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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 9  |  Issue : 2  |  Page : 135-139

Duties, responsibilities, and challenges of community health workers: Evidence from a health block of northern Indian province


1 District Program Officer Office of Chief Medical Officer (Health and Family Welfare), Chandigarh, India
2 Centre for Public Health Punjab University, Chandigarh, India
3 Department of Pharmacology, Dr. H.S. Judge Dental Institute, Chandigarh, India
4 Department of Community Medicine, Dr. Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India

Date of Submission10-Mar-2021
Date of Decision23-Jun-2021
Date of Acceptance29-Jul-2021
Date of Web Publication20-Dec-2022

Correspondence Address:
Ankit Chaudhary
Dr. Rajendra Prasad Government Medical College, Kangra, Tanda, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_35_21

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  Abstract 


Introduction: Accredited Social Health Activist (ASHA) worker is a significant frontline health worker that acts as a link between community and health services and helps delivering quality health services to vulnerable section of the society. The present study was conducted with an objective to explore the duties and responsibilities of the ASHA worker along with obstacles faced by them while discharging their duties. Methods: It was a cross-sectional study including 150 ASHA workers of a health block in Himachal Pradesh. Data were collected using a semi-structured questionnaire consisting of six subsections dedicated to different dimensions related to ASHA workers. Results: Majority of ASHAs stated that their job had a positive effect on their social relationships, confidence as well as their physical and mental health. About two-thirds workers failed to fulfill targets due to many activities running simultaneously. About 43.3% felt mental stress during the job and 20.7% workers experienced harassment by hospital staff. About 40% stated that they had received unsatisfactory training. Toilet facility was available for only 59.3% workers and safe drinking water for 64.7% ASHAs. Only 4.7% of ASHAs were satisfied with their monthly income. Conclusion: While ASHAs are working with dedication in the field, still they are experiencing many problems associated with their personal life, community norms, terrain of the workplace, transportation, and organizational issues. The study recommends few amendments as ASHAs being an integral part of Indian health system must be given their due consideration so that the vision of universal health coverage and sustained development can be attained effectively.

Keywords: Accredited Social Health Activist workers, challenges, duties, responsibilities


How to cite this article:
Rattu RK, Kumar M, Sekhri K, Chaudhary A. Duties, responsibilities, and challenges of community health workers: Evidence from a health block of northern Indian province. CHRISMED J Health Res 2022;9:135-9

How to cite this URL:
Rattu RK, Kumar M, Sekhri K, Chaudhary A. Duties, responsibilities, and challenges of community health workers: Evidence from a health block of northern Indian province. CHRISMED J Health Res [serial online] 2022 [cited 2023 Jan 30];9:135-9. Available from: https://www.cjhr.org/text.asp?2022/9/2/135/364533




  Introduction Top


Since the inception of Community Health Worker scheme in 1977 in India with a vision of providing health services at the doorsteps of villagers, it has undergone paradigm transformation recently.[1] Introduction of Accredited Social Health Activist (ASHA) workers under the umbrella of the National Health Mission has opened up new horizons and avenues for health service delivery in the community. More than 9.15 lac ASHAs are in place across the country and serve as facilitators, mobilizers, and providers of community level care. These are community members that work exclusively in community settings and serve as bridge between health care consumers and providers to promote health among groups that traditionally lack access to adequate care. A community health worker caters creatively to local needs by recognizing community problems, developing innovative solutions, and translating them into practice.[2] ASHA is the first port of call in the community especially for marginalized sections of the population, with a focus on women and children. Apart from being a health activist, she has responsibility of generating health awareness, providing counseling services, mobilizing community for accessing and utilizing health services, working in collaboration with local governing bodies, providing antenatal and home-based newborn care, providing medical care for common ailments, acting depot for essential drugs and consumables along with active case finding in various diseases such as tuberculosis and COVID-19 and noncommunicable diseases.[3],[4] Several evaluations and assessments have revealed ASHAs as a key figure in contributing to the positive outcomes such as increase in institutional delivery, immunization, control of infectious diseases, and improved breastfeeding and nutrition practices. Further, the States have placed an active training and support system for the ASHAs to ensure continuing training, on site field mentoring and performance monitoring.[5],[6]

