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Field level experiences in delivering COVID-19-related services by accredited social health activists in a block of Purba Bardhaman District, West Bengal: A qualitative study


 Department of Community Medicine, Burdwan Medical College, Bardhaman, West Bengal, India

Date of Submission24-Mar-2021
Date of Decision24-May-2021
Date of Acceptance27-Aug-2021

Correspondence Address:
Niladri Banerjee,
Indrakanan, Sripalli, Burdwan, Purba Bardhaman - 713 103, West Bengal
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_219_21

  Abstract 


Background: Health-care workers at all levels are putting their best efforts to contain the COVID-19 pandemic. In resource-poor country like India, the community health workers are given primary responsibility for prevention and control measures at the village level. Learning from their experiences and addressing constraints will ensure improved service delivery in the face of further waves of pandemic. Aim: The aim of the study is to explore the field level experiences of Accredited Social Health Activists (ASHAs), working in Bhatar block of Purba Bardhaman district, West Bengal, while delivering COVID-19 response services and to elicit the nature of constraints faced by them. Materials and Methods: This was a qualitative study with phenomenological approach conducted among ASHA workers from December 2020 to January 2021. Convenient sampling was done to select 8 participants for data collection by focused group discussion (FGD) using FGD guide. A total of four FGDs with 32 participants were conducted. Data were analyzed using thematic framework approach to identify codes and themes. Results: The experiences are presented under five broad themes and in subthemes. ASHAs were engaged in extensive work amidst various challenges, though they received ample support and cooperation from society and general administration. ASHAs faced issues with inadequate supply of protective equipment and were in need for refresher trainings. Events of social stigma and ostracizations had also surfaced. Limited financial incentives, increased susceptibility to COVID-19, and detachment from family were the main source of stress among ASHAs. Conclusion: The issues identified in this study can be addressed to further utilize ASHAs in delivering services in pandemic context.

Keywords: Accredited Social Health Activists, community health worker, COVID-19, focused group discussion, Purba Bardhaman, West Bengal



How to cite this URL:
Gupta S, Samsuzzaman M, Banerjee N, Das DK. Field level experiences in delivering COVID-19-related services by accredited social health activists in a block of Purba Bardhaman District, West Bengal: A qualitative study. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2021 Nov 30]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=330698




  Introduction Top


COVID-19, caused by SARS-CoV-2, made the entire world face an unprecedented situation. On March 11, 2020, the World Health Organization declared the novel coronavirus disease outbreak a pandemic,[1] which already had swept into over 215 countries claiming casualty of more than 2 lakh worldwide.[2]

In India, the epidemic curve for COVID-19 is uprising for the second time with significant daily death toll. In such situation, the health-care delivery system is facing immense pressure to contain the outbreak which is directly percolated to health-care providers, especially the community health workers (CHWs), namely Accredited Social Health Activists (ASHAs), auxiliary nurse midwives (ANMs), Anganwadi workers, nurses, and doctors.

The concept of CHWs became prominent with the Alma Ata Declaration in 1978 that recognized primary health care as the key element for improving the health of the community,[3] more so in the light of poor doctor population ratio in rural areas. The CHW program mainly conceptualizes them as service extension workers and as an activist for social change. Various programs have incorporated the CHWs as the grassroot level resource person for its effective implementation. Upon success from other programs and poor doctor population ratio in rural areas, rollout of CHWs has become a popular strategy to deliver primary health care at the community level.[4]

As the COVID-19 pandemic unfolded in India, the primary responsibilities of the ASHA workers were expanded, being the vital resource and first point of contact to the health system at community level. They were entrusted for door-to-door surveys, watching out for signs of COVID-19, monitoring people in home quarantine, disseminating pandemic precaution and safety tips to people, tracing primary and secondary contacts, clearing the myths and stigma associated with the disease, and so on. They have also been assigned with the difficult work to keep an eye on migrant workers and ensure that they are observing their quarantine period in the designated centers.[5] Besides all this, the ASHAs need to carry on with their regular activities of providing basic medical care, health services, maternal and child health services, ensuring basic sanitation, activities pertaining to national health programs, health education, etc., Various reports suggest that they have been overloaded with responsibilities coupled with lack of appropriate training, stigmatization and even were suffering from physical abuse.[6]

