RAJIVEGANDHI UNIVERSITY OF HEALTH SCIENCES

BANGLORE, KARNATAKA,

SYNOPSIS FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. NAME OF THE CANDIDATE :- BIJI KURIAKOSE

1ST YEAR M.Sc NURSING

BGS COLLEGE OF NURSING

APOLLO BGS HOSPITAL

MYSORE

2. NAME OF THE INSTITUTION: - BGS COLLEGE OF NURSING

MYSORE

3. COURSE OF STUDY :- I YEAR M.Sc NURSING

COMMUNITY HEALTH

NURSING

4. DATE OF ADMISSION :- 15-06-2008

5. TITLE OF THE TOPIC :- “ MOTHERS PERCEIVED

PERFORMANCE AND

ATTITUDE TOWARDS

ASHA”

1

6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

“The secret of nations health lies in the homes of the people”1

Health is important not only to the individual but to the society as well. The challenge that

exist today in many countries is to reach the whole population with adequate health care services

and to ensure their utilization. Health is one of the vital indicators reflecting quality of human life.

Health services must be shared equally to all people. Article 25 of the Universal Declaration of

Human Rights undeniably states that healthcare for the preservation and promotion of health is one

of the most basic human rights.

Recognizing the importance of health in the process of economic and social development

and improving the quality of life of our citizens, the Government of India has launched the National

Rural Health Mission( 2005-2012) to carry out necessary architectural correction in the basic health

care delivery system. The Goal of the National Rural Health Mission is to improve the availability

and access to quality health care by people, especially for those residing in rural areas, the poor,

women and children.2

The Sub-centre is the most peripheral level of contact with the community under the public

health infrastructure. With only about 50% MPW (M) being available in these States, the ANM is

heavily overworked, which impacts outreach services in rural areas. To reduce their work stress

Government of India launched National Rural Health Mission to provide every village in the

country with a trained female community health activist ‘ASHA’ or Accredited Social Health

Activist. Selected from the village itself and accountable to it, the ASHA will be trained to work as

an interface between the community and the public health system. ASHA is a volunteer who acts as

a bridge between the community and the available health care system. The ASHA strengthens the

link between health sector and community .3

ASHAs are the link person between the community and the health facilities. The guidelines

for selection are:-2

1)   ASHA must primarily be a woman resident of the village – married/ widowed/ divorced,

preferably in the age group of 25 to 45 years.4

2)   ASHA should be a literate woman with formal education up to class eight. This may be relaxed

only if no suitable person with this qualification is available.

3) Capacity building of ASHA is being seen as a continuous process. ASHA will have to undergo

series of training episodes to acquire the necessary knowledge, skills and confidence for performing

her spelled out roles.5

The ASHA is appointed to take steps to create awareness and provide information to the

community on determinants of health such as nutrition, basic sanitation and hygiene practices,

healthy living condition for working conditions, information on existing health services and timely

utilization of health and family welfare services. She will counsel women on birth preparedness,

importance of safe delivery, breast feeding and complementary feeding, immunization,

contraception and prevention of common infections including respiratory tract infections and

sexually transmitted diseases and care of young child.6

At the village level it is recognized that ASHA cannot function without adequate

institutional support. Women’s committees (like self-help groups or women’s health committees),

village Health & Sanitation Committee of the Gram Panchayat, peripheral health workers especially

ANMs and Anganwadi workers, and the trainers of ASHA and in-service periodic training would

be a major source of support to ASHA.7

6.1 NEED FOR STUDY

One of the key components of the National Rural Health Mission is to provide every village

in the country with a trained female community health activist – ‘ASHA’ or Accredited Social

Health Activist.

3

According to the survey 2001, rural area consists of 742,490,639 population and in urban

286,119,689 population. So total 72.2 % of population are concentrated in rural community and

27.8 % in urban community.8 In India most of the population are concentrated in rural area and it is

crucial for the development of any nation, because healthy people will be able to contribute to the

maximum. It is important to improve the availability of and access to quality health care by people,

especially for those residing in rural areas, the poor, women and children.

Maternal and child health status is assessed through measurements of mortality and

morbidity1. 63 infants out of every 1000 live births die before reaching their first birthday9, and

maternal mortality stands at an alarming rate of 407 per 100,000 live births according to national

health policy.10 Diarrhoea, malaria and acute respiratory problems are the main causes of illness

and mortality among children and infants.. Health care for our rural population has become a

nightmare with no facilities nearby, thereby forcing the rural poor to travel long distances for

medical help. Other factors contributing to inadequate reach of services are illegality, social

exclusion of slums, hidden slum pockets, weak social fabric, lacking coordination among various

stakeholders and neglected political consciousness.

