INTRODUCTION: Diarrhoeal diseases and their associated consequences for child malnutrition and stunting remain a pressing concern in India. The ambitious target set under the Government of India’s POSHAN Mission in 2018 to achieve a 6% reduction in child stunting by 2022 is fast approaching[1]. Yet, child stunting rates are stagnating[2] and even increasing across several states, according to the latest figures from the National Family Health Survey 2020[3]. Exposure to faecal pathogens and poor water, sanitation and hygiene (WASH) conditions are increasingly recognised as a primary cause of child stunting[4]. National programmes tackling WASH and infant diarrhoea prevention are integral to accelerate progress in child malnutrition and stunting. In India, since 2005, Accredited Social Health Activists (ASHAs) have served as frontline health workers, acting as a link between the health system and the rural populations. ASHAs also have a crucial role as health activists to deliver family welfare programmes, including WASH promotion and infant diarrhoea prevention services at the village level[5]. Tribal communities in most states of India, including Rajasthan, continue to have poorer health and development indicators. Hence, we aimed to explore barriers to the delivery and uptake of WASH promotion and infant diarrhoea prevention services at the village-level, across rural tribal villages in Rajasthan.
METHODS: A rapid ethnographic assessment was carried out from September to December 2019 across nine tribal casestudy villages in the Banswara district of Rajasthan. Findings are based on ethnographic and qualitative data collected in extensive field memos from informal conversations and unstructured observations across the study villages and semi-structured data collected in 42 household visits to families of infants, 12 interviews with the frontline health workers, 4 focus group discussions with mothers of infants, and 4 observations of community health meetings. Verbatim transcripts and field memos were imported into NVivo software for analysis of textual data. Guided by the aim of the study, qualitative data were analysed thematically, where social phenomena and core themes were derived inductively from the data.
RESULTS:
Barriers to the delivery of services: ASHAs had multiple responsibilities, and they placed an unequal emphasis on their incentive-based and linkworker roles to the detriment of their health activism roles. ASHAs incentive-based and link-worker responsibilities included more mechanistic tasks such as providing logistical support for child vaccination, institutional deliveries and pre-and post-natal home checks. However, ASHAs lacked community mobilisation skills, with frequent reports that “villagers do not listen” to their health advice. Observations of their work routines revealed that ASHAs were unclear on how to deliver information, education and communication activities and mobilise communities to improve child health and hygiene habits. Additionally, the lack of monitoring, accountability and incentives for such activities further hindered the delivery of WASH promotion and infant diarrhoea prevention services.
Barriers to the uptake of services: At the same time, tribal communities did not trust ASHAs health knowledge or the quality of healthcare provided in government facilities. Traditional beliefs about health and disease among tribal communities led to a widespread preference for informal or un-regulated healthcare and treatment practices. Parents seldom sought child healthcare from public facilities, which hindered the uptake of public child health services.
CONCLUSIONS: The recent years have seen a policy shift by the Government of India with increased attention, funds and programmes addressing WASH and child stunting determinants under several national flagship programmes such as the Swachh Bharat Mission and the National Health Mission. Findings from this study suggest there is a disconnect between the policy-level shifts in WASH and child health and how they have translated into shifting village-level realities in rural tribal Banswara. ASHAs placed an unequal emphasis on their community mobilisation and health activism roles which hindered the delivery of WASH promotion, and parents often did not trust public child healthcare services which hindered the uptake of infant diarrhoea prevention services. The observed disconnect may be part of a larger crisis of care where the delivery of health promotion services and policy implementation remains a significant gap, as it has been recently highlighted[1] [6]. Strengthening ASHAs health promotion and mobilisation skills and improving trust and rapport between tribal communities and frontline health workers will be key to address the determinants of child stunting and accelerate progress towards achieving the POSHAN Mission by 2022 and the Sustainable Development Goals by 2030.