Few studies have analyzed the problems and challenges faced by ASHAs while discharging their duties in community setting. Hostility by community, noncooperation by beneficiaries, nonpayment or delayed payment of incentives, poor working conditions and timings, ill attitude by colleagues and superiors and lack of administrative support, etc., have been highlighted.[7],[8],[9],[10] Although the significance of ASHAs has been proved beyond any doubt, yet their problems and challenges are heard and solved infrequently. Moreover, the region-specific data on such account are also lacking which further obscures the countermeasures. Keeping all this in consideration, the present study was conducted with an objective to explore the duties - responsibilities and problems faced by ASHAs while performing their duties in the community to frame and execute effective interventions for the betterment of indispensable community health workers in the form of ASHA workers.


  Methods Top


The study was carried out in a health block of District Una, Himachal Pradesh, comprising of 1 Civil Hospital, 2 Community Health Centers, 6 Primary Health Centers, and 43 sub-centers. It was a cross-sectional study and all the 150 ASHA workers working in the study area were included in the study. Data were collected over a period of 4 months from January 2019 to April 2019. Prior approval from Institutional Ethics Committee was taken. Personal identifiers were removed to maintain anonymity and confidentiality of the participants.

The data were collected using a semi-structured interview schedule. The whole questionnaire was divided into six parts. The first part was related about personal information about ASHA, second to demography of workplace, third one was about problems related to personal life, fourth part was related to problems at workplace, fifth was related to organizational setup, and last one was related to the geographical issues. The tool was developed and tested before data collection. Data were entered into Microsoft Excel spreadsheet, cleaned and transferred to Epi Info™, version 7.2 (Centers for Disease Control and Prevention (CDC) Atlanta, Georgia, USA) software for analysis. Discrete variables are presented as percentages and proportions of each.


  Results Top


A total of 150 ASHAs were included for study purpose. The socio-demographic profile of the study participants is presented in [Table 1]. About 95.3% of the workers were married, about 16% were having less than matriculation status, about 56% had monthly family income <Rs. 10,000 and 15.3% participants had children aged < 5 years. [Table 2] highlights the attributes of the workplace of ASHA workers. Majority (52%) of workers were performing their duties in villages having population of 800–1200. About 54% of participants had been assigned only one village with about 69.3% working 101–200 houses. About 45.3% were visiting her field area/houses for about 2.6–5.0 h/day. About 36% had conducted visits in the range of 201–400 from the commencement of their duties.
Table 1: Sociodemographic profile of study participants

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Table 2: Demographic profile of work place of study participants

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About work profile of ASHAs, it was observed that about 52.7% ASHAs registered <50 antenatal women while 46% did 51–100 registrations. About 1.3% registered more than 150 antenatal women. Similar numbers were also achieved for birth registration. About 95% of ASHAs registered <50 deaths in their field area. [Table 3] depicts the effect of job on personal life of ASHAs after joining the duties. It was observed that about 79.4% ASHAs stated that their job had a positive effect on their social relationships. About 6.7% of participants stated that it had negative impact on the care of their elders at home. About 69.3% and 78% ASHAs stated that they had improved physical and mental health after joining job, respectively. Majority (98%) ASHAs stated that they had increased self-confidence after joining the job.
Table 3: Effect of job on personal life of accredited social health activists after joining the duties