In the course of this pandemic, these frontline workers while delivering their services have experienced stigmatization, isolation, and social ostracization. These frontline workers are also at heightened risk for contracting COVID-19 due to their occupational exposure and are experiencing social and psychological trauma.[7]

The violence against health-care providers has increased and this surge can be attributed to fear, anxiety, panic, misinformation (as to how the SARS CoV-2 virus outbreak may spread and affect individuals), mistrust, and misplaced quotes in the social media.[8] Health professionals are recognized as “newer untouchables.”[9]

Although there are many studies assessing the difficulties faced by health-care workers such as nurses and doctors, in service delivery during COVID-19 pandemic, field-level evidence of the same on ASHA workers is rare. With this perspective, this qualitative study was conducted on ASHA workers with the objective to explore the field level experiences of ASHAs, working in villages of Bhatar block of Purba Bardhaman district, West Bengal, while delivering COVID-19 response services and to elicit the nature of constraints faced by them during service delivery.


  Materials and Methods Top


Study design and setting

This qualitative study with phenomenological approach was conducted during December 2020–January 2021 among ASHA workers of Bhatar community development block, Purba Bardhaman district, West Bengal, who took part in COVID-19 response activities in their respective service areas.

Study population, sampling and selection of study subjects

A total of 184 ASHA workers are presently working in 104 villages of the study area. The target population was ASHAs working in the study area for at least one year and involved in COVID related activities. The only exclusion criterion was not willing to participate in the study. Convenient sampling was used for selecting the study subjects. Names of the eligible subjects were arranged in a random order to prepare the sampling frame. From the sampling frame, consecutive ASHAs were communicated over telephone, they were briefed about the study and asked for consent. This process was continued until eight ASHAs were found available for the first focused group discussions (FGDs). Similar method of selection was adopted for subsequent FGDs.

Data collection, tools and techniques

Data were collected by FGD. FGD guide was prepared with the help of a subject expert. The guide consisted of probes aimed at encouraging the participants in sharing their overall experiences and constraints faced in delivering services. It was translated into local language from English and back translated by another researcher to see the linguistic equivalence.

A total of four FGDs were done until the point of data saturation. Each FGD consisted of 8 participants, conducted in the presence of a moderator/facilitator and a note taker using a FGD guide. It was taken care of that the notes should contain all relevant information provided by the participants including the nonverbal cues. Each FGD took about 1 h to complete. All FGDs were audio-recorded with proper consent.

Data management and analysis

Collected notes and audio records were gone through rigorously by two experts trained in qualitative research and the final verbatim was prepared. Familiarity was gained by reading the transcripts multiple times. Inductive analysis of the verbatim was undertaken to generate codes/categories and themes. These themes represent the collective understanding of the data as per perceived experiences and constraints. The data were entered and analyzed by using Nvivo (release 1.0, QSR International) software. The report was prepared following the reporting guidelines of COREQ.[10]

Ethical considerations

Ethics clearance was obtained (Memo no. BMC/IEC/023) from the Institutional Ethics Committee of Burdwan Medical College and Hospital. Necessary permissions for conducting the study were taken from appropriate authorities. On the days of data collection, the nature and the purpose of the study were briefed to the participants. They were assured about the confidentiality and anonymity of information collected and that the audio-recording done was only for analysis purpose. Informed written consent was taken.


  Results Top


FGDs were done with 32 ASHAs recruited from all ASHAs working in villages of Bhatar block and involved in COVID-19 response and containment measure task.

Following themes and subthemes were emerged from the analysis:

  1. Service delivery


    • Nature of work
    • Challenges
    • Facilitators.


  2. Support and cooperation


    • Social support
    • From general administration
    • From health-care workers.


  3. Social stigma and ostracization
  4. Training and protective equipment


    • Training needs
    • Provision of personal protective equipment.


  5. Perceived stress and satisfaction


  • Incentives
  • Stress related to detachment from family
  • Stress related to increased susceptibility.