In India, the Number of ASHA  selected during the year 2005-06 were 1,30,315, 2006-07

were 2,60,904, 2007-08 were 81,341, year 2008-09 are 3,559.So Total is 476119.11

Chattopadhyay (2004), conducted a cross sectional study to assess the knowledge and skills

of Anganwadi Workers . In this study they found that the knowledge and skills of Anganwadi

workers in many key areas need improvement. Government of India launched ASHA under

NRHM to mobilize the community and facilitate them in accessing health and health related

services available at the Anganwadi/sub-centre/primary health centers. ASHA will support the

Anganwadi workers in mobilizing pregnant and lactating women and infants for nutrition

supplement. She would also take initiative for bringing the beneficiaries from the village on specific

4

days of immunisation, health check-ups/health days etc. to Anganwadi Centers. So further research

is needed to confirm the performance of ASHA.12

Most of the rural peoples are unaware of the heath services available for them, so there is a

need to understand the activities of ASHA. ASHA is the recently formulated services for rural

people. Till date there is no studies on perceived performance and attitude towards ASHA among

rural population.

Brown cm (2006), conducted a study to assess effects of Trained Birth Attendants (TBA)

training on health behaviors and pregnancy outcomes. In his study he found that the potential of

TBA training to reduce peri-neonatal mortality is promising when combined with improved health

services. ASHA will act as a support system for TBA`s.13

The findings of the study will help the researcher to contribute as an input for further studies

related to perceived performance and attitude of ASHA. This would enable the administrators also

to evaluate the activities and community`s attitude towards ASHA. On the other hand the quality of

service can be improved by increasing the awareness level of the users. This motivated the

researcher to conduct a study regarding the performance of ASHA in rural population.

6.2 REVIEW OF LITERATURE

The review of literature for the present study is described under two headings

1) Studies related to performance of health volunteers like village health guide, trained birth

attendants,ASHA, anganwadi workers

2) Studies related to attitude towards health volunteers

5

1) Studies related to performance of health volunteers(village health guide, trained birth

attendants,ASHA, anganwadi workers)

Mayhew M (2008), conducted a cross-sectional study on determinants of skilled birth

attendant. They conducted a cross-sectional study in all 33 provinces in 2004, yielding data from

617 health facilities and 9917 women who lived near the facilities and had given birth in the past 2

years. Only 13% of respondents had used skilled birth attendants. Women from the wealthiest

quintile (vs the poorest quintile) had higher odds of use (odds ratio [OR] = 6.3; 95% confidence

interval [CI] = 4.4, 8.9). Women living less than 60 minutes from the facility (OR = 1.5; 95% CI =

1.1, 2.0) and residing near a facility with a female midwife or doctor (OR = 1.4; 95% CI = 1.1, 1.8).

Women living near facilities that charged user fees (OR = 0.8; 95% CI = 0.6, 1.0) and that had male

community health workers (OR = 0.6; 95% CI = 0.5, 0.9) had lower odds of use.

Ministry of Health and Family Welfare, Government of India (2008), conducted a

study on evaluation of Village Health Guide Scheme in Belgaum District. The study was aimed at

assessing the functioning of Village Health Guide (VHGs) Schemes, community’s knowledge and

utilization of the scheme and the Health Functionaries Assessment of the functioning of the scheme.

In the study, 94 VHGs, 500 Community Members, 87 Health Workers (ANM and Male Health

Workers) and 18 Medical Officers were interviewed. The findings of this study indicate that the

VHG scheme is not functioning well in the district, although the VHGs have been recruited and

trained when the scheme was introduced in the district during 1983-84. The supply of materials

essentials for VHGs, service delivery and refresher training to improve their knowledge have been

stopped for more than a decade now. Because of this, most of VHGS although they draw monthly

honorarium, as before, are not effectively functioning as prescribed in the scheme.15

G. Narayana, (2008), conducted an operations research on the functioning of the model

developed for ASHA like workers in Uttarakhand, to be carried out in two select blocks in each of

the three upper Himalayan districts, in order to provide the necessary evidence base for its adoption

in the hilly region in the state of Uttarakhand Major activities NGOs selected and contracts signed

