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The impact of India's accredited social health activist (ASHA) program on the utilization of maternity services: a nationally representative longitudinal modelling study.

ABSTRACT: BACKGROUND:In 2006, the Government of India launched the accredited social health activist (ASHA) program, with the goal to connect marginalized communities to the health care system. We assessed the effect of the ASHA program on the utilization of maternity services. METHODS:We used data from Indian Human Development Surveys done in 2004-2005 and in 2011-2012 to assess demographic and socioeconomic factors associated with the receipt of ASHA services, and used difference-in-difference analysis with cluster-level fixed effects to assess the effect of the program on the utilization of at least one antenatal care (ANC) visit, four or more ANC visits, skilled birth attendance (SBA), and giving birth at a health facility. RESULTS:Substantial variations in the receipt of ASHA services were reported with 66% of women in northeastern states, 30% in high-focus states, and 16% of women in other states. In areas where active ASHA activity was reported, the poorest women, and women belonging to scheduled castes and other backward castes, had the highest odds of receiving ASHA services. Exposure to ASHA services was associated with a 17% (95% CI 11.8-22.1) increase in ANC-1, 5% increase in four or more ANC visits (95% CI?-?1.6-11.1), 26% increase in SBA (95% CI 20-31.1), and 28% increase (95% CI 22.4-32.8) in facility births. CONCLUSIONS:Our results suggest that the ASHA program is successfully connecting marginalized communities to maternity health services. Given the potential of the ASHA in impacting service utilization, we emphasize the need to strengthen strategies to recruit, train, incentivize, and retain ASHAs.

SUBMITTER: Agarwal S

PROVIDER: S-EPMC6701148 | biostudies-literature | 2019 Aug

REPOSITORIES: biostudies-literature

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The impact of India's accredited social health activist (ASHA) program on the utilization of maternity services: a nationally representative longitudinal modelling study.

Agarwal Smisha S Curtis Sian L SL Angeles Gustavo G Speizer Ilene S IS Singh Kavita K Thomas James C JC

Human resources for health 20190819 1

<h4>Background</h4>In 2006, the Government of India launched the accredited social health activist (ASHA) program, with the goal to connect marginalized communities to the health care system. We assessed the effect of the ASHA program on the utilization of maternity services.<h4>Methods</h4>We used data from Indian Human Development Surveys done in 2004-2005 and in 2011-2012 to assess demographic and socioeconomic factors associated with the receipt of ASHA services, and used difference-in-diffe ...[more]

PMID: 31426801

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Project description:ObjectiveThis study examined the performance motivation of community health workers (CHWs) and its determinants on India's Accredited Social Health Activist (ASHA) programme.DesignCross-sectional study employing mixed-methods approach involved survey and focus group discussions.SettingThe state of Orissa.Participants386 CHWs representing 10% of the total CHWs in the chosen districts and from settings selected through a multi-stage stratified sampling.Primary and secondary outcome measuresThe level of performance motivation among the CHWs, its determinants and their current status as per the perceptions of the CHWs.ResultsThe level of performance motivation was the highest for the individual and the community level factors (mean score 5.94-4.06), while the health system factors scored the least (2.70-3.279). Those ASHAs who felt having more community and system-level recognition also had higher levels of earning as CHWs (p=0.040, 95% CI 0.06 to 0.12), a sense of social responsibility (p=0.0005, 95% CI 0.12 to 0.25) and a feeling of self-efficacy (p=0.000, 95% CI 0.38 to 0.54) on their responsibilities. There was no association established between their level of dissatisfaction on the incentives (p=0.385) and the extent of motivation. The inadequate healthcare delivery status and certain working modalities reduced their motivation. Gender mainstreaming in the community health approach, especially on the demand-side and community participation were the positive externalities of the CHW programme.ConclusionsThe CHW programme could motivate and empower local lay women on community health largely. The desire to gain social recognition, a sense of social responsibility and self-efficacy motivated them to perform. The healthcare delivery system improvements might further motivate and enable them to gain the community trust. The CHW management needs amendments to ensure adequate supportive supervision, skill and knowledge enhancement and enabling working modalities.

