitative study was conducted in Arang block of Raipur. Five villages were selected coming under the sector Mandir Hasaud. Nonprobability purposive sampling was done and in-depth interview was conducted with 18 ASHAs till saturation of the data. Interview findings were analyzed with a thematic frame work.
Results: The study shows that the ASHAs have a good knowledge about the routine immunization services. She is clear with her role. Recognition by community and support from family and coworkers were some of the motivating factors. Insufficient and delayed incentives and quality trainings were found to be significant factors in keeping her motivated for providing the immunization services.
Conclusion: Regular refresher training, satisfactory monitory incentives, regular disbursal of incentives can be more effective and keep the motivation high for an ASHA for her services delivery in further improving the childhood immunization.
Keywords: Epidemiology, Healthcare workers, India, Vaccine.
INTRODUCTION
Government of India has started Expanded Program on Immunization in 1978 in urban areas to control the vaccine-preventable diseases. It was renamed as Universal Immunization Program in 1985. Later it became an integral part of National Rural Health Mission in 2005.1 A new brand of community-based functionaries, Mitanin, was pioneered in Chhattisgarh in 2002 which was later expanded and rolled out across the nation in the name of Accredited Social Health Activist (ASHA) from 2005 stating the ASHA to be the first point of contact for any health-related demands of the assigned sections of the population, especially women and children, who find it difficult to access health services. A Mitanin is supporting various national programs of which Universal Immunization Program is one of the major programs she has to support. The full immunization coverage in Chhattisgarh has never been very bad but the improvement is rather insignificant over the years. Fully immunized children coverage of Chhattisgarh as per NFHS-3 (2005–2006) is 48.7%, DLHS-3 (2007–2008) is 59.3%, and further improved to 76.4% NFHS-4 (2015–2016), and for Raipur District it is 80.1% as per NFHS-4 (2015–2016). Ministry of Health and Family Welfare, Government of India, implemented “Mission Indradhanush” in December 2014 with an aim to achieve 90% Full Immunization. It has been observed that the program advocacy and mobilization is one of the factors for less immunization in which a Mitanin/ASHA worker can very well address and help improve immunization. The knowledge and practice of Mitanin gets deeply linked with the counseling and mobilization of the parents of the children’s which may reflect in improvement in the children’s full immunization. She works under the supervision of an ANM (Auxiliary Nurse Midwife) and a Mitanin trainer. Her roles and responsibilities with respect to the knowledge about the program, her perception, and motivation get deeply linked with her work performance. There are certain factors which contribute in working of the ASHA.
Nearly 2.3 million children continue to die each year globally from vaccine-preventable diseases, even while the overall mortality rate of children continues to drop, reported the GAVI Alliance2 of which five lakh children die in India due to vaccine-preventable diseases and another 89 lakh children remain at risk due to partial or no immunization. Nearly one million children die before their fifth birthday in India. About one of every four of these deaths are caused by pneumonia and diarrhea which are vaccine-preventable diseases causing child deaths worldwide.3 Several studies have examined various aspects of ASHAs providing health services related to many national programs including childhood immunization and come out with diverse findings. 65.6% of the Mitanins have knowledge on counseling to pregnant mother on maternal and child health and out of this prevalence of its practice was found to be 75.4%. Their less knowledge for content of responsibility significantly affected their practices in community.4 Other study on knowledge and practice of ASHA for maternal healthcare delivery in Delhi showed that ASHAs’ knowledge is good but their practices are poor due to number of problems faced by them.5 A study done in Karnataka showed that ASHAs were predominantly (>80%) involved in certain tasks: home-visits, antenatal counseling, delivery escort services, breastfeeding advice, and immunization advice. The ASHA workers were found to be functional in some areas with the scope for improvement in others. The role of an ASHA worker was perceived to be more of a link worker/facilitator rather than a community health worker or a social activist.6 Despite the training given to ASHAs, lacunae still exists in their knowledge regarding various aspects of child health morbidity. 50.4% ASHAs considered a baby crying for more than 3 hours following immunization not worth referring to a first referral unit.7 Raipur is seen lagging behind to achieve the required target of 90% for Full Immunization (by around 10%). To cover up this lag, it is important to understand the role of ASHA and how it helps in vaccination especially in rural areas of Raipur. Therefore, this study is specially directed toward the understanding of the roles that ASHAs play during her job and the factors which influence their performance negatively or positively.
OBJECTIVES
To study the awareness and perception of ASHAs regarding their roles in delivering RI services.
To study the facilitating and inhibiting factors affecting their performance in delivering RI services.
