The Impact of Ritual on Healthcare Provider Behavior in Bihar, India
Also known as Project RISE (Ritual to Improve Service-delivery and Empower health workers), this project seeks to understand the rituals and motivation of community health workers (CHWs) in India. Using a human-centered design approach research will be leveraged to design solutions for sustainable improvements the quality of services to new and expectant mothers and women of reproductive age.
Working in collaboration with Scope Impact and Project Concern International, the RISE project integrates social science research with human-centered design to leverage the power of ritual and lived experience to design interventions that improve the utilization and accountability of the existing health services.
The key focus of the project is to understand the complex cultural ecology of motivations and social dynamics of both CHWs and women of reproductive age within the community, as well as other health and non-health influencers. RISE uses a ritual lens as a link between the complexities of social and psychological inputs and health behavior. We will use this knowledge to design solutions for sustainable improvements in the motivation of CHWs and the quality of CHW services to new and expectant mothers and women of reproductive age.
Project RISE uses a multi-disciplinary mixed-methodological approach—including ethnography, focus group discussions, key informant interviews, in-depth large-scale surveys, and co-design—to understand CHW and beneficiary behaviors, as well as their perceptions of those behaviors and the patterns formed by those behaviors from multiple perspectives. In this way, Project RISE captures intrinsic motivations and the systems that influence behavior and belief.
Project RISE is unique in its emphasis on the lived experiences of both health workers and their beneficiaries. The ritual framework helps identify the interconnectedness of behaviors and ways that cultural embeddedness can vary greatly from one kind of target outcome to another.
Current Studies
Mixed-methodological approaches to studying perinatal health
We use an interdisciplinary, mixed-methods design framework to conduct public health research. This includes an iterative process that incorporates both qualitative and quantitative design as well as multiple methods to explore constructs and behaviors of interest. In addition, we suggest designing methods around targeted outcomes and studying the context and cultural ecology. We discuss how these processes and decisions were made throughout Project RISE, and we formulate recommendations for other public health academics and practitioners.
Ritual as biomedicine
High levels of risk require strategies for reducing it and alleviating the anxiety associated with perceived threats. During times of uncertainty, stress, and danger, people turn to rituals as a means of coping with stress and exerting some measure of control. Rituals, normative, and social conventions are the product of a hazard precaution system, a psychological system geared toward responding to social threats in the environment such as social exclusion and physical threats, such as the presence of pathogens or contamination.
Understanding the rituals of a community provides critical insight into their identity, norms, values, and goals. Yet social and behavioral change initiatives, including the promotion of biomedical practices, often neglect the rituals of communities they seek to influence. Biomedicine is a new kind of ritual repertoire that coexists with traditional medicine. Rather than viewing existing rituals as obstacles to overcome, understanding the ritual practices surrounding health has the potential to transform the efficacy and impact of behavioral change initiatives. There are multiple ways to harness the power of rituals to improve health outcomes: new rituals can be created, existing rituals can be reframed or modified. This research proposes that biomedical health initiatives combatting COVID-19 should build upon existing health rituals, which serve similar functions, to promote better health outcomes.
Project RISE Report: Ritual and lived experience among community health workers in Bihar, India
Project RISE is a mixed-methods collaborative project aimed at harnessing the power of ritual to improve the efficacy of Accredited Social Health Activists (ASHAs) in Bihar, India. ASHAs are a type of community health worker (CHW), which are employed in many regions of the world as a means of extending health service capacities to under-serviced communities (Liu et al., 2011). The Report covers data analysis and synthesis for the major empirical sections of Project RISE, including ethnography, qualitative, quantitative, and vignettes, and how these data streams were synthesized for a process of human-centered co-design.
The Project RISE Report includes the following information:
What: Description of behaviors and rituals that surround pregnancy and childbirth. This includes a description of ritual and health behavior and identifying the ‘target’ behaviors or those with the greatest potential to positively improve health by intervention.
Who: Understanding who informs decision-making for perinatal health behaviors (health influencers)
Why: Understanding of the reasoning behind decisions of whether or not to practice these behaviors
How: Factors that affect motivation, ability, or support of the ASHA
Where: Where are the key touchpoints between ASHAs and beneficiaries located? Where are rituals and focal behaviors of concern situated in the maternal space, and how does this affect influence, accessibility, or other factors needed to adopt an effective health-outreach strategy?
Key insights:
One of the crosscutting insights is the coexistence of traditional medicine, cultural beliefs, and community influencers alongside biomedicine and modern healthcare systems. Our research found a dynamic interaction and interconnectedness among these factors, which shape health behaviors outcomes and create a complex ecology of health.
Our qualitative research revealed that the overwhelming majority of perinatal rituals are done with the motivation to promote health or avoid risk. Most of these are not of biomedical concern as they are either neutral or positive with respect to health. We also found evidence for generational effects; younger women might be more receptive to ASHAs than older women. To the degree that this is generally true, interventions and health initiatives might need to understand how it affects uptake in a community.