Project description:BackgroundMaternal mortality is a persistent public health problem worldwide. The maternal mortality ratio of Myanmar was 250 deaths per 100,000 live births in 2017 which was the second-highest among ASEAN member countries in that year. Myanmar's infant mortality rate was twice the average of ASEAN member countries in 2020. This study examined factors influencing institutional maternity service utilization and identified the need for improved maternal health outcomes.MethodsA cross-sectional study design was used to examine the experience of 3,642 women from the 2015-16 Myanmar Demographic and Health Survey by adapting Andersen's Behavioral Model. Both descriptive and inferential statistics were applied. Adjusted odds ratios and 95% confidence interval were reported in the logistic regression results.ResultsThe findings illustrate that the proportion of women who delivered their last child in a health/clinical care facility was 39.7%. Women live in rural areas, states/regions with a high levels of poverty, poor households, experience with financial burden and the husband's occupation in agriculture or unskilled labor were negatively associated with institutional delivery. While a greater number of ANC visits and level of the couple's education had a positive association with institutional delivery.ConclusionThe determinants of institutional delivery utilization in this study related to the institutional facilities environment imply an improvement of the institutional availability and accessibility in rural areas, and different states/regions, particularly Chin, Kayah and Kachin States- the poorest states in Myanmar. The poverty reduction strategies are urgently implemented because problems on health care costs and household economic status played important roles in institutional delivery utilization. The ANC visits indicated a significant increase in institutional delivery. The government needs to motivate vulnerable population groups to seek ANC and institutional delivery. Moreover, education is crucial in increasing health knowledge, skills, and capabilities. Thus, improving access to quality, formal, and informal education is necessary.

Project description:BackgroundHypertension is a major risk factor for cardiovascular disease, a leading cause of premature death and disability in India. Since access to health services is poor in rural India and Accredited Social Health Activists (ASHAs) are available throughout India for maternal and child health, a potential solution for improving hypertension control is by utilising this available workforce. We aimed to develop and implement a training package for ASHAs to identify and control hypertension in the community, and evaluate the effectiveness of the training program using the Kirkpatrick Evaluation Model.MethodsThe training program was part of a cluster randomised feasibility trial of a 3-month intervention to improve hypertension outcomes in South India. Training materials incorporated details on managing hypertension, goal setting, facilitating group meetings, and how to measure blood pressure and weight. The 15 ASHAs attended a five-day training workshop that was delivered using interactive instructional strategies. ASHAs then led community-based education support groups for 3 months. Training was evaluated using Kirkpatrick's evaluation model for measuring reactions, learning, behaviour and results using tests on knowledge at baseline, post-training and post-intervention, observation of performance during meetings and post-intervention interviews.ResultsThe ASHAs' knowledge of hypertension improved from a mean score of 64% at baseline to 76% post-training and 84% after the 3-month intervention. Research officers, who observed the community meetings, reported that ASHAs delivered the self-management content effectively without additional assistance. The ASHAs reported that the training materials were easy to understand and useful in educating community members.ConclusionASHAs can be trained to lead community-based group educational discussions and support individuals for the management of high blood pressure.Trial registrationThe feasibility trial is registered with the Clinical Trials Registry - India (CTRI) CTRI/2016/02/006678 (25/02/2016).