METHODS
Qualitative methodology is used with an aim to investigate deeply the personally lived-in experience of the participants as well to understand the participant’s perception and knowledge. Content analysis for deeper interpretative insights based on focused and exclusive views and experiences of the participants was done. As a qualitative methodology, thematic analysis is largely employed on a small sample of respondents with an aim to gain in-depth or deeper insights from participants’ responses, and it acts as a complement to quantitative studies to get a better understanding of the underlying phenomenon.
Sample Size
According to Fetters, Curry, and Creswell (2013) in a phenomenological research tradition, “the size of the participants can be between 2 and 25.” Total sample size of around 20–25 was targeted for the study but the saturation of the data was achieved by the time 18th participant was interviewed. Semistructured interviews were conducted to source primary data with regards to the roles and perception of the ASHAs.
Sampling Technique
Purposive sampling was utilized to select the sample for the study from the population. The participants involved in the study were eligible to be a part of the study. In total, 18 respondents, with age ranging from 33 to 57 years, showed their willingness and volunteered to be a part of a study.
Inclusion Criteria
ASHAs who have been recruited ≥3 years
Willing to participate in the study
Exclusion Criteria
ASHAs who have been recruited (<3 years)
Not willing to participate in the study
Data Collection
In-depth interview via semistructured questions regarding awareness and perception of ASHAs regarding their role in the community and factors influencing their performances was done. They were encouraged to share their work-related experiences and views. An open-ended field guide was used at the time of conducting interviews, which were verified for its reliability and validity by two experts in the field, and due modifications were incorporated according to the given suggestions. To meet the time schedule, all the interviews were carried out at the participants’ work place; however, some interviews were taken on phone as well. The mean time duration of the interview was 30 minutes, with overall timings of the interviews fluctuating between 25 and 35 minutes.
Data Analysis
Data was analyzed with the help of a thematic frame work. From the questionnaire data collected, these transcripts were used and the themes were identified accordingly as main-order themes, second-order themes, and first-order themes (Table 1).
| Main theme 1—RI service delivery by ASHA—roles and knowledge | |
|---|---|
| Secondary theme | Primary theme |
| As a link person and facilitator | House to house survey |
| Home visit for immunization IPC | |
| Home visit on the day of RI for mobilization | |
| Mentor | Knowledge and counseling on RI services |
| As a facility provider | Home visit |
| Counseling | |
| Coordination with partners | |
| As an activist | Incentive |
| Recognition | |
| Immunization coverage | |
| Main theme 2—Barriers and motivators in delivering RI services | |
|---|---|
| Secondary theme | Primary theme |
| Motivators | |
| Individual level | Appreciation |
| External support | |
| Promotion | |
| Group level | Support from coworker |
| Organization level | Regular training |
| Appropriate supervision | |
| Barriers | |
| Individual level | Insufficient incentive |
| Deferred incentive | |
| Population coverage | |
| Group level | Revision training |
| Organization level | Frequent training |
| Supportive supervision | |
RESULTS
There were five important roles which ASHAs usually play in delivering RI services, according the study. The identified roles are given below:
As a facilitator: All the ASHAs were aware about their role as a major link person between the community people and the health structure. People know them as a facilitator of various health services including immunization. For example, one ASHA said in the interview, “Agar aaj tikakaran hai to ek din pehle chale jate hai aur aap log aa jana tika ke liye kehte hai”
“We visit the family of the beneficiary one day before the vaccination and tell them to come for vaccination (of their child).”
Sensitizer for vaccination: ASHAs in the role of facilitator of the vaccination program also sensitize the parents. Sharing one of her life experiences to facilitate a reluctant parent for immunization one ASHA said, “Ek baar laika roat hai to mana kar rahe bhaiyya” “Rudhi vadhi jan kaar, tanu mana kar dis, Baiyya nu samjhais” means once a child cried so he was not vaccinated by his father, traditional people do not favor vaccination, so father was sensitized for importance of vaccination.
As an educator: Most of the ASHAs said that they give correct information about the diseases preventable by immunization. This is their day-to-day work to do program advocacy and educate people about the importance about immunization. For example, another participant (Mitanin_04) said, “Sahi samay pe tika lag jaye to bacche bimari se bach te hai” which means vaccine when given at right time saves the child from the diseases.” Similarly another interviewee (Mitanin_01) said that “Suru se BCG ka tika lagta hai janam hote saath, dedh mahina, dhai mahina, sadateen mahina nau mahina dedh saal aur paanch saaal me booster lagta hai” which mean BCG vaccine is given at the start, then at 1.5, 2.5, 3.5 month, then at 9 months and then at 1.5 year booster vaccine is given. Therefore, most of the ASHAs know the correct schedule of the vaccination for children given under UIP (Universal Immunization Program) and they helped people to become aware about vaccination to their level best.