547 ASHA Plus to cover six blocks selected Performance based payments system covering a wide 6

range of services finalized Interactive training material developed, pre tested and finalized 547

ASHA Plus workers have undergone three phases of training Household survey and ELCO (eligible

couple) mapping done by ASHA Plus. Flexible population coverage in hilly regions improves

efficiency. Quality of training and incremental training is critical in developing the skills of

worker.16

Sibley LM( 2007) ,conducted a study on traditional birth attendant training and pregnancy

outcomes. Four studies, involving over 2000 TBAs and nearly 27,000 women, are included. One

cluster-randomized trial found significantly lower rates in the intervention group regarding

stillbirths (adjusted OR 0.69, 95% confidence interval (CI) 0.57 to 0.83, P < 0.001), perinatal death

rate (adjusted OR 0.70, 95% CI 0.59 to 0.83, P < 0.001) and neonatal death rate (adjusted OR 0.71,

95% CI 0.61 to 0.82, P < 0.001). Maternal death rate was lower but not significant (adjusted OR

0.74, 95% CI 0.45 to 1.22, P = 0.24) while referral rates were significantly higher (adjusted OR

1.50, 95% CI 1.18 to 1.90, P < 0.001). A controlled before/after study among women who were

referred to a health service found perinatal deaths decreased in both intervention and control groups

with no significant difference between groups (OR 1.02, 95% CI 0.59 to 1.76, P = 0.95). Similarly,

the mean number of monthly referrals did not differ between groups (P = 0.321). One RCT found a

significant difference in advice about introduction of complementary foods (OR 2.07, 95% CI 1.10

to 3.90, P = 0.02) but no significant difference for immediate feeding of colostrum (OR 1.37, 95%

CI 0.62 to 3.03, P = 0.44). Another RCT found no significant differences in frequency of

postpartum haemorrhage (OR 0.94, 95% CI 0.76 to 1.17, P = 0.60) among women cared for by

trained versus TBAs 17

Dongre AR, (2007) conducted a study to find out the nutritional status of under-six

children attending ICDS scheme and to study Anganwadi workers’(AWW) perceived work load

and operational problems. A triangulated research design of quantitative (survey) and qualitative

(Venn diagram, seasonal calendar) methods was used. Nutritional status of children was assessed

by a survey. Participatory methods like Venn diagram and Seasonal calendars were used to collect

qualitative data regarding AWWs perceived work load and food security with malnourished

7

children. Overall, prevalence of underweight and severe underweight among children under-six was

found to be 53% and 15% respectively and among children below three years it was 47% and 15%

respectively. 18

Bhuiyan AB (2005) conducted a pilot study on evaluation of a trained Birth Attendants

performance. The study was conducted in three phases adopting both qualitative and quantitative

methods: assessment of training program; evaluation of after training performances of TBAs; and

evaluation of performance of providers in non-TBA areas. During the post-training period it was

observed that on an average the TBAs performed 3-4 deliveries per month. They were able to

perform different life saving skills. In the areas served by the SBAs, they performed 29% deliveries

and 47% were performed by the TBAs. In control areas TBAs performed 61% deliveries.19

Apantaku, S.O (2005), conducted a study Relevance to primary health care of village

health workers and traditional birth attendants in rural areas.The objectives of the study were to

investigate the relevance of traditional birth attendants (TBAs) and village health workers (VHWs)

in primary health care of rural people, to identify problems encountered by TBAs/VHWs in the

course of their activities, and to determine the attitude of residents (clients and non-clients) towards

the services provided. The study area was rural Ibarapa in Oyo State, Nigeria. The sample consisted

of 30 VHWs, 30 TBAs, their clients (120) and 240 local residents. Data were collected through a

validated and pre-tested structured interview guide. The study concluded that VHWs and TBAs

play a tremendous role and provide essential services in primary health care delivery for rural

people. Problems encountered by VHWs and TBAs were irregular supply of drugs, unsatisfactory

monitoring, supervision and evaluation by higher health officers from the local government and

primary health care centres and poor remuneration.20

Lalit Kant (2003), conducted a study to assess anganwadi workers and their knowledge

about ICDS Profile of 96 anganwadi workers of Inderpuri project area in Delhi and their knowledge

about ICDS was assessed through a questionnaire. 92.71 percent AWW were trained, and only