The themes and subthemes are presented in [Figure 1] with their relative contribution that emerged from the analysis.
Figure 1: Treemap of themes and subthemes depicting the relative contribution of various themes and subthemes that emerged from analysis by allocation of proportionate areas to each of them

Click here to view


Description of themes

Service delivery

Nature of work

Before the pandemic, an ASHA worked on an average for 5–6 h per day. To fight the new disease at grassroot level, the average work duration increased by 2–3 h per day for most participants. This included house-to-house survey to gather information on the health profile of household members, travel histories and details, increase awareness on preventive and control measures.

According to an ASHA: “I have to do house to house survey to find out if anyone has fever, cold, cough, sore throat. I had to send them to Bhatar hospital for swab testing….along with this spread awareness about physical distancing, mask wearing and usage….”

Roughly, they had to visit 40–50 houses per day. Besides, they had to support patients and family members of home quarantine by providing quarantine instructions, monitoring contacts, and checking their symptoms, follow-up; identification of high-risk individuals, mobilize community and facilitate them in accessing health-related services (testing) in response to COVID-19. Some of them had to provide service at the quarantine center along with the ANMs: “I had extra duty of supervising at quarantine centre along with didi (ANM).”

Challenges

The usual routine work was jeopardized to some extent and few services like VHND and immunization got interrupted in the initial 2–3 months of lockdown. Following resumption of services, there was reframing of regular works to ensure “the new normal.”

Lack of transportation facility created a lot of distress for ASHAs. Accompanying an antenatal mother to hospital was difficult as said by one ASHA: “….one pregnant mother, called me at middle of night that she was having pain…instantly I went out and reached her home, checked her and found she needed admission. Immediately called 102 ambulance and sent her to hospital, but could not accompany her because I had no transport facility to return”

Support to patients returning from quarantine center was provided by ASHAs and in doing so, they had to face a lot of criticism from community whenever there was lack of facility at quarantine center as quoted by one ASHA: “…didi, no treatment is being given at quarantine centre, poor water supply, mosquito nuisance….”

In spite of their best efforts, villagers will mostly hide their information to avoid being tested or sent to quarantine center for isolation. They were of opinion that as many beneficiaries would test positive, ASHAs would get monetary benefit of 3 lakh rupees.

Facilitators

On the other hand, some facilitators made their task easy as screening for tuberculosis cases was feasible during COVID survey owing to their similar presentations:

We were instructed that anyone with cough, cold, fever needs to be evaluated for TB as well as swab testing for COVID. The two surveys together saved our time.”

Support and co-operation

Social support

Community support enabled them to perform better and various community representatives came forward to resolve issues in difficult times:

I got a list containing the name of that household where one person came from Maharshtra…when I went to their house, they denied of any such visitor…then their next door pressurised the household to tell the truth…….”

Occasionally, few houses would not follow home quarantine guidelines and neighbors helped ASHAs in providing these information. They also developed community network circle for emergency planning and contact tracing.

From general administration

The ASHAs were assisted by local influencers, namely administrative heads, local police, civic volunteers, community circles (club) whenever they faced conflicts with villagers in delivering services. Their efforts were given due appraisal and recognition. All the participants were proud to be awarded the “corona warrior” certificate from the chief minister of the state. One ASHA was appreciated thrice in public forums which boosted her confidence.

From health-care workers

Different functionaries of health-care delivery such as ANM, Anganwadi Workers, Block Medical Officer of Health, Medical Officers, Block ASHA Facilitators (BAFs), and fellow colleagues cooperated with ASHAs. On most of the occasions, BAF would provide with all necessary details of visitors/migrants so that they could be prepared on time to reach the spot and motivate them to shift to quarantine center. In times of difficulty, interacting with co-workers and other health-care workers made them realize that they were not alone and gave them a sense of safety.

Social stigma and ostracization

The issues of stigma related to infectious illnesses are longstanding in the society. Due to the unknown nature of the disease, many incidents of social ostracization were experienced by the workers. Neighbors viewed them as potential spreaders when they returned from work. Two such experiences were shared:

“you are moving here and there in field, you are carrying the disease, so please keep away.”

