This study used a qualitative exploratory design for understanding the implementation of arthritis education program conducted in two geographically similar villages; Hiriyadka and Athradi, Karnataka, India. All the ASHAs who worked at Hiriyadka (n=6) and Athradi (n=2) Primary Health Centers were recruited for the study. The study was conducted during March, 2013 to May, 2013. ASHAs involved in the Primary Health Centers of these two villages were recruited and they underwent a two week training program. The training was carried out by the principal investigator while pursuing her postgraduation in community physiotherapy. The training module contained screening and evaluation of individuals with arthritis along with education, regular reinforcements, and re-evaluation to determine the effectiveness of the education. The training was kept simple, with clearly defined objectives. It also included on-field practice. The training module was formulated as per the protocol suggested by O’Brien MJ et al., in 2009 [9].

The education program used handouts with pictorial representations and descriptions about the pathology of arthritis, pain relief techniques, joint protection and energy conservation, active exercises, nutrition and general physical fitness which were adapted from the reviews done by Riemsma RP et al., and Johnson A [6,10].

Performance based incentives were provided to ASHAs as per guidelines by World Health Organization in 2008 [11]. The incentives were both monetary and non-monetary. A sum of thirty five rupees was provided for each individual recruited by ASHAs. The non-monetary benefit was free treatment at the Department of Physiotherapy of the source hospital. ASHAs were regularly telephonically encouraged for follow ups. The ASHAs were given a period of three months to recruit individuals with arthritis and implement the arthritis education program. This study was conducted subsequent to implementation of the program. The sampling technique adopted was purposive sampling for homogenous recruitment of ASHAs. Focused Group Discussions (FGDs) were conducted for each of the homogeneous group of ASHAs.

Homogeneity was ensured by categorizing ASHAs based on their performance (i.e., number of patients recruited) which formed high, average and low performance groups. Three FGDs were conducted, each one by a moderator along with an observer and a scriber [Table/Fig-1]. Number of ASHAs in each category of FGDs were two in high performance group, three each for average and low performance group. The moderator carried out the discussion, the observer monitored equal participation by ASHAs and the note-taker took notes of expressions and involvements. Each interview lasted for 45-60 mins and it was audio recorded.

[Table/Fig-1]:

Seating arrangement for the FGDs.

FGDs were based on a pre-developed conceptual framework as shown in [Table/Fig-2]. This framework aimed at addressing the issues of ASHAs while carrying out the arthritis education program. The framework was used to develop open-ended questions and probes to direct the interviews. [Table/Fig-3] gives a detailed description of the open-ended questions and probes used to conduct the interview. The data of the FGDs were transcribed in Kannada by a native speaker and back to English. The transcribed data was thematically analyzed.

Approval to conduct the study was obtained from Institutional Research Committee, SOAHS and ethical clearance from Institutional Ethics Committee, Kasturba Hospital prior to the commencement of the study. Written informed consent was obtained from ASHAs for audio recording of the interviews.

Data analysis was done using SPSS version 15.0. Descriptive statistics was used to describe the characteristics of ASHAs. Inductive coding was carried out by three researchers independently using Microsoft Word 2007. Finally data from interviews was summarized into codes, categories and themes.

Eight ASHAs participated in three FGDs conducted by the investigators. There was no substantial difference in the years of experience in field work among the ASHAs. There was one class difference on Kuppuswamy’s socioeconomic scale between ASHAs from both the villages [Table/Fig-4].

The data of the FGDs were transcribed in Kannada and back to English. The transcribed data was thematically analyzed. Data analysis revealed codes which were categorized into themes. The themes were analyzed to determine emergent themes, regarding the experiences of ASHAs while conducting the field work and factors influencing their performance of recruiting individuals with arthritis. [Table/Fig-5] shows a summary of the results obtained from data analysis of the FGDs.

Three broad emergent themes were revealed after analysis of transcribed data. The themes were:

The [Table/Fig-6] shows the comments by ASHAs during FGDs which have been categorized under the emergent themes.

i) ASHA-related factors influencing performance: Each ASHA has been assigned to 1000 population in an area as per the National Rural Health Mission, 2005 guidelines [12,13]. All the ASHAs had difficulty to overcome remote and scattered households and environmental barriers like forests, dogs and lonely roads. Walking being the only mode of transportation for service delivery, ASHAs considered it a reason for low performance. Few ASHAs have suggested that provision of a bicycle by the government may improve their efficiency.

The villages where this study was conducted have a low population density and the houses are situated in various terrains; like hills and forests. Though there are roads but, lack of means of transport reduced the accessibility to village dwellers.

ASHAs informed that they did not have any problem in combining the work assigned by the government along with the arthritis program. Moreover, this helped them to save time and reduce extra burden. If they would have done on separate days, the burden of alternate job and household work would have reduced their efficiency.

Five out of the eight ASHAs had alternative jobs. Managing time for field work, household chores and alternative earning methods might have reduced the efficiency. All five ASHAs with alternative jobs informed that they like the field work as they gained knowledge and respect in their community. But they preferred spending time on the alternative jobs since it provided better income. One of the ASHAs involved in beedi packaging industry reported that the company provided good salary and other incentives like scholarships for her child, health cards, and also she could work from home.

Monetary and safety concerns were the major contributors to reduced family support for ASHAs. ASHAs spend three days per week for community activities but earn marginal incentives.

The ASHAs spent three days per week for this study along with regular field work. They started in the morning and continued till late evening, for data collection and interventions. In the villages, most of the community dwelling individuals with arthritis were employed and were involved in housekeeping at households, temples, hostels and hospitals. These individuals had to leave for work early and return late and therefore were frequently unavailable during the arrival of ASHAs at their home. This posed a great problem for recruitment as well as follow up.

