An evaluation of ASHA worker’s awareness and practice of their responsibilities in rural Haryana

Abstract

Introduction-Currently Government of India is providing comprehensive integrated health care to the rural people under the umbrella of National Rural Health Mission (NRHM). A village level community health worker " Accredited Social Health Activist " (ASHA)' acts as an interface between the community and the public health system. Therefore present study was conducted to access the socio-demographic profile of ASHA workers and to assess the knowledge, awareness and practice of their responsibilities.

Full text

Open Access Article│www.njcmindia.org pISSN 0976 3325│eISSN 2229 6816
National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013 Page 76
Original Article ▌
AN EVALUATION OF ASHA WORKER’S AWARENESS AND
PRACTICE OF THEIR RESPONSIBILITIES IN RURAL
HARYANA
P K Garg1, Anu Bhardwaj2, Abhishek Singh3, S. K. Ahluwalia4
Financial Support: None declared
Conflict of interest: None declared
Copy right: The Journal retains the
copyrights of this article. However,
reproduction of this article in the
part or total in any form is
permissible with due
acknowledgement of the source.
How to cite this article:
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(1): 76-80.
Author’s Affiliation:
1 Associate Professor; 2 Assistant
Professor; 3 Resident; 4 Professor
and Head, Department of
Community Medicine, Maharishi
Markandeshwar Institute of
Medical Sciences, Mullana
Correspondence:
Dr Abhishek Singh,
Email: abhishekparleg@gmail.com
Date of Submission: 14-09-12
Date of Acceptance: 28-01-13
Date of Publication: 31-03-13
ABSTRACT
Introduction- Currently Government of India is providing
comprehensive integrated health care to the rural people under
the umbrella of National Rural Health Mission (NRHM). A
village level community health worker “Accredited Social Health
Activist” (ASHA)’ acts as an interface between the community
and the public health system. Therefore present study was
conducted to access the socio-demographic profile of ASHA
workers and to assess the knowledge, awareness and practice of
their responsibilities.
Methodology- The study was conducted in the rural field practice
area of the department of community medicine, MMIMSR,
Mullana. All 105 ASHA workers in the area were included in the
study and were interviewed using a self designed semi-structured
questionnaire. Data was analyzed using SPSS and valid
conclusions were drawn.
Results- Majority of ASHA workers were aware about helping in
immunization, accompanying clients for delivery, providing
ANC and family planning services as a part of responsibility.
Only 17-19% of ASHAs knew about registration of births and
deaths, assisting Auxiliary Nurse Midwife (ANM) in village
health planning, creating awareness on basic sanitation and
personal hygiene.
Conclusion- ASHAs do provide constellation of services and play
a potential role in providing primary health care but still they
need to put into practice their knowledge about while providing
services and/or advice to negotiate health care for poor women
and children.
Key words- ASHA, Awareness, Responsibility, Practice
INTRODUCTION
The Government of India launched the National
Rural Health Mission (NRHM) on 12th April
2005, to provide accessible, accountable,
affordable, effective and reliable primary health
care, especially to the poor and vulnerable
sections of the population.1,2 The Mission adopts
a synergistic approach by relating health to
determinants of good health viz. segments of
nutrition, sanitation, hygiene and safe drinking
water.3 One of the key components of the
mission is creating a band of female health
volunteers, appropriately named “Accredited
Social Health Activist” (ASHA) in each village
within the identified States. These village level
community health workers would act as a
‘bridge’ or an interface between the rural people

