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Background: COVID-19 pandemic has impacted every aspect of life. Health-care workers and health-care delivery were affected the most. Accredited Social Health Activist (ASHA) workers are the backbone of health-care system in India as they are involved in grass root level activities. They have been at the forefront of India's emergency health response system. Lockdowns disrupted day-to-day activities, and delivery of health-care services became a huge challenge.
Objective: The objective of this study is to identify the challenges faced by ASHA workers while delivering health-care services during the COVID-19 lockdowns.
Subjects and Methods: A qualitative study in the form of focus group discussion (FGD) was carried out among the ASHA workers of urban and rural field practice areas. Two FGDs-one each in urban and rural area were conducted. Discussions were about 50–60 min.
Results: The collected data were analyzed by translation and transcription. The transcripted data was divided into topics and subtopics using NVivo version 12. Topics were fear and social stigma, job-related concerns, difficulties in the community, issues in reaching the center, and financial worries.
Conclusion: The present study found that the paucity of transport, workload, late payment, and overtime are the biggest hindrances and challenges for ASHA workers in carrying out their work efficiently. Challenges faced by ASHA workers can be solved within the existing framework of the health-care system. However, addressing the issues they have faced will help combat future epidemics and pandemics.
Keywords: Accredited Social Health Activist workers, challenges, COVID-19, focus group discussion, lockdown
How to cite this URL:
Mohiuddin SA, Butool S, Kenche B. COVID-19 Lockdowns: A Qualitative StudyChallenges Faced by Accredited Social Health Activist Workers in Delivering Health-care Services During. MRIMS J Health Sci [Epub ahead of print] [cited 2023 Mar 30]. Available from: http://www.mrimsjournal.com/preprintarticle.asp?id=362539 |
| Introduction | |  |
The COVID-19 pandemic has impacted every aspect of life worldwide. It has drastically changed every country's health-care delivery system. Due to this unprecedented pandemic causing loss of life and unexplained suffering to humankind, there have been adverse effects on the health-care system worldwide. COVID-19 has disrupted essential health-care delivery services in 90% of countries. Almost 66% of countries reported health workforce-related reasons as the most common causes of service disruption.[1] More than half of the countries recruited additional staff to boost the health-care workforce. The COVID-19 pandemic has affected 43.4 million Indians, of which about 0.5 million have died.[2] To curb the number of cases and subsequent deaths, India imposed two lockdowns, one in the first wave, i.e., from March 24, 2020, to June 30, 2020, and the other in the second wave, i.e., from May 12, 2021, to June 20, 2021.[3],[4]
All the sectors of the country were shut down during these lockdowns except the health-care sector. Health-care workers worked tirelessly to provide uninterrupted health-care services in urban and rural areas. Implementation of the lockdowns has changed the flow of health-care delivery system in the country. India took the lead in providing the best preventive and curative measures depending on the available knowledge about the disease and based on guidelines issued by the World Health Organization for the COVID-19 pandemic. The basic essential health-care services were made possible by the availability of a large cadre of frontline workers, i.e., Accredited Social Health Activist (ASHA), Auxiliary Nurse Midwives, and Anganwadi Teachers.
In India, ASHA workers are grass root level workers acting as a bridge between the community and the government health-care sector. ASHA workers were initially recruited under the National Rural Health Mission in 2005 mainly to provide mother and child health-care services, covering 1000 population.[5] Initially recruited as incentive-based health-care workers for mother and child health services, at present, the job responsibilities assigned to ASHA workers have increased tremendously. From carrying out tasks such as health education and motivation, National Health Programs to fever surveys, home delivery of medicines, and demonstration of COVID-19 precautions.
ASHA workers form the backbone of the health-care system in India. They play a significant role in delivering health-care services at the community level. However, the COVID-19 pandemic and subsequent lockdowns disrupted India's day-to-day activities and routine functioning of primary health care. Nevertheless, through the efforts of frontline workers, India could effectively manage the health crisis arising due to the COVID-19 pandemic. Hence, the present study was conducted to identify the challenges faced by the ASHA workers during the COVID-19 lockdown.
The objectives are to identify the challenges faced by ASHA workers while delivering health-care services during the COVID-19 lockdowns.
| Subjects and Methods | | |
A qualitative study in the form of focus group discussion (FGD) was conducted for 1 month (September 2021) in the urban and rural field practice area of Osmania Medical College, Hyderabad, Telangana. It was carried out among the ASHA workers who worked actively in the COVID-19 response activities in their respective health centers.