The ASHAs were trained to reinforce regular exercise and joint protection techniques to the subjects once in every two weeks. Few individuals had reported to ASHAs that lack of adherence to exercise was due to unavailability of time after household chores or after return from work.

Education and attitude towards exercise play a major role in incorporating exercise in daily routine. One of the ASHA reported that individuals, who were educated like teachers, understood the necessity of exercise for joint pain and arthritis and therefore agreed to participate in the study and also showed good adherence to the exercise program.

ASHAs told they had screened seventy three individuals but, only forty eight gave consent for participation. Though ASHAs were selected from their community they reported that community dwellers lacked trust in them. Community dwellers suspected the knowledge acquired through training by ASHAs. Hence, the ASHAs requested the instructors to accompany them and spread awareness about their acceptance as health care providers.

The desire to take medication and topical applications like oil, pain reliving ointments were the principal requests put forth by the individuals with arthritis. ASHAs were unable to change this attitude of the individuals towards medication, and also they were unable to educate regarding the adverse effects of long-term intake of medications. Hence, this could have affected the trust on ASHAs.

ASHAs stated that the training was appropriate and understandable and they were able to incorporate on-field recruitments and intervention. But, community dwellers had queries like what are the harms of taking medications and how exercise is effective compared to medications. These aspects were not included in the training module. Inability to answer the queries might have weakened the trust of individuals recruited by ASHAs.

On field demonstrations were included in the module but only at the initiation of the program. Additional on-field demonstrations and methods of creating awareness in the community about their skills through camps, or recognition ceremony might augment the performance of ASHAs. Similarly in this study, ASHAs stated in order to improve their confidence they needed more on-field demonstrations at frequent intervals. Hence, this might have posed a barrier to better performance of ASHAs.

Financial and non-financial incentives were provided to ASHAs during the study. But the financial incentive provided was performance based hence. ASHAs received only when they recruited individuals with arthritis.

Encouraging factors reported by ASHAs were, service satisfaction and additional knowledge about arthritis. Training related factors that facilitated ASHAs for this activity were the provision of pictorial handouts, incentives and regular telephonic encouragements. A simple and easy to enforce education module was planned and implemented. The program module was planned to address the issue of multitasking by ASHAs by keeping it simple and easy.

The ASHAs in this study were trained and experienced field workers with an average age above 35 years, belonging to lower socioeconomic status. Previous studies have reported a significant influence of sociodemographic and socioeconomic variables on the performance of community health workers like ASHAs [14].

Studies have reported that the time of transportation and geographical terrain as a problem faced by the ASHAs making them unable to complete the coverage of designated households [15–17]. The villages where this study was conducted have a low population density and the houses are situated in various terrains; like hilly areas and forests. Though there are roads built but, a lack of means of transport reduced the accessibility to village dwellers. Governmental intervention through the provision of bicycles was also reported.

Influence of multiple tasks, time and family were reported by ASHAs. Factors like multitasking including household chores and alternate jobs in limited time can negatively influence the performance of community health workers [14,18]. Kok MC et al., reviewed studies that showed both positive and negative influences of family on community activities. The burden of household duties was found to negatively impact performance [14].

Community response to exercises and towards ASHAs was also reported. Mailey EL et al., found working beyond house activities posed as a barrier to exercise and physical activities [19]. Studies by Kok MC et al., Mpembeni RN et al., and Mishra A, have advocated the need for the trust and respect of community dwellers on ASHAs for their better performance [14,20,21].

ASHAs are altruistic lay health workers hence their desire to provide services is influenced by training and the return gained from services. Lopes S et al., found that training helped to improve the performance of community health workers but the effects of training reduced within three months [22]. Saprii L et al., and Mpembeni R et al., reported the need for regular and adequate incentives for better performance and any deviation may affect the altruism of ASHAs [17,20].

This study also identified factors motivating ASHAs like respect from the community, service satisfaction, and additional knowledge about a widespread and common disability like arthritis. Bajpai N et al., and Saprii L et al., have also reported similar motivating factors by ASHAs for service provision [12,17].

A major problem in conducting community programs is large attrition of community personnel involved in health care delivery [15]. While carrying out this study, none of the ASHAs dropped out. Issues like alternate jobs, low monetary benefits, increased workload, and poor acceptance in the community were reported but none of the ASHAs withdrew participation from the study. This is contrary to studies by Bhattacharyya K et al., and Alam et al., who have reported attrition of community health workers [15,23]. But this can be accounted for the less number of ASHAs in this study, direct supervision, and regular telephonic follow up. Financial and non-financial incentives were other added advantages.

The strengths of this study are that the identified barriers can be addressed prior to large-scale integration of rehabilitation programs with other rural health programs. Rehabilitation professionals can implement programs by integrating ASHAs. The involvement of ASHAs in a program will help to empower the community, reduce health care expenditure in long run and help to reach a large scale population [13,24]. Also, this study was carried out based on Community Based Rehabilitation (CBR) guidelines by WHO in 2010 [25]. Hence, it involves capacity building of the people with arthritis and mobilization of community resources through training of ASHAs.

Limitation of this study is that the performances of ASHAs may differ based on region, demographic characteristics like their age, household responsibilities and socio-economic status which were not explored in this study. Moreover, each FGD must be conducted on 6-12 participants. Due to less ASHAs recruited, this criteria could not be met.

The FGDs revealed that ASHAