3.1. Quantitative findings
Out of the 349 CHWs sampled from two zones of the Ahmedabad city, 288 were FHWs, and 61 were MHW, with a mean age of 40.38 ± 7.65 and 36.25 ± 6.48 respectively. Although secondary education is the minimum qualification for the FHWs, we have documented that one-third of the sampled FHWs only completed primary education. Most of the MHWs were found to have at least a bachelor's degree. The professional experience in both categories was found to be similar: 8.29 ± 4.56 and 8.40 ± 3.78 years respectively. The mean catering population per FHW was found to be 3,183 ± 2,108, as compared to the 47,718 ± 66,966 for the MHW. The mean working hours per day were found to be 4.49 ± 0.73 and 8.13 ± 0 .81 for FHW and MHW respectively. As the FHWs are on incentive-based working models, their mean income in INR was found to be 4,098± 1,190, whereas MHWs are on salary-based models with mean incomes of 28,662 ± 6,914. The detailed differences are presented in table 1.
Table 1. Socio-professional details of the community health workers in Ahmedabad, India during 2019
|
Profile
|
FHW
n =288(%)
|
MHW
n=61(%)
|
Age (in years)
|
40.38 ± 7.65
|
36.25 ± 6.48
|
Education
Up to secondary
Secondary/Higher
Graduate/above
|
88 (30.6)
132 (45.8)
68 (23.6)
|
0
13 (21.3)
48 (78.7)
|
Professional experience (in years)
|
8.29 ± 4.56
|
8.40 ± 3.78
|
Catering population
|
3183 ± 2108
|
47718 ± 66966
|
Monthly Income (INR)
|
4098± 1190
|
28662 ± 6914
|
Working hours per day
|
4.49 ± 0.73
|
8.13 ± 0 .81
|
FHW: Female Health Worker; MHW: Male Health worker; INR: Indian Rupee
Continuous variables are expressed as mean ± SD
|
3.1.1. Training and knowledge on zoonoses
Table 2 represents the awareness of the selected zoonotic diseases, which was found to be higher overall among the FHWs as compared to the MHWs, except for the national program on rabies and brucellosis symptoms. Most of the FHWs were aware of the anti-rabies vaccination, which was reflected in their practice such as the higher proportion of ARV counseling or ARC referral. Similarly, the higher awareness about the flu symptoms reflected in the practices of FHWs such as either providing basic medications or UHC referral in case of flu-like cases. Overall, a higher proportion of FHWs as compared to MHWs were aware of at least one symptom of human rabies, influenza.
Table 2. Awareness and practices on selected zoonotic diseases among the community health workers in Ahmedabad, India during 2019
|
Factors
|
FHW
n =288 (%)
|
MHW
n=61 (%)
|
p-value
|
|
Awareness
|
|
|
|
|
Awareness about National Rabies control Programme
|
99 (34.4)
|
45 (73.8)
|
0.000
|
|
Awareness about the influenza vaccine?
|
246 (85.4)
|
54 (88.5)
|
0.526
|
|
Awareness about anti-rabies vaccines
|
287 (99.7)
|
59 (96.7)
|
0.024
|
|
Aware about at least one symptom of rabies
|
226 (86.6)
|
41 (67.2)
|
0.060
|
|
Aware about at least one symptom of brucellosis
|
3 (1.1)
|
3 (4.9)
|
0.034
|
|
Aware about at least one symptom of flu
|
285 (98.9)
|
60 (98.3)
|
0.690
|
|
Practices
|
|
Ever received zoonosis training
|
229 (79.5)
|
16 (26.2)
|
0.000
|
|
Ever participated zoonosis campaigning
|
194 (67.6)
|
49 (80.3)
|
0.049
|
|
What you do when you come across a case of a dog bite?
Counsel for ARV
Refer to UHC/ ARC
Inform to FHS/MO
|
43 (14.9)
203 (70.5)
15 (5.2)
|
6 (9.8)
29 (47.5)
0
|
0.298
0.001
0.068
|
|
What you do when you come across a case of flu-like symptoms?
Give basic medicines
Refer to UHC
Inform to FHS/MO
|
117 (40.6)
256 (88.9)
9 (3.1)
|
1 (1.6)
47 (77)
3 (4.9)
|
0.000
0.013
0.485
|
|
*p<0.05 is considered as significant, derived from the Chi-squared test for the female and male health worker
FHW: Female Health Worker; MHW: Male Health worker; ARV: Anti-rabies vaccine, UHC: Urban Health center; ARC: Anti-rabies Clinic; FHS: Female Health Supervisor; MO: Medical Officer
3.2. Qualitative findings
Six FGDs (4 among the FHWs and 2 among the MHWs) were conducted across two zones of the city. On exploring the current challenges and their motivation for becoming OHAs, the opinions were clustered on the individual, community, and health system levels based on the thematic analysis.
3.2.1. Individual-level
The current job activities and work profile of the FHWs were to implement most of the national health programs like maternal child health, non-communicable diseases, or immunization. Although they are the backbone of the health system at the grass-root level, they felt demotivated due to several reasons. One of the major reasons might be the absence of appreciation of their dedication that they got neither from the employer nor from the community. In contrast, the MHWs are under fixed-term salaries and they are bound to be transferred to other departments within the city municipal corporation, indicating their lack of consistency in the current role. The low appreciation from the community also remained the same for the MHWs.