About 26 and 25 ASHA workers are in the urban health center (UHC) and rural health center, respectively. ASHA workers working for their respective health centers before the onset of the COVID-19 pandemic are included in the study. Those who did not give consent were excluded from the study. From each health center, 12 ASHA workers were selected by simple random sampling using a lottery method. Before conducting the FGD, a team of eight members were created consisting of one assistant professor, two postgraduates, three interns, and two medicosocial workers. They were given training with regard to various aspects of conducting an FGD.
FGDs were used as a data collection method using the FGD topic guide. The topic guide for conducting FGD was prepared by assistant professor of the community medicine department and it was reviewed by the professor and head of the department. It was prepared by review of the literature and prior face-to-face conversations with the ASHA workers of a UHC area in Hyderabad as a pilot study. After conducting the pilot study, topic guide was further reviewed and necessary changes were made to it. The data collected were in the local language, Telugu. First, it was translated into English then transcription and analysis were done. Transcription was carried out by two postgraduates who were trained before inception of the study.
Two FGDs, one each in urban and rural areas until the point of saturation. Twelve ASHA workers from urban and 12 from rural areas participated in the study under the guidance of a moderator/facilitator and a note taker. Before the conduction of the study, the researchers ensured good rapport between the moderator and study participants and gained confidence in the smooth conduction of FGD. Ice breaking was done by asking about their tasks and duties. It was taken care that all the relevant information, including nonverbal cues, was recorded appropriately by the note taker. Discussions were about 50–60 min. Permission was taken for the audiovisual recording of the responses.
After going through the collected notes and audiovisual recordings thrice, a final verbatim was prepared, which was analyzed in NVivo 12 version. Finally, analyzed results are presented in the form of topics and subtopics.
Ethical consideration
Ethical clearance was taken from the Institutional Ethics Committee of Osmania Medical College. All the ASHA workers were briefed about the study and its nature. Assurance about the confidentiality of their names and anonymity of the collected information and audiovisual recording was given to the study participants. Informed written consent was taken.
| Results | | |
Two FGDs were done with 12 ASHA workers in urban and 12 in rural areas. The following are the main topics and subtopics obtained after data analysis.
Topics and subtopics:
- Fear and stigma
- Fear of spreading the COVID-19 infection to family members
- Social stigma
- Demand to vacate the house.
- Job-related concerns
- Increased workload
- Overtime
- Assigned additional area for survey
- Household chores
- Self-care.
- Difficulties in the community
- Wrong address
- Resistance from people.
- Issues in reaching centre
- Paucity of transport
- Police challan.
- Financial worries
- Late payment
- Financial crisis
- No social security.
Fear and stigma
During 1st and 2nd wave of COVID-19 infection, there was intense fear and anxiety about contracting the infection among the general population and health-care workers. The lack of proper knowledge about the mode of spread of disease increased this fear to a great extent. Due to this intense fear of acquiring COVID-19 infection and mortality related to COVID-19, there were large-scale isolation and ostracization of health-care workers in the community. Most of the ASHA workers were infected with the COVID-19 infection and were isolated. Some were quarantined as they were in contact with the infected individuals. All the ASHA workers feared they might become the source of spreading the infection to their family members.
Fear of spreading the COVID-19 infection to family members
“I was terrified when I was infected with COVID-19 infection because I have a 5-year-old son and 60 years old mother-in-law, as I may spread the infection to them and endanger their lives with the disease.”
Social stigma
Social stigma (untouchability) is an ancient myth for many communicable diseases when little is known about their communicability. Many patients have been subjected to social stigma for several diseases for many years, but in a few diseases, even health-care staff treating such diseases is also subjected to stigma.
“When we went for the survey, we were not allowed to touch the door handles and stairs.
We were not even given a glass of water to drink.”
“Community members commented that we are carrying the virus and spreading it by doing house-to-house surveys.”
“They blamed us for always bringing the bad news.”
“Bring a cure or medicines of COVID-19; don't come empty-handed with some lectures.”
Demand to vacate the house
“My owner asked me to vacate the house as they have small kids and old individuals staying with them.”
“I was asked to pay an extra amount if I want to stay in my owner's house.”
Job-related concerns
Increased workload
During the COVID-19 pandemic, the work of ASHA workers increased 4–5 folds compared to work before the COVID-19 pandemic. They carry out tasks such as immunizing children and pregnant women, accompanying them to antenatal clinics, noncommunicable diseases surveys, Village Health and Nutrition Day, health programs, health education, health promotion, and maintaining health records from pregnancy to noncommunicable diseases.