“While on a field visit, I went for washing hands at the community tap…local people stopped me, they did not allow me to use the tap for washing hands….”

It was challenging to carry out some regular activity when beneficiary preferred not to allow them to touch or weigh the baby while delivering home-based newborn care services…“caregivers told us please check the baby from far…donot touch her…you ask us whatever you need to know we can tell you but please don't take our child for weighing.”

On the other hand, ASHAs supported individuals, newly tested positive for COVID-19, to tide over the circumstances of social discrimination against them.

Training and protective equipment

Job-related training was conducted before utilizing the ASHAs for containment and response measures.

Training needs

The participants recalled that there was only 1-day training at the local administrative office just before the initiation of lockdown and it was inadequate to the actual nature of their work. They perceived lack of quality training as a barrier to encourage community participation and felt the need for refresher training. As described by one ASHA “only 1 day training was given at the local administrative office………on March 11…nothing in details was explained to us…and we were only told to track migrants who come from outside….no training material provided.”

Provision of personal protective equipment

ASHAs reported being provided insufficient protective gear while undertaking their COVID-19 duties. Most of them received cloth masks and caps and were asked to wash and reuse them.“initial 3 months we were supplied with sanitiser and cloth mask from block thereafter discontinued….didnot get adequate gloves.”

Perceived stress and satisfaction

Incentives

In all FGDs, monetary incentive was cited as an important factor shaping their performance at the field level. Monetary concern was one of the contributing factors to reduced family support during this pandemic situation as most of them belonged to families with agricultural background. According to an ASHA, “pandemic has led to loss of daily wage of our family members and I being only earning member, it is difficult to support family with this meagre incentive amount.”

They were also unaware of any social insurance being provided from government level.

Stress related to detachment from family

Deliberating on this issue, few ASHAs disclosed that they considered themselves as the potential risks to their families. Some of the respondents avoided getting close to children or elderly parents to take care of them. Long duty hours kept them busy and most of them could not give time to their family. Detachment from family reminded them of the infectious nature of the disease and created stress…“I cannot even give time to my own family and family members were sometimes annoyed due to this….”

Stress related to increased susceptibility

Given the nature of their work, ASHAs were at high risk of contracting the infection. Discussion revealed that they were worried about their safety and had to be always vigilant at work. With media news revealing huge number of affected and death toll on rise, they always felt insecure and stressed.

“I cried…most of the days I would break crying at home. couldnot get proper sleep at night…. tension increased when I heard one case got detected at Bhatar block…till now I get anxious if I have to go to BMCH/Guskara….

Self-isolation or availability of separate toilet during home quarantine was largely impossible for them in their existing housing conditions. The only measure ASHAs took to ensure the safety of household members were wearing masks, washing hands, bathing, and disinfecting their uniforms immediately after returning from work. None of the ASHAs had prior experience with working in pandemic and lack of understanding regarding the transmission of disease created fear among them.

In spite of all the difficulties, there was an urge to work in this pandemic situation. ASHAs compared their workplace to a battlefield and adapted quickly to the changing situation in larger interest of the public.


  Discussion Top


This study has described the experiences of ASHAs in containment and response measures during COVID-19. Findings suggest that their workload intensified during COVID-19 pandemic and they also had to carry out non-COVID duties to avoid disruption of services. In doing so, they faced constraints in their work which could possibly due to the unknown nature of the disease and inappropriate risk perception associated with it. In regard to their additional workload in carrying out COVID-19 containment and response measures, all of them agreed to have worked for at least extra 2–3 h daily and the same has been reported by Niyati and Mandela[11] in their study. This is largely due to the additional responsibility and new normal state of regular activities.

Administrative support in the form of incentives, appraisals from local influencers, and cooperation from co-workers inspired the ASHAs to work tirelessly. The amount provided as monetary support was felt to be insufficient in comparison to their workload. Moreover, the fact that their job did not entitle them to avail social security benefits was distressing for the ASHAs. Association between higher incentives and ASHAs' job accomplishment was reported in other studies.[12],[13]

While serving the community during the pandemic, ASHA workers faced incidents of ostracization and stigmatization. This finding is in line with the study by Niyati and Mandela[11] who also shared similar instances among their study subjects.