Project description:Food production is a major driver of environmental change, and unhealthy diets are the leading cause of global disease burden. In high-income countries (HICs), modelling studies suggest that adoption of healthy diets could improve population health and reduce environmental footprints associated with food production. We assessed whether such benefits from dietary change could occur in India, where under-nutrition and overweight and obesity are simultaneously prevalent. We calculated the potential changes in greenhouse gas (GHG) emissions, blue and green water footprints (WFs), and land use (LU), that would result from shifting current national food consumption patterns in India to healthy diets (meeting dietary guidelines) and to "affluent diets" (those consumed by the wealthiest quartile of households, which may represent future purchasing power and nutritional trajectories). Dietary data were derived from the 2011-12 nationally-representative household expenditure survey, and we assessed dietary scenarios nationally and across six Indian sub-regions, by rural or urban location, and for those consuming above or below recommended dietary energy intakes. We modelled the changes in consumption of 34 food groups necessary to meet Indian dietary guidelines, as well as an affluent diet representative of those in the highest wealth quartile. These changes were combined with food-specific data on GHG emissions, calculated using the Cool Farm Tool, and WF and LU adapted from the Water Footprint Network and Food and Agriculture Organization, respectively. Shifting to healthy guidelines nationally required a minor increase in dietary energy (3%), with larger increases in fruit (18%) and vegetable (72%) intake, though baseline proportion of dietary energy from fat and protein was adequate and did not change significantly. Meeting healthy guidelines slightly increased environmental footprints by about 3-5% across GHG emissions, blue and green WFs, and LU. However, these national averages masked substantial variation within sub-populations. For example, shifting to healthy diets among those with dietary energy intake below recommended guidelines would result in increases of 28% in GHG emissions, 18 and 34% in blue and green WFs, respectively, and 41% in LU. Decreased environmental impacts were seen among those who currently consume above recommended dietary energy (-6 to -16% across footprints). Adoption of affluent diets by the whole population would result in increases of 19-36% across the environmental indicators. Specific food groups contributing to these shifts varied by scenario. Environmental impacts also varied markedly between six major Indian sub-regions. In India, where undernutrition is prevalent, widespread adoption of healthy diets may lead to small increases in the environmental footprints of the food system relative to the status quo, although much larger increases would occur if there was widespread adoption of diets currently consumed by the wealthiest quartile of the population. To achieve lower diet-related disease burdens and reduced environmental footprints of the food system, greater efficiency of food production and reductions in food waste are likely to be required alongside promotion of healthy diets.

Project description:BackgroundYoung people with physical disabilities face barriers to accessing health care; however, few studies have followed adolescents with physical disabilities longitudinally through the transition of care into adulthood. The objective of this study was to investigate differences in health care utilization between adolescents with physical disabilities and those without during the transition period from adolescent to adult care.MethodsWe utilized the National Longitudinal Study of Adolescent to Adult Health, a prospective cohort study following adolescents ages 11-18 at baseline (1994-1995) through adulthood. Baseline physical disability status was defined as difficulty using limbs, using assistive devices or braces, or having an artificial limb; controls met none of these criteria. Health care utilization outcomes were measured seven years after baseline (ages 18-26). These included yearly physical check-ups, unmet health care needs, and utilization of last-resort medical care, such as emergency departments, inpatient hospital wards, and inpatient mental health facilities. Multiple logistic regression models were used to predict health care utilization, controlling for age, sex, race/ethnicity, insurance status, and history of depression.ResultsThirteen thousand four hundred thirty-six participants met inclusion criteria, including 4.2% with a physical disability and 95.8% without. Half (50%) of the sample were women, and the average age at baseline was 15.9 years (SE = 0.12). In logistic regression models, those with a disability had higher odds of unmet health care needs in the past year (Odds Ratio (OR) 1.41 95% CI 1.07-1.87), two or more emergency department visits in the past five years (OR 1.34 95% CI 1.06-1.70), and any hospitalizations in the past five years (OR 1.36 95% CI 1.07-1.72). No statistically significant differences in preventive yearly check-ups or admission to mental health facilities were noted.ConclusionsYoung adults with physical disabilities are at higher risk of having unmet health care needs and using last-resort health care services compared to their non-disabled peers.

