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

BackgroundAccredited 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.MethodsWe 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.ResultsWe 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.ConclusionWe 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.

Factors enabling community health workers and volunteers to overcome socio-cultural barriers to behaviour change: meta-synthesis using the concept of social capital

“…The CH W / V and the community members both stressed that their role is respected and separate to being a normal member of the community. This enables them to accompany community members who lack autonomy and decision making power by working with husbands and religious leaders [ 27 ]. "…when they say that their men [Husbands] do not allow them to use contraceptives…next time I go to their house at a time that her man is at home, and I ask her to call her man too, and counsel them together."…”

“…Empowerment is a goal or vision for most CH W / V who are constrained by the social norms of the community. These constraints are seen more acutely when CH W / V are from different social, religious or geographical backgrounds than the people they serve [ 27 ]. CH W/V of both genders are also expected to maintain their roles as spouses, parents and workers (if they are already working on their farms, for example).…”

Bringing Greater Precision to Interactions Between Community Health Workers and Households to Improve Maternal and Newborn Health Outcomes in India

“…It is unclear to what extent the ASHA alone can overcome such norms, and most likely a government-driven effort is needed as was done to establish facility delivery as a norm. 24 Previous research often recommends that ASHAs improve their communication skills, 10 but specific recommendations are lacking or based on small qualitative samples. ASHA training gives general communication tips but lacks specific recommendations to influence households on key behaviors and rarely mentions involving other stakeholders within the household.…”

“They have been neglected for a long time”: a qualitative study on the role and recognition of rural health motivators in the Shiselweni region, Eswatini

“…the presence of more men in the programme might address widespread notions that community health work is for women and deals with “women’s issues” only. However, careful attention must be paid to not further compound gender inequality [ 36 , 37 ].…”