In our study, perceived stress due to higher susceptibility to COVID and detachment from family further contributed to their challenging work environment. Similar findings have been depicted in other studies carried out among frontline workers in India and outside.[7],[14]

On March 27, MoHFW released a training toolkit[5] for the frontline workers but our study finds that none of the ASHAs received adequate COVID-19 specific trainings to address issues on community visit. The workers at the forefront need protection and safety at workplace, but our study reveals that the ASHAs are not getting adequate supply of personal protective equipment.


  Conclusion Top


COVID-19-related activities significantly increased the workload of ASHAs. Support from various sectors of the society helped them overcome incidents of stigmatization and to perform their role amidst various challenges. Need for adequate incentive, provision of personal protective equipment, and trainings were palpable among the ASHAs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
WHO Director-General's Opening Remarks at the Media Briefing on COVID-19-11 March 2020. World Health Organisation; 2020. Available from: https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-mediabriefing-on-covid-19—11-march-2020. [Last accessed on 2021 Jan 27].  Back to cited text no. 1
    
2.
Corona Virus Update (Live). Available from: https://www.worldometers.info/coronavirus/. [Last accessed on 2021 Jan 26].  Back to cited text no. 2
    
3.
World Health Organisation (WHO). Alma Ata Declaration. Geneva: World Health Organization; 1978.  Back to cited text no. 3
    
4.
Witmer A, Seifer SD, Finocchio L, Leslie J, O'Neil EH. Community health workers: Integral members of the health care work force. Am J Public Health 1995;85:1055-8.  Back to cited text no. 4
    
5.
Ministry of Health and Family Welfare (MoHFW), Government of India (GoI). COVID-19 Book of Five Response and Containment Measures for Measures for ANM, ASHA, AWW 2020. Available form: https://www.mohfw.gov.in/pdf/3Pocketbookof5_COVID19_27March.pdf. [Last accessed on 2021 Jan 22].  Back to cited text no. 5
    
6.
Bhaumik S, Moola S, Tyagi J, Nambiar D, Kakoti M. Community health workers for pandemic response: A rapid evidence synthesis. BMJ Glob Health 2020;5:e002769.  Back to cited text no. 6
    
7.
Sagar S, Ravish KS, Ranganath TS, Ahmed MT, Shanmugapriya D. Professional stress levels among healthcare workers of Nelamangala: A cross sectional study. Int J Community Med Public Health 2017;4:4685-91.  Back to cited text no. 7
    
8.
McKay D, Heisler M, Mishori R, Catton H, Kloiber O. Attacks against health-care personnel must stop, especially as the world fights COVID-19. Lancet 2020;395:1743-5.  Back to cited text no. 8
    
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Iyengar KP, Jain VK, Vaishya R. Current situation with doctors and healthcare workers during COVID-19 pandemic in India. Postgrad Med J 2020:1-2.  Back to cited text no. 9
    
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Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. Int J Qual Health Care 2007;19:349-57.  Back to cited text no. 10
    
11.
Niyati S, Mandela SN. Impact of the pandemic on accredited social health activists (ASHA) in India. Rev Agrar Stud 2020;10:204-12.  Back to cited text no. 11
    
12.
Saprii L, Richards E, Kokho P, Theobald S. Community health workers in rural India: analysing the opportunities and challenges Accredited Social Health Activists (ASHAs) face in realising their multiple roles. Hum Resour Health 2015;13:95.  Back to cited text no. 12
    
13.
Bajpai N, Towle M, Vynatheya J. Model districts as a roadmap for public health scale-up in India. Public Health 2011;4:1-21.  Back to cited text no. 13
    
14.
Liu Q, Luo D, Haase JE, Guo Q, Wang XQ, Liu S, et al. The experiences of health-care providers during the COVID-19 crisis in China: A qualitative study. Lancet Glob Health 2020;8:e790-8.  Back to cited text no. 14
    


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