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Regarding problems faced during job, about 20% of ASHAs stated that they encountered community noncooperation frequently. About 66.7% workers stated that they encountered noncompletion of their targets sometimes due to too many activities running simultaneously. About 43.3% stated that they felt mental stress during the job. About 28% revealed that they encountered problems while mobilizing the patient/beneficiary to the health institution. About 20.7% workers stated that harassment by hospital staff was a common experience for them. On further exploration of community noncooperation, common reasons responsible were hesitation (56%), caste factors (24.7%), family disputes (14%), and religious attributes (7.3%). In addition, it was observed that about 92% had experienced lack of stationery items in one or another form. About 40% stated that they had received unsatisfactory training, 32% stated that they lacked updation of skills, while 50% had experienced shortage of IEC material in some form [Table 4].
Table 4: Problems faced by accredited social health activists

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[Table 5] shows the facilities available for ASHA at their work place. Toilet facility was available for only 59.3% workers, safe drinking water for 64.7% ASHAs, while only 7.3% study participants had tele-communication facility. Regarding monthly income of ASHAs, it was noticed that majority (94%) were earning <Rs. 4000/month through incentives and only 4.7% of ASHAs were satisfied with their monthly income. About 80% of participants were not satisfied with training due to training scheduled at distant venues and long schedules of training sessions.
Table 5: Facilities for accredited social health activists at the workplace

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  Discussion Top


The provision for new band of community-based functionaries in Indian health system, named as ASHA was made to further strengthen the health care delivery at most peripheral level especially in rural India and that too for vulnerable sections of society. ASHA as a front-line worker in health department has been given certain job responsibilities, duties, and activities. The present study assessed the same along with the problems faced by them while discharging their duties.

In the present study, the majority of ASHAs were matriculate followed by senior secondary level of education; these results were similar to study done by Shrivastava and Shrivastava in Uttar Pradesh which showed 70% of ASHAs are with qualification below senior secondary.[11] About family income, there were more ASHAs whose total family income was <Rs. 10,000 per month. The demographic scenario in the study population shows that the responsibilities and duties of ASHAs have become more organized, structured, and well maintained; and these duties and responsibilities are more keenly observed and supervised by higher officials. This relationship is also confirmed in study by Garg et al.[12] More than half of the study participants had assisted in antenatal registration of the beneficiary and facilitation of institutional deliveries; findings were corroborated by study conducted in Uttar Pradesh.[11] About 20% of ASHAs who are facing problem in the community relate this to religion- and caste-based discrimination, which affects their proper working. This relation is also highlighted in study by Dagar et al., where 37.5% of ASHAs faced resistance from community.[8] The present study raised concern of ASHAs being harassed by staff of medical facilities; major reason being that these employees have a misconception that ASHAs are not the important part of health services as these are not given any fixed salary. About one-third study participants revealed that they had faced problems during training sessions; similar to findings of study by Panda et al.[13]


  Conclusion Top


The present study evaluated the duties, responsibilities, and problems faced by ASHA workers. It was observed that all the deponents were working well in the field of antenatal registration, birth, and death registration ensuring frequent home visits. While discharging their duties in community, ASHAs suffered from many problems related to their personal life, geographical condition of the workplace, transport facilities, and organizational problems. Most concerning was that ASHAs were facing problems on the basis of caste, religion, and noncooperation from society due to various norms and taboos. Moreover, some ASHAs also felt neglected by hospital staff where they have to go routinely for checkup of patients.

Based on study findings, few amendments must be made to improve community health more comprehensively. There is need to upscale the monthly income by providing them some fixed emoluments as well as enhancement of incentives given to them. Training and counseling sessions should be arranged to enhance their self-confidence and intellectual skills to motivate the community for various health services. The provision of transport facility for mobilization to training venue during training sessions must be ensured. There should be a provision of stationery material, photostat facility, phones/tablets, and other bag articles. Basic amenities such as appropriate sitting area, safe drinking water, and toilet must be provided. In addition, orientation programs for the staff of the hospital for promoting adequate behavior and enlightening them about the importance of ASHAs in health care infrastructure must be conducted. Promotion and advertisement of roles and responsibilities of ASHAs through media must be addressed to minimize caste and religion-based discrimination in the community. ASHAs are an important link between community and the health services and their significance can neither be undermined nor underrated. The vision of sustained development and universal health coverage cannot be realized if we neglect the most peripheral yet most significant front-line functionaries of health.