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and health service outlets and would play a
central role, in achieving national health and
population policy goals.4,5
Framework of the NRHM underlines ASHA as a
health activist in the community.5 She is
expected to Provide primary medical care with
her kit, Control of diseases by information,
education, sanitation and surveillance, antenatal,
natal & postnatal services to women ,
counselling on family planning, safe abortion,
child Immunization and Vitamin A
supplementations, change in behaviour in breast
feeding, birth spacing, sex discrimination, child
marriage, girls education, care of the child
especially newborn, household survey,
collaborating with health functionaries, working
with community for disease control, to create
awareness on health and its determinants,
mobilize the community towards local health
planning, and increase the utilization of the
existing health services.6,7
The current study has been designed for
ascertaining how efficient the ASHAs are to play
their defined roles effectively. They can play an
important role in identifying problems at the
earliest and help in improving community health
status. Therefore the present study was
undertaken to understand the functioning of the
ASHAs in the community. Objectives of the
study were to assess the socio-demographic
profile of ASHA workers and to study their
knowledge, awareness and practice of their
responsibilities.
MATERIALS AND METHODS
The present cross sectional study was carried out
in the rural field practice area of the department
of community medicine, Maharishi
Markandeshwar Institute of Medical Sciences
And Research (MMIMSR), Mullana (Ambala)
during the period of June 2010 to May 2011. The
Field practice area covers 95 villages covering
population of 135000 and has a total of 105
ASHA workers. All ASHA workers in the area
were included in the study. However, those who
could not be contacted despite three visits were
excluded. Finally data collected from 105 ASHA
workers was included in the study. The Medical
officers In charge of the respective PHC’s were
met and the days of the meeting with ASHA
workers were ascertained. Ethical committee
approved the study. Informed consent was
obtained from the study participants.
The ASHA workers were interviewed by post
graduate student of Department of Community
Medicine after the meetings using a self designed
semi-structured questionnaire. The questionnaire
was pilot tested on 10 subjects and amended for
clarity with the addition of some answer options
and was modified accordingly. The
questionnaire was designed in English initially
and later translated in Hindi and back translated
to English to check validity of translated
questionnaire contained. A detailed proforma for
the purpose of recording socio-demographic
profile of ASHA workers, their knowledge and
practices regarding things to be done for
antenatal cases, possible complications during
pregnancy, actions supposed to be taken if
ASHA foresees a complication, possible
complications during delivery, knowledge and
practices regarding immunization, knowledge
and practices about general responsibilities,
knowledge and practices about record keeping
and other relevant data etc was prepared for the
purpose of filling observations of the present
study. The collected data was entered in
Microsoft Excel. Coding of the variables was
done. SPSS version 11.5 was used for analysis.
Interpretation of the collected data was done by
using appropriate statistical methods like
percentage and proportions.
RESULTS
Socio-demographic profile of ASHA
functionaries
Data of 105 ASHA workers was included and
analysed in the study. Majority 41 (39.05%) of the
ASHA workers were in the age group of 20-29
years. Mean age of ASHA workers was 31.36
years. Most 89 (84.76%) of the ASHA workers
were Hindus. Most 101 (96.19%) of ASHA
workers completed 8th std or more of schooling.
Of the 105 ASHAs interviewed 93 were married
accounting for 88.57% of the subjects. 102
(97.14%) of ASHA workers completed training
before working as ASHA. In general ASHA
workers were satisfied and happy with their
training.
Knowledge and awareness of her
responsibilities-
A large proportion of the ASHAs commonly
cited vomiting (80.95 %) and swelling of hands
and feet (69.52 %) as pregnancy complications
that women are likely to experience.