In our quantitative research, we find that ASHA interaction has a positive effect on the uptake of biomedically recommended behaviors and that this uptake of biomedically recommended behaviors seems to be mostly unaffected by differences between the ASHA and the beneficiary, including caste, religion, wealth, age, and education. However, the connectedness and relative complexity of behaviors make it more difficult for ASHAs to influence some behaviors than others.
ASHAs’ beliefs about many rituals and traditional practices echo the community’s beliefs. The health system established the embedded ASHA role so that she can leverage her lived experience to navigate the complex ecosystem and act as a cultural facilitator. However, our project found that the health system has limited its focus to the service extender aspect of her role in terms of tasks, trainings, and incentives. Furthermore, the inherent liminality in the ASHA role yields to tensions in her personal and professional lives and influences her motivation and ability to perform tasks.
Previous Studies
Perinatal risk and the cultural ecology of health in Bihar, India
The objective of this study is to examine the cultural ecology of health associated with mitigating perinatal risk in Bihar, India. We describe the occurrences, objectives, and explanations of health-related beliefs and behaviors during pregnancy and postpartum using focus group discussions with younger and older mothers. First, we document perceived physical and supernatural threats and the constellation of traditional and biomedical practices, including taboos, superstitions, and rituals used to mitigate them. Second, we describe the extent to which these practices are explained as risk-preventing versus health-promoting behavior. Third, we discuss the extent to which these practices are consistent, inconsistent, or unrelated to biomedical health practices and describe the extent to which traditional and biomedical health practices compete, conflict, and coexist. Finally, we conclude with a discussion of the relationships between traditional and biomedical practices in the context of the cultural ecology of health and reflect on how a comprehensive understanding of perinatal health practices can improve the efficacy of health interventions and improve outcomes. Overall, we found that traditional medical practices focused on physical and supernatural risk reduction for the mother and the infant. These traditional practices often coexisted with biomedical practices, and in fact, can provide important social functions that improve the efficacy of biomedical practices.
Demographic variation in the perinatal dietary choice among mothers and community health workers in Bihar, India
This study involved the examination of demographic variation in the extent to which perinatal dietary choice among mothers and Community Health Workers (CHWs) in Bihar, India, is consistent with biomedical recommendations. A total of 1200 recent mothers and 400 CHWs in Bihar, India, completed a self-report interview of perinatal diet choice. We investigated the extent to which there is alignment between perinatal maternal dietary choice and biomedical recommendations to (a) increase overall diet, (b) avoid removing nutritious foods from the diet, and (c) consume foods and supplements rich in folic acid, iron, and Vitamin A. We also examined the extent to which alignment with biomedical recommendations for maternal, perinatal diet choice varies between mothers and CHWs, and due to variation in education, income, caste, religion, and parity. CHWs are (a) more likely to increase their diets, (b) less likely to avoid foods, and (c) more likely to add Vitamin A rich foods, leafy greens, or complete the recommended IFA tablet regimen during the perinatal period than mothers, particularly mothers with lower education and from Scheduled Castes and Tribes.
Information about lack of alignment with biomedical recommendations for perinatal diet is critical to inform the design of interventions for the most at-risk populations and to inform the design of training programs for CHWs on the maternal perinatal diet. The major perinatal health risks we identified are restriction of caloric intake and consumption of insufficient nutrient-rich foods, which we found to be more common among mothers. Based on our findings, perinatal diet recommendations for this region would be to discourage caloric restriction during pregnancy and encourage dietary diversity and the consumption of nutrient-dense foods.
Collaborators
at Austin
- Project PI: Cristine Legare, Professor of Psychology and Director of the Center for Applied Cognitive Science
- Oskar Burger, Director of Design & Development, Center for Applied Cognitive Science
- Faiz A. Hashmi,Research Scientist, Center for Applied Cognitive Science
- Hannah Lunkenheimer, Research Scientist, Center for Applied Cognitive Science
- Sudipta Mondal, Senior Director - Monitoring, Learning and Evaluation, India
- Santosh Akhauri, State Manager - Monitoring, Learning and Evaluation, India
- Indrajit Chaudhuri, Country Director, India
- Janine Schooley, Senior Vice President of Programs
- Palash Singh, Design Lead
- Mari Tikkanen, Interim CEO & Co-Founder
- Joan Vinyets, Design Director
- Joseph Savage, Service Designer
- Tracy Johnson, Senior Program Officer, Global Delivery Programs / Strategy & Insights, Global Development Program
- Neela Saldanha, Independent Consultant
- Nachiket Mor, Banyan Academy of Leadership in Mental Health, India
- Micah Goldwater, Senior Lecturer, University of Sydney
- Emily Little, Founder & Executive Director, Nurturely
Funding
The project is funded by The Bill and Melinda Gates Foundation. Cristine Legare is the PI on the grant.
Field Sites
- Bihar, India