Limitations

Being a time bound and financially constrained study, the reasons for problems, challenges, and points of unsatisfaction among study participants could not be studied in-depth. Open-ended questionnaire, qualitative data analysis, association between variables, and test of significance for various parameters could have detailed the study results in a more comprehensive manner.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Leslie C. India's community health workers scheme: A sociological analysis. Anc Sci Life 1989;9:40-53.  Back to cited text no. 1
    
2.
Witmer A, Seifer SD, Finocchio L, Jodi ON, Edward H. Community health workers: Integral members of the health care work force. Am J Public Health 1995;85:1055-61.  Back to cited text no. 2
    
3.
Guidelines on Accredited Social Health Activitists (ASHA). Available from: https://nhm.gov.in/images/pdf/communi tisation/task-group-reports/guidelines-on-asha.pdf. [Last accessed on 2021 Feb 17].  Back to cited text no. 3
    
4.
Module for Multi-Purpose Workers (MPW) - Female/Male on Prevention, Screening and Control of Common Non-Communicable Diseases. Available from: https://main.mohfw.gov.in/sites/default/files/Module%20for%20MultiPurpose%20Workers%20%20Prevention%2C%20Screening%20and%20Control%20of%20Common%20NCDS_2.pdf. [Last accessed on 2021 Feb 14].  Back to cited text no. 4
    
5.
Agarwal S, Curtis SL, Angeles G, Speizer IS, Singh K, Thomas JC, et al. The impact of India's accredited social health activist (ASHA) program on the utilization of maternity services: A nationally representative longitudinal modelling study. Hum Resour Health 2019;17:68.  Back to cited text no. 5
    
6.
Fathima FN, Raju M, Varadharajan KS, Krishnamurthy A, Ananthkumar SR, Mony PK. Assessment of accredited social health activists-A national community health volunteer scheme in Karnataka State, India. J Health Popul Nutr 2015;33:137-45.  Back to cited text no. 6
    
7.
USAID Assist Project: Challenges facing the ASHA Female Community Health Workers. Available from: https://www.usaidassist.org/blog/challenges-facing-asha-female-community-health-workers-vital-part-health-system-india. [Last accessed on 2021 Jan 21].  Back to cited text no. 7
    
8.
Dagar N, Bharadwaj U, Bansal P. The problems faced by ASHAs (Accredited Social Health Activist)-A qualitative study. J Nurs Sci Pract 2017;7:25-30.  Back to cited text no. 8
    
9.
Sharma R, Webster P, Bhattacharyya S. Factors affecting the performance of community health workers in India: A multi-stakeholder perspective. Glob Health Action 2014;7:25352.  Back to cited text no. 9
    
10.
Mohapatra S, Nandakumar G, Dharmaraj SK. Barriers Encountered by Accredited Social Health Activists (ASHA) in arthritis rehabilitation: A qualitative study. J Clin Diagn Res 2017;11:C01-4.  Back to cited text no. 10
    
11.
Shrivastava SR, Shrivastava PS. Evaluation of trained Accredited Social Health Activist (ASHA) workers regarding their knowledge, attitude and practices about child health. Rural Remote Health 2012;12:2099.  Back to cited text no. 11
    
12.
Garg PK, Bhardwaj A, Singh A, Ahluwalia SK. An evaluation of ASHA worker's awareness and practice of their responsibilities in rural Haryana. Natl J Community Med 2013;4:76-80.  Back to cited text no. 12
    
13.
Panda M, Nanda S, Giri RC. A study on the work profile of ASHA workers in a district of Odisha in eastern India. Int J Community Med Public Health 2019;6:675-81.  Back to cited text no. 13
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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