8

17.71 percent lived and worked in the small locality. The number of children under 2 they would

expect in an anganwadi was known to only one (1.04%) and the number of pregnant and lactating

mother to only 3.12 percent. Majority 92.71 percent could not tell full form of ICDS. Most of them

(90.62%) could not enumerate all the services being provided and none could list out their job

responsibilities. 21

Meghachandrasingh (2003), conducted a study to assess the Effectiveness of training on

the knowledge of vitamin A deficiency among 95 anganwadi workers (AWW) were done in two

groups in a rural block of Haryana State, India to impart knowledge on vitamin A deficiency

(VAD) through lecture, demonstration, discussion. In group A consisting of 56 AWW to whom

colored film slide was shown while in group B consisting of 39 AWW no film slide was shown.

During pre-test 90.5% participants had medium score with an overall mean (± SD) score of 14.1 (±

3.0). Post-test conducted after 6 months showed a significant increase in knowledge of AWW

regarding VAD with a mean score of 211.3 (± 4.51), (P<0.01). Mean score of group A [22.5 (±

4.04)] was significantly higher than mean score of group B [17.4 (± 3.5); P<0.05]. This study

reveals the need for in-service training of AWW using appropriate teaching methods incorportating

audiovisual aids like film slide show for control of VAD.22

2) Studies related to attitude towards health volunteer

Chipfakacha(2000) conducted a study to assess the attitudes of women towards traditional

midwives--a survey in the Kgalagadi (Kalahari) region. 249 women of childbearing age from 20

villages in the Kgalagadi (Kalahari) desert region, who had borne a child, were asked about their

attitudes towards institutional and non-institutional deliveries. 202 (81.6%) women preferred to

give birth at home. 117 (46.9%) attended antenatal clinics at health facilities but virtually none of

these attended postnatal clinics. 41% of the women who prefer to give birth at home do so because

at home they receive African 'muti' and an abdominal massage; 22.5% deliver at home because they

feel it is safer and more convenient. Most African women and communities are reluctant to entrust

the sluicing of their placenta and other products of conception to strangers such as nurses. 90% of

9

respondents suggested that traditional midwives and health personnel should work together to

improve community maternal health services.23

Christopher N (2006) conducted a study to assess the attitudes toward Nurse Practitioner. A

total of 212 subjects completed the survey, for a total response rate of 53% (physicians, 44%; nurse

practitioners, 61%). Most physicians (79.5%) reported that nurse practitioners saw patients in their

practice. Most physicians (80.0%) and nurse practitioners (95.7%) believed that the proposed model

of care would improve the control of chronic illnesses. In addition, most physicians (73.8%) and

nurse practitioners (87.6%) believed that the model of care would be of interest to similar

providers.24

STATEMENT OF THE PROBLEM

“A DESCRIPTIVE STUDY ON PERCEIVED PERFORMANCE AND ATTITUDE

TOWARDS ASHA AMONG MOTHERS IN YELVALA PHC MYSORE”

6.3 OBJECTIVES

1) To describe the perceived performance of ASHA among mothers

2) To determine the perceived attitude towards ASHA among mothers

3) To correlate perceived performance and attitude towards ASHA among

mothers

4) To test the association between selected factors and perceived

performance of ASHA among mothers

5) To test the association between selected factors and perceived attitude

towards ASHA among mothers

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OPERATIONAL DEFINITIONS

1) Perceived performance:- Refers to the observed fulfillment of duty of

ASHA as an interface between the community and the health sector as

listed in the interview schedule

2) Perceived attitude: Refers to the observed settled opinion regarding

ASHA by the rural people as measured by the semantic differential

Scale

3) ASHA:- Refers to the community worker as named in National Rural

Health Mission who are designed to be the first port of call for any

health related demands of deprived sections of the population, especially

women and children, who find it difficult to access health services.

4) Mother:- Refers to women in specific location, geographic area and

boundaries who had received maternal and child care through ASHA.

5) Selected factors:- Refers to those factors which are thought to influence

the perceived performance and attitude towards ASHA such as age, sex,

literacy, instructional media, health, community participation.