Project description:BackgroundIntimate partner violence (IPV) adversely affects women's reproductive health outcomes but to what extent women's justification of IPV affects maternal health care service utilization is unexplored.MethodsThe secondary cross-sectional datasets from multiple indicator cluster surveys of Afghanistan, Bhutan, Nepal and Pakistan conducted between 2010 and 2015 were used. We used a generalized linear mixed model with random effects, at both cluster- and country-level, to determine the odds ratio of maternal health service utilization at the regional level and a multivariable logistic regression model adjusting for complex survey design at the country level. Interaction between women's justification of IPV and residential location, and linear trend in the utilization of maternal health care services associated with increasing levels of women's justification of IPV, were examined using the Likelihood Ratio Test (LRT).ResultsA total of 26,029 women aged 15-49 years, living with their partners and had a pregnancy outcome 2 years prior to the survey were included. Women justifying IPV were less likely to utilize contraceptive methods (aOR) = 0.86, 95% CI 0.84, 0.88), at-least one Antenatal Care (ANC) visit (aOR = 0.80, 95% CI 0.72, 0.88), four or more ANC services (aOR = 0.81, 95% CI 0.76, 0.86), institutional delivery (aOR = 0.87, 95% CI 0.80, 0.94) and Post-natal Care (aOR = 0.76, 95% CI 0.62, 0.95) services. A decreasing linear trend was observed for four or more ANC visits (LRT P = 0.96) and institutional delivery (LRT P = 0.80) with increasing levels of IPV justification. Women justifying IPV were less likely to have at least one ANC visit in urban (aOR 0.67, 95% CI 0.60, 0.75) compared to rural areas (aOR 0.83, 95% CI 0.73, 0.94).ConclusionsWomen's justification of IPV was associated with decreased odds of utilizing a wide range of maternal health care services at the regional level. Although further research that may help establish a causal link is important before formulating public health interventions, our study indicates interventions targeting women's condoning attitude toward IPV, delivered sooner rather than later, could potentially help to improve women's utilization of essential maternal health care services in the South Asian region that comprises Afghanistan, Bhutan, Nepal, and Pakistan.

Project description:BackgroundThe World Health Organization (WHO) defines quality health services as being effective, safe, people-centered, timely, equitable, integrated and efficient. It is critical to understand people's perspectives and care experiences to measure progress against these goals. However, many low- and middle-income governments do not routinely collect such information. In this study, we aim to measure health systems performance from the perspective of the adult population of users and non-users in Lao PDR.MethodsUsing the People's Voice Survey (PVS), a novel phone-based survey designed to integrate people's voices into primary care performance measurement, we conducted a cross-sectional survey of the general adult (18+) population in Lao PDR in 2022. We analyzed health care utilization patterns, user-reported quality of care, and coverage of key preventive health services. Data from the most recent MICS survey was used to create sampling weights generating nationally representative estimates.ResultsA total of 2007 adults completed interviews in approximately 3.5 months. About two thirds (65%) of respondents reported visiting a health facility in the past year and, of these, the majority (61%) visited a hospital as opposed to a health center or clinic. Among those that recently visited health facilities, 28% rated their experience as "poor" or "fair". 16% had unmet need for care and 12% reported discrimination during treatment in the past year. 12% of women over 50 years old reported receiving a mammogram and 59% of adults reported receiving blood pressure screening in the previous year.ConclusionsThe study presents data from the first nationally representative survey in Lao PDR to measure health system performance. The results indicate that, despite progress towards universal coverage of health insurance in Lao PDR, significant gaps remain, particularly with respect to bypassing of primary care facilities, significant unmet need for care, experiences of discrimination, and overall low perceptions of quality of care.

Dataset Information

The impact of India's accredited social health activist (ASHA) program on the utilization of maternity services: a nationally representative longitudinal modelling study.

Publications

The impact of India's accredited social health activist (ASHA) program on the utilization of maternity services: a nationally representative longitudinal modelling study.

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