During the COVID-19 pandemic, they performed many additional tasks, which intensified their work. In addition to the regular tasks, they performed fever surveys, health education about COVID-19 precautionary practices, home delivery of medicines to the patients, tracing contacts and travelers, giving instructions, and monitoring patients and their contacts under quarantine and isolation. Before the emergence of COVID infection, one ASHA worker has to cover 1000 populations. To contain the spread of the disease, they have to screen more populations than on other days as instructed by the higher authorities.
“During COVID, we had to do fever survey for 500 population and 100 houses per day.”
Overtime
When the ASHA worker scheme was started in 2005, they worked for only 2–4 h per day during antenatal and immunization clinics. However, due to the sudden onset of the pandemic and increased workload, they had to work extra hours to provide uninterrupted health-care services.
All the ASHA workers in both areas said they had to work almost 10 h daily, i.e., 5 h more than the regular days.
“I must work 12 h to complete my assigned task without any breaks.”
Assigned additional area for survey
Many ASHA workers acquired COVID-19 infection during their health-care services. Therefore, to compensate for the absence of the COVID-19-positive ASHA workers, the remaining ASHA workers had to carry out their duties.
“Already we have the heavy burden of our work, carrying out other ASHA workers tasks has increased workload on us jeopardizing our health.”
Household chores due to work
Double burden in the form of increased workload in the field area and household chores due to lockdowns (schools were closed). Work was increased in both segments.
“When my children had symptoms, I had to cook different food for them and us.”
Self-care
“I don't have time for meditation, food, or self-care.”
Difficulties in the community
Wrong address
“To escape from testing and quarantine procedures, many patients hide travel history, gave wrong addresses.”
Resistance from people
“Our neighbors, relatives, and family members were not talking to us on the telephone.”
“When I went to duty, our neighbors were not allowing my children in their house.”
Issues in reaching the center
To halt the spread of disease, the government of India restricted the movement of all forms of transport and implemented strict lockdowns all over the country. Due to this, ASHA workers have faced many difficulties in carrying out their tasks.
Paucity of transport
“In the lockdown, I walked for 5 kilometers in the hot blazing summer to reach the health center as there were no transport facilities.”
Police challan
“I was traveling in my brother's auto to the health care center, and passes were not issued at that time police gave challan of rs. 1000/- to us we had to pay it from our pocket.”
“I was traveling with my husband to my field area; police took away my husband's bike; when we showed our pass to them, they said these all are fake. So we had to pay 10000/-to get our bike back.”
Financial worries
Despite all the difficulties with travel and other issues, ASHA workers worked tirelessly but were not paid accordingly. There was a delay in the payment of their incentives for about 2–3 months, due to which they have faced a lot of financial crisis.
Late payment
“Initially, we got the payment for one month; after that, we were paid once in 3–4 months. After that, performance-based incentives were stopped, and only 1000/- for 1 month was given. We worked hard and took so much pain, but we didn't get the fruit of our work done.”
Financial crisis
Due to the lockdown, all the businesses were shut down daily wage workers suffered a lot increasing financial burden on their family members.
“I was the only source of income in my house as my husband lost my job.”
No social security
Health-care workers are at maximum risk of acquiring COVID-19 infection, putting their life and their family member's life at maximum risk. The majority of them did not have any social security schemes. Among health-care workers, ASHA workers had the maximum financial insecurity and lacked government social security support.
“We don't have any insurance; please tell the government to provide any schemes to us.”
“If they want us to work wholeheartedly, then they should also give monetary benefit to us.”
All the ASHA workers in both areas said they were provided with the personal protective equipment kits, sanitizers, and all the necessary medicines on time. All the higher authority members such as medical officers and nurses helped them immensely. Their family members also motivated them and helped them accomplish their tasks efficiently.
ASHA workers in both areas, i.e., urban and rural areas, faced challenges such as fear of spreading the COVID-19 infection to family members, paucity of transport, work-related issues, late payment, and overtime.
Problems which were explicitly stated by ASHA workers of urban areas were – no social security scheme, wrong address, police challan, demand to vacate the house, and social stigma.
The problems ASHA workers in rural areas expressly stated self-care, financial crisis, and household affairs due to work.