As a service provider: ASHA as a service provider is providing health services for many diseases. For immunization also she provides correct information keeping the immunization card safe at her center for further tracking of the missed doses. She was satisfied as a service provider when asked about services provided for immunization. Their awareness as a service provider was found to be satisfactory by the interviews as a interviewee (Mitanin_07) said that “Sabki sewa karat hai, madat karat hai, Maan samman bhi milat hai” which means that she takes care of all, help all, so get recognition from all, for the services provided. They also make sure that every child gets vaccine. Like a participant (Mitanin_01) said, “Nahi chuttee hai, sabhi ko lag jate hai” which means that no child is left without vaccination, all gets covered due to the services she provides to the people.
As an activist: ASHAs said we get involve with our colleagues, provide support at an Anganwadi center, also do survey, and participate in meetings. Training issues came as some of the points where she can further explore more to improve immunization. ASHA (Mitanin_15) said they motivate people to bring change, which has shown an improvement in people thinking and they have become alert and informed to take care of their children’s, “Maholla me jake batate hai hamare didi log aaye hai mohalla me, chalo tika lagva lo” aaisa prosahit kate hai” which means that our ANM has come in the community/locality; motivate people to please get vaccination done for children.” Further the second participant (Mitanin_02) told about the increased awareness in community, “Abhi sab jagrook ho gaye hai apne apne baccho ke liye” which means that now all have become informed for the good for their children.”
Factors Affecting their Performance in Delivering RI Services
Delayed incentive: It was found that a high incentive-based work would be a preferred choice for the ASHA or else the existing incentive should be revised so that it could be adequate for their livelihood. Less incentive for immunization services can be a factor for them sometime to focus more on other health programs which has been assigned more incentive. Dearing the interview some ASHAs (Mitanin_10) responded that “ekdum harach mahine nahi aa sakat, bahut late bhi ho ja rees” which means incentive do not come every month, gets to late also.”
Insufficient incentive: Talking about the amount of money they receive in general a participant said (Mitanin_10) “ek mahin me dava, panji, diary, mitanin panji karke pandaraso hot hai” which means that for 1 month activities related to medicine, registration, documentation, ASHA registration we get 1500. Another participant (Mitanin_11) said, “do so rupaya dete hai man dey me ek mahine me” which means we get 200 rupees as an incentive in a month (for immunization mobilization).
In relation to the same participant 4 (Mitanin_04) aggressively said that “Anganwadi worker ko 6000 rupees to hame bhi milne cahiye” means an Anganwadi worker gets a pay of 6000 rupee, hence we should also get it.
Aspiration: Most of the ASHAs were happy to serve as ASHA and not willing to get promoted as Mitanin Trainer thinking as they are not that much literate, work area will be more with more travel issues as well enjoy their work in their own area as ASHA. Those who wanted to be Mitanin trainers were found interested to get promoted. A participant said (Mitanin_12) “Mitanin me bahut badhiya lagta hai” means being a Mitanin worker is what I like. However, some ASHAs showed their grief not to become Mitanin trainer (MT), like participant 15, who said, “Mai to MT bante bante picche reh gayi” means I tried to be a MT but missed the opportunity.” Most of them were inspired to become a Mitanin and it motivated them.
Training: Most of the ASHAs were quite informed about their work of vaccination. In response to a question regarding vaccination they (Mitanin_4) responded “tika lagnese sisshu mrituye kum hogi” which means vaccination reduces death rate in child. Further another Mitanin_8 said that “Janam ke time BCG ka lagta hai, baad me penta lagta hai, polio pilat hi aur rota virus aur 9 manhine me khasra ka lag jaat hai” which means at birth BCG vaccination happens then penta and polio and khasra at 9 months. It shows their awareness about their work and the effectiveness of training that they receive.
Refresher training: All the ASHAs said about getting training when they were taken in the health department. Some have acknowledged about getting refresher training on an annual basis, but pointed out that the frequency of training is not adequate and needs to increase to help them informed about new developments with respect to the immunization programs as newer vaccines get launched and new strategies are developed for improving the immunization. Many of them were in support of regular training sessions so that they can brush up if something is left. Like the following response by a participant (Mitanin_11), “Training honi chaiye kuch kuch chuut jata hai” which means training should be conducted as some of the things get missed. Further another participant (Mitanin_10) suggested that “Training saal me ek baar saat din ka hot hai, uhi 6-6 mahina ka kar dena chahiye” which means that currently we have training once a year, it should be conducted half yearly.