“Our name is ‘ASHA’ (in the vernacular language it means Hope!), but we do not have any ‘ASHA’ (in the vernacular language it means also Expectations), they do not appreciate us, ASHA has no any appreciation” (FHW-FGD-3)
“The problem is we are not working for the malaria department only, right now I am working in the malaria department, but I may get transferred to some other department within a few months. Like I was working in the solid waste management department before current assignment” (MHW-FGD-2)
In addition, both of these workers perceived more motivation when they have been involved in larger team activities like the last outbreaks of swine flu or bird flu. Most of these workers worked extensively during the outbreaks with or without formal training. Apart from routine work, FHWs also evinced working on the implementation of any new public health programs or piloting new interventions. They are also working with school-teachers in school health programs and some of them are also involved in mass sanitation campaigning (i.e. Sabarmati River cleaning). This indicates the multidisciplinary working culture of FHWs compared to that of the MHWs.
3.2.2. Community-level
The support of the community members is a major driving force for these FHWs; they felt motivated to work hard when the community accepted them. There was mixed opinion documented for the community perceptions. Although the appreciation was low for the FHWs in most of the cases, most of them mentioned a positive reception by community members, from which they gain goodwill and recognition. However, some CHWs reported negative reactions from the community while disseminating their daily routine. This might be one among other contributing factors for the low motivation among these CHWs.
“…..we feel proud that we are doing some good work, we feel good as they listen to us if we don’t go then they call us and tell that why we did not go there, even if we don’t go for a single day than also, they ask for us, they miss us!” (FHW-FGD-1)
“…..in field people still do not understand, they think we are a beggar and came for begging something, so they use to treat us like a beggar and say ‘aage jao’ means go to next door” (FHW-FGD-2)
“People do not cooperate with us! If we go for fogging in the morning, they ask to come in the afternoon, and when we go in their time, then the houses found to be locked and if we request to access to a rooftop or the water tank, they don’t allow us nor follow our any instructions” (MHW-FGD-1)
3.3.3. Health system-level
FHWs are prime actors at the grass-root level with the multidisciplinary working culture for various health programs. Due to the inception of new programs, the activities are increasing tremendously among the FHWs, which sometimes resulted in non-scheduled work. In addition, failure to receive the financial incentives due to the non-completion of tasks or unavailability of data forms an important system challenge. The major issue remained the incentive-based payment system. Some of them mentioned that introducing a fixed payment for a package of services would increase their motivation for the work they do. There were no such system-level challenges documented by the MHWs.
“We don’t have any fixed work schedule, they (superiors) give us diverse fieldwork if it is from the health department than ‘okay’, but it’s not like that. Today they tell to do this and next day anything else, everyday new work.” (FHW-FGD-1)
“Even though all ASHA workers are working more or less the same, but do not get equal incentives, someone has more population so earning more and someone has not that much population so not getting that much. Even if we work during an outbreak, it was free; we did not get any extra incentives for that.” (FHW-FGD-3)
“At present, we do not have fix pay, we people are doing work on incentive, we will get incentive according to completion of our task, the problem is if we have started any work and couldn’t complete it because of the patient side problem than we will not get the incentive for that. For an example of immunization, we have worked from the first dose of vaccination and in case if a patient would not ready to get measles dose or patient had migrated so, in that case, we would not get incentive even though we worked for rest all.” (FHW-FGD-2)
3.3.4. Motivation for becoming OHAs
Although FHWs have low motivation scores, there are certain factors documented that might increase the motivation of FHWs. One factor is confidence in what they do and another is financial, which might motivate them to take on the additional task of OHAs. Some of them voiced concerns towards the additive task also from the community perspective i.e. opposite gender might not respond well. In addition, the acceptance of new tasks produced a concern as most of their current time is spent on data documentation. Most of FHWs indicated that if the new assignment would generate additional incentives for them, they would be pleased to do so. Therefore, an incentive package is the most important driver for the FHWs to become OHAs. In contrast, the concerns of the MHWs are mostly operational, rather than financial. MHWs were found to be least concerned about the financial matters, as they are on fixed payroll as a salaried employee. MHWs have also produced similar concerns except for financial matters. Further, some of the MHWs refused to consider these additional responsibilities.
“We (ASHA) people were entered in reproductive child health care, that time we didn’t know anything, gradually family planning, vaccination, now non-communicable diseases, yoga many more we are expert, now you can send us anywhere, we can do everything” (FHW-FGD-3)
“Whether we get an incentive or not, but we always do all work for goodness of our area, all people do not think like that if incentive will be more than we will work more dedicatedly” (FHW-FGD-2)
“There should be a specific day for that, and it should be merged with your routine work so you can work in between and instead of two different reports it should go at one place so whoever wants to share about their field they can” (MHW-FGD-1)
“….first of all, we don’t have time. We already have our routine work which we have to finish as per the deadline” (MHW-FGD-2)
In addition, both types of workers have expressed their interest in proper training and skill development in the domain of OH, as this is completely new for them. They have also requested for the vigorous handholding training and practices across the domains of OH. On the one hand, one group proposed that OH activities should happen on a specific day of each week (as like currently Mamata day, a day for maternal/childcare), on the other hand, another group proposed OH activities need to be integrated into their daily routine. In summary, promoting MHWs as OHAs requires more stringent top-down directives while FHWs require additional financial incentives to act as OHAs.