7 MATERIALS AND METHODS

7.1 Source of data:- Mothers in yelwala PHC

7.1.1 Research design:- A descriptive survey

7.1.2 Setting:- Yelwala community

7.1.3 Population:- Mothers in Yelwala PHC

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7.2 METHODS OF DATA COLLECTION

7.2.1 Sampling procedure:- Random sampling is adopted for the study

7.2.2 Sample: Mothers who received maternal and child care in Yelwala

PHC

7.2.3 Sample size:- 80

7.2.4 SAMPLE CRITERIA

7.2.4.1 Inclusion criteria

1) Mothers who are beneficiaries of ASHA in Yelwala PHC

2) Mothers who had delivery or antenatal care in Yelwala PHC in past one year

7.2.4.2 Exclusion criteria

1) Mothers who are uncooperative

2) Mothers who are unable to give information due to severe health problem

3) Migrant mothers to Yelwala PHC

7.2.5 DATA COLLECTION METHOD

1) Interview method( Likert`s scale to measure perceived performance)

2) Semantic differential scale to measure attitude towards ASHA

12

7.2.6 DATA ANALYSIS PLAN

Use descriptive and inferential analysis

Duration:- 4 weeks

7.3 Does the study require any investigations or intervention to be conducted on patients or

humans?

No

7.4 Has ethical clearance been obtained from your institution

Yes

1) due permission from authorities will be obtained

2) informed consent will be obtained from village leader

3) Data collected will be kept confidential

4) No physical or psychological harm is caused

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8 LIST OF REFERENCES

1) K park,Textbook of preventive and social medicine, 19 edition,

banarsidas publication,2007.

2) National rural health mission, document available at

www.mohfw.nic.in.

3) Accredited Social Health Activist, available at www.orissa.gov.in.

4)“Uttarkhant health and family welfare society ASHA” available at

http://gov.ua.nic.in.

5) NRHM- ASHA, Ahealthy nation available at http://mohfw.nic.in

6) Guidelines on ASHA, available at mohfw.nic.in.

7) Accredited Social Health Activist, available at mohfw.nic.in.

8) Office of the registrar general and censes commissioner India, “censes

of India”,available at www.censusindia.gov.in.

9) Press trust of India, Bangladesh beats India saving infants, available

at www.expressindia.com.

10) Women child birth and health, Who cries when women dies,

available at www.indiatogether.org.

11) NRHM, ASHA, available at mohfw.nic.in.

12) Chattopadhyay (2004), Study to assess Knowledge and Skills of

Anganwadi Workers, Indian journal of community medicine

vol XXIX no:3.

13)Brown cm (2006), Study to assess effects of TBA training on health

behaviours and pregnancy outcomes, journal of gynaecology and

midwifery, 24(4) :427-8.

14) Mayhew 2008, Study on determinants of skilled birth attendant,

journal of public health,98(10): 49-56.

14

15) Dg satihal(2008),Evaluation of VHG scheme in belgam district

Karnataka, available at http://prcsmohfw.nic.in.

16) G narayana,(2008), ASHA plus project in Uttarakanda, available

at www.usaid.gov.

17) Sibley LM 2007, Study on traditional birth attendant training and

pregnancy outcomes, available at www.cochran.com.

18) Dongre AR, (2007), Study Anganwadi workers’(AWW) perceived

work load and operational problems, ojhas online journal of health

and allied science volume-7.

19) Bhuiyan AB (2005), Study on evaluation of a trained Birth

Attendants performance, international journal gynecology and

obstetrics,90(1): 56-60.

20) Apantaku(2005), Study on relevance to primary health care of

village health worker, the international journal of sustainable

development and world ecology, volume 12, number3, September

2005, pp 256-265(10).

21) Lalit Kant (2003), Study to assess anganwadi workers and their

knowledge about ICDS, journal of public health44(4) :118-23.

22) Megachandrasingh, Effectiveness of training on knowledge of

vitamin A among anganwadi workers’ available at http;//cat.inist.fr.

23) Chipfakacha v , Study on attitudes of women towards traditional

midwives--a survey in the Kgalagadi (Kalahari) region, afr journal

of medicine 2000 Jan;84(1):30-2.

24) Christopher(2006), Attitudes toward Nurse Practitioner,

American Journal of Medical Quality, Vol. 21, No. 6, 375-381 (2006) .

15

9 Signature of candidate :-

10 Remarks of the guide :-

11 Name and designation of guide :- Mrs V ijayalakshmi

Vice principal

11.1 Signature of the guide :-

11.2 Head of the department :- Mrs Vijayalakshmi

11.3 Signature :-

12 Remarks of principal :-

12.1 Signature of the principal :-

16