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1
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Actions
s
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tions wome
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c
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g
of hands and
/
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n
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e
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g
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t
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sturbance
s
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tel
y
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a
l FRU
r
to
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r
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c
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tions durin
g
e
bleedin
g
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l position of
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ons/fit
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e in mother’s
problem
n
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t
otal 105, 60
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r
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ASHAs' a
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nd of trai
n
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g
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m
e
remainin
g
w
%
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r
this kit.
o
n of birth & de
a
a
ge health plan
n
i
tation and hyg
i
b
ilizing commu
n
u
al health prob
s
ic curative serv
o
od health prac
t
b
out breast fee
d
Provide ANC
c
Family plan
n
y
ing delivery c
a
l
p in immuniza
t
s
sue 1│Jan – M
y
r
(%)
.
95)
.
52)
.
71)
.
80)
.
95)
.
14)
.
47)
.
47)
8
5)
z
e
.
42)
.
42)
.
71)
.
61)
.
57)
.
09)
.
19)
.
00)
5
2)
.
28)
.
47)
8
5)
On
t
31.4
the
nex
t
In
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ask
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g
iv
e
dos
e
Tab
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c
B
C
D
P
o
Me
a
Tet
a
Re
ga
ri
gh
soo
n
of
A
The
tas
k
AN
M
aw
a
h
ygi
thei
r
w
areness abo
w
ere
n
in
g
.
m
uch
w
ere
r
kers
Rec
o
sati
s
rec
o
res
p
The
0%
2
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ths
n
ing
i
ene
n
ity
lem
ices
t
ices
d
ing
c
are
n
ing
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ses
t
io
n
a
r 2013
t
he other ha
n
2% of the
A
pre
g
nant
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t
da
y
. (Table
order to
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kers about
e
d about w
h
e
n? Where
t
e
s to be
g
ive
n
le -2: Respo
n
wled
g
e abo
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c
cine
Satisf
a
C
G 63 (6
0
PT 66 (6
2
o
lio 85 (8
0
a
sles 80 (7
6
a
nus 32 (3
0
a
rdin
g
ne
w
h
tl
y
said tha
t
n
after birth
A
SHAs repor
stud
y
explo
k
s. Ver
y
fe
w
M
in vill
a
a
reness on
i
ene and re
g
r
responsibi
l
ut her resp
o
o
rd keepi
n
s
factor
y
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c
o
rds which
p
ect to their
people pri
m
17%
21%
26%
37
%
2
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pISSN 0
9
n
d, it was s
u
A
SHAs said
w
oman to c
o
1)
a
scertain k
n
immunizat
h
en and ho
w
t
o take the
n
. (Table 2)
n
se of ASH
A
u
t immuniz
a
Response (
%
a
ctory Not s
a
0
.00) 36
2
.85) 31
0
.95) 20
6
.19) 18
0
.47) 64
w
born care,
t
newborns
a
(67.62%), f
o
tin
g
deaths
i
red ASHAs
w
ASHAs
ag
e health
basic san
i
g
istration o
f
l
ities. (Fi
g
ur
e
o
nsibilities
ng
practice
c
ept birth
&
were relat
i
maintenan
c
m
aril
y
inspi
r
%
66%
60%
8
9
76 3325
│
eISS
N
u
rprisin
g
to
h
that the
y
w
o
nsult the
A
n
owled
g
e o
f
ion questio
w
man
y
do
s
child? An
d
A
s re
g
ardin
g
a
tion
%
)
r
e
a
tisfactory
(34.28)
6
(29.53)
8
(19.05)
0
(17.14)
7
(60.95)
9
ma
j
orit
y
of
a
re most lik
e
o
llowed b
y
a
i
n first week
familiarit
y
w
mentioned
plannin
g
,
i
tation &
f
births &
d
e
1)
b
y
ASH
A
&
death re
g
i
vel
y
defici
e
c
e and com
p
r
in
g
them to
80.40%
91.10
%
92.90
%
96.1
96.
4
98
%
1
0
8
0% 100%
N
2229 6816
Page 78
h
ear that
ould ask
A
NM the
f
ASHA
ns were
s
es to be
d
booster
g
their
No
e
sponse
6
(5.72)
8
(7.62)
0
(0.00)
7
(6.67)
9
(8.58)
ASHAs
e
l
y
to die
a
quarter
of life.
w
ith their
assistin
g
creatin
g
personal
d
eaths as
A
s was
g
istration
e
nt with
p
leteness.
work as
%
%
0%
4
0%
%
0
0%
120%