Coworker support: All the ASHAs acknowledged the support of coworkers, ANMs, and Anganwadi workers whenever required. They mainly work in teams. Hence, cooperation is a motivating factor for ASHAs found during their work. As a participant (Mitanin_01) said “Saath me chale jaat hai” means we move together (during field activities).
Supervision support: All ASHAs acknowledge that they are being supervised by the Mitanin trainer, at some time by the ANM also. There are meetings happening with the supervisor, but some of the doubts are left uncleared during meetings hence regular refresher trainings were raised by the workers. According to a participant (Mitanin_02), “Mahina mahina me teen baar aat hai MT, aur bata rahat hai” which means MT comes thrice in a month and tells about” (work). The study shows that the Mitanins have a good knowledge about the routine immunization services, they are engaged with. In this particular study five themes came out to diversify their roles as an ASHA during their work: (1) as a facilitator, (2) as a sensitizer, (3) as an educator, (4) as a service provider, and (5) as an activist. It shows us the importance and significance of their role in society. It also makes us aware about the breath of the role, which can be further thought about and can influence the society more by empowering ASHAs. When the factors were studied which influences her work, it was found that there are certain motivating factors like her recognition by the community as an ASHA worker, getting good support from family and community, and support from coworkers in the field. Many ASHAs were found happy to work as an ASHA rather than getting promoted to Mitanin Trainer. It was also known that she is involved in many other health activities for which she has been given incentive. However, they are dissatisfied with the amount of incentive as well as some delay in amount incurrence which often happens to them. It may reduce their motivation of good work and therefore study suggests regularizing and enhancing incentive. The training part is another area which the study had focused and it was found that the basic knowledge is sufficient but there is a requirement for regularly keeping their knowledge updated especially when newer vaccines have been launched in vaccination programs. If not monthly then may be after every 2–3 months which can remain them updated.
DISCUSSION
The study found that ASHAs were clear about their role in strengthening the childhood immunization. Their work was influenced by capacity building training programs and the incentive which is linked with their work performance, supervision, and the expectation for achieving a target for higher immunization coverage from the health authority.
As per the study done by Guha et al. in 2021, in Maharashtra, concluded that quality training is very important to improve a ASHAs performance and increase her efficiency in participation in healthcare delivery system including childhood immunization which was one of the major findings of our study.8 A similar association was also found in other study done by Saprii et al. which was carried out in Manipur in 2015 on ASHAs work opportunities and challenges faced by her while performing various roles in the field. The study concluded that ASHAs performance has a direct relation with the work. Incentives as small and irregular monetary incentives demotivate ASHAs to perform well.9 Other study by Kaushik on factors influencing the work performance of ASHA done in Uttar Pradesh in 2013 showed that ASHAs are more inclined toward incentive-oriented practices and delayed and inadequate payment of incentives for ASHAs influences their work performance. This finding was observed in our study also that the delayed payment was one of the barriers related to ASHAs work performance in mobilization of immunization beneficiaries.10
The remuneration ASHAs received was a strong motivating factor for continued participation in the program, and for many, ASHA was the only chance they had to access for much-needed money. The remuneration ASHAs received was a strong motivating factor for continued participation in the program, and for many, ASHAs was the only chance they had to access much-needed money. The remuneration that ASHA received was a strong motivator for continued participation in health program, as well for some ASHAs it was the only chance to assess much needed money which our study also had found out.11 The study conducted by Garg in rural Haryana concluded that the most important motivational factor for ASHAs was the financial gain.12 ASHA worker received an incentive of ₹100 for Full Immunization per beneficiary and ₹50 for complete immunization per beneficiary. Similar finding was noted in our study that incentive motivates the ASHAs work as she does not have any other source of income to earn her livelihood. Under NHM she is also entitled to get an incentive of ₹150 per month or per immunization session for mobilization of the beneficiaries at the immunization site for getting the due children’s vaccination.
CONCLUSION
Hence from the study it is concluded that the ASHAs are very clear with roles related to childhood immunization. She is found to be one of the important factors in improvement of vaccination and their contribution is found satisfactory with the scope of further improvement can be noted. Regular refresher training, satisfactory monitory incentives, regular disbursal of incentives can be more effective and keep the motivation high for an ASHA for her services delivery in further improving the childhood routine immunization.
Limitation
Limitation to the study was that it was limited to a single block of Raipur district.
ORCID
Harshal Mendhe https://orcid.org/0000-0002-2719-6168
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