| Discussion | | |
This study highlights the role of ASHA workers in delivering health-care services during COVID-19 lockdowns and describes the challenges faced. Most of the challenges they faced were similar in urban and rural areas, but few were unique to ASHA workers of each area. Findings from the present study suggest that ASHA workers' workload was amplified greatly during the COVID-19 pandemic as they carried out extensive COVID-19 surveys and other COVID-19-related activities in addition to their routine tasks. They were also forced to work extra days due to extra COVID-19-related activities. These findings are similar to a study by Gupta et al.,[6] Niyati and Mandela,[7] Kalita et al.,[8] and Liu et al.[9] COVID-19 is an infectious disease and due to a lack of information about the spread of the disease most ASHA workers had to face the issue of social stigma and ostracization this finding is similar to the study by Gupta et al.,[6] Kalita et al.,[8] and Gogoi.[10] Due to this sudden outbreak of the COVID-19 pandemic, the violence against health-care workers has increased to many folds from verbal abuse to aggressive behavior ASHA workers of UHC have also faced the issue of verbal abuse and depressing comments from their community members this finding is similar with the study by Iyengar et al.[11]
Due to increased workload and overtime in the fields to complete the assigned task of COVID-19-related activities, ASHA workers face the issue of no self-care or meditation adding to the stress this finding is similar to the study done by Gupta et al.[6] Due to lockdowns, all forms of transport were paused ASHA workers faced many difficulties to reach the assigned area this finding is similar to a study by Gupta et al.,[6] Gogoi,[10] Saprii et al.,[12] and Meena et al.[13] Many ASHA workers commented that they joined health-care delivery services to help their community members enjoy the highest standard of health and well-being in addition to monetary support to them and their family members. There was a delay in the payment for 3–4 months and a low payment. These findings are similar to the study by Niyati and Mandela[7] Kalita et al.,[8] Gogoi,[10] and Meena et al.[13] During COVID-19 lockdowns, all the sectors of the country were shut which led to the loss of jobs of daily wage workers leading to economic loss and financial crisis. These findings are similar to the study by Gupta et al.,[6] and Niyati and Mandela[7] Many ASHA workers were infected with the COVID-19 infection and they were afraid that they may spread the infection to their family members and other community members. This finding is the same as the study by Kalita et al.[8] and Liu et al.[9]
ASHA workers in both areas said that they were supported by higher authorities such as medical officers and other influential persons of the community which motivated them to work wholeheartedly and enthusiastically. This finding is similar to a study by Gupta et al.,[6] and Liu et al.[9] During COVID-19 lockdowns, to provide uninterrupted services to the community members, the ASHA workers took the extra burden on their part and home delivery of medicines at the doorsteps of the infected persons. This finding is similar to a study by Saprii et al.[12] During their field surveys, ASHA workers have to be in contact with the patients who are infected with the deadliest infectious communicable diseases such as tuberculosis and COVID-19 and are at constant risk of acquiring the infections and endangering their lives. To secure the lives of their family members, they need social security schemes and other monetary benefits. Most of the ASHA workers were worried about the same. These findings are the same as the study by Bajpai et al.[14]
| Conclusion | | |
ASHA workers are the primary grass root level workers who ensure that all the health-care services are delivered to the community's doorsteps. The present study found that the paucity of transport, workload, late payment, and overtime are the biggest hindrances and challenges for ASHA workers in carrying out their work efficiently. Addressing these challenges and resolving most of them are very much possible within the framework of the existing health-care system. A more efficient and robust health-care system will effectively combat future epidemics and pandemics.
Acknowledgment
The author would like to thank the medical officers and all the ASHA workers of urban and rural health centers for helping carry out the research project.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | Gupta S, Samsuzzaman M, Banerjee N, Das DK. Field-level experiences 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 2022;15:8.Available from: https://www.mjdrdypv.org/preprintarticle.asp?Id=330698. [Last accessed on 2022 May 21].  |
| 7. | Niyati S, Mandela SN. Impact of the pandemic on accredited social health activists (ASHA) in India. Rev Agrar Stud 2020;10:204-12. |
| 8. | Kalita M, Borah G, Koch M. Role of accredited social health activists (ASHA) workers in Assam: An analysis in the context of coronavirus disease of 2019 (COVID-19) pandemic. Clin Med 2020;7:5. |
| 9. | 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. |
| 10. | Gogoi MM. ASHA worker as human resource and problem faced by them before and after Covid-19. PalArch's J Archaeol Egypt Egyptol 2020;17:11172-8. |
| 11. | Iyengar KP, Jain VK, Vaishya R. Current situation with doctors and healthcare workers during COVID-19 pandemic in India. Postgrad Med J 2020;98:121-2. |
| 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. |
| 13. | Meena S, Rathore M, Kumawat P, Singh A. Challenges faced by ASHAs during their field works: A cross sectional observational study in rural area of Jaipur, Rajasthan. Int J Med Public Health 2020;10:97-9. |
| 14. | Bajpai N, Towle M, Vynatheya J. Model districts as a roadmap for public health scale-up in India. Public Health 2011;4:1-21. |
Correspondence Address:
Bhavani Kenche,
Department of Community Medicine, Osmania Medical College, Hyderabad, Telangana
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/mjhs.mjhs_84_22
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