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National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013 Page 79
ASHA were Gram Pradhan (70.47%) and family
members (52.38%). (Table 3)
Table 3: Practice of ASHAs regarding record
keeping and their views about inspirational
force behind them
Study Variable Number (%)
Various record keeping by ASHA workers *
ANC records 101 (96.19)
Immunization records 98 (93.33)
Delivery records 96 (91.43)
Family planning records 90 (85.71)
Birth & death registration records 73 (69.52)
Household survey records 83 (79.05)
Inspirational Force Behind ASHA workers *
Gram Pradhan 74 (70.47)
family members 55 (52.38)
ANMs 48 (45.71)
Others 25 (23.81)
* Multiple responses
Table 4: Distribution of ASHAs according to
motivational factors to become ASHA, cash
remuneration received and expectations for
better work by them
Study Variable Number (%)
Motivational factors for ASHA workers*
To provide health services 54 (51.43)
To earn money 85 (80.95)
Doing work gives satisfaction 58 (55.24)
To do something (pass time) 32 (30.48)
Serving/helping the community 65 (61.90)
Hoping for absorption in
government job
21 (20.00)
Amount of monthly cash remuneration
received (in Rupees)
<200 22 (20.95)
200-500 35 (33.33)
500-800 28 (26.67)
>800 20 (19.05)
Expectations by ASHA for better work*
Better Incentives 89 (84.76)
Fixed regular monthly payment 98 (93.33)
Better means of transportation of
patients
27 (25.71)
Incentive for more work 35 (33.33)
More medicines 14 (13.33)
Others 7 (6.67)
* Multiple responses
Major motivating factor for ASHAs were either
financial gain (80.95%) or serving/helping the
community (61.90%). About one-fifth of ASHAs
were earning more than Rs.800 per month
whereas one-fifth were earning less than Rs. 200
per month, showing the varying capability of
ASHAs. Majority of the ASHAs (71.66%) were
not satisfied with their incentives. There was a
general demand from all stakeholders for a
regular monthly payment to each ASHA besides
the job related incentives. For betterment of work
around 84.76% expect better pay. (Table 4)
DISCUSSION
Majority (39.05%) of the ASHA workers were in
the age group of 20-29 years. Similar result was
observed by others.4,8 Thus majority of the
ASHAs may be considered young and this may
be strength for programme as they are energetic
and enthusiastic and may deliver better service
with proper motivation and capacity building.
ASHA envisage a total period of 23 days training
in five episodes. It is said that ASHA training is a
continuous one and that she develops the
necessary skills & expertise through continuous
on the job training.9 Regarding level of
education, most of ASHA workers had
completed minimum 8th std but a few i.e. 4
ASHAs (3.80%) had education less than 8th std.
Another report shows percentage of ASHAs
educated below 8th std as high as 32.8%.2 This
can be explained by the fact that selection criteria
are 8th Class and at some places it has been
reduced to 5 th Class.8 Similar findings were
obtained by others.2,10
Report on assessment of ASHA and Janani
Suraksha Yojana (JSY) in Rajasthan shows that
only 19.7% of ASHAs cited that pregnant women
are likely to experience vomiting.11 This is in
contrast to our finding which shows > 80% of
ASHAs said so. Our findings indicate low
knowledge levels with special reference to direct
Obstetric complications during delivery and post
partum period (Table 1). Prolonged labour as a
complication was not mentioned by ASHAs and
this could be life threatening if not managed in
time.
As far as ASHAs knowledge about
immunization was concerned, their overall
response was not satisfactory specifically
regarding tetanus immunization. Most of the
ASHAs preferred helping in delivery and
immunization. These activities are also
associated with financial incentives. But many
other jobs like promotion of awareness on
hygiene and sanitation, counselling on family
planning etc. were drawing lesser attention
probably due to lack of incentives. They were

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National Journal of Community Medicine│Volume 4│Issue 1│Jan – Mar 2013 Page 80
also not very much aware about their role in
birth and death registration. These could be
areas requiring reorientation.
The study revealed that only 57.14% of the
ASHAs received drug kit, immediately after
training. Non-availability of drug kits is a matter
of concern. Not surprisingly, finding of our
study mimics the finding presented by ‘Rapid
appraisal of functioning of ASHA in Orissa’.8
Availability of drug kit helps ASHAs in not only
attending some primary medical care needs, but
also builds confidence of community in ASHAs
as someone available in “ hour of need”.
The present study revealed that the most
important motivational factor for the ASHAs
were the financial gain. Others studies have
observed similar result.4,6,8 ASHA workers
received incentive of Rs. 25/- per ANC for a
maximum of 03 ANC visits for a particular
pregnant woman, Rs. 200/- for facilitating
pregnant women per institutional delivery, Rs.
100/- per case for complete immunization of
children other than routine immunization
coverage, Rs. 50/- per case for birth & death
registration.12
Hope of being absorbed in government job was
least important motivational factor in our study
whereas this factor was ranked second most
important motivational factor in another study
conducted in Uttar Pradesh in 2008.10 This study
contradicts our observation on this aspect.
Initially they had immense hope from
government but hope got blunted with the
passage of time, could be a possible explanation
for the same.
CONCLUSION
In general ASHAs are satisfied and happy with
the training. But their perception about the in job
responsibilities appeared to be incomplete and
improper. Many of them were not aware about
their role in assisting ANM in village health
planning, creating awareness on basic sanitation
& personal hygiene. They were also not very
much aware about their role in birth and death
registration. Incentives in monitory terms and
capacity building in the weak areas of training
can act as driving force in delivering better
health services. ASHAs do provide constellation
of services and play a potential role in providing
primary health care but still they need to put into
practice their knowledge about while providing
services and/or advice to negotiate health care
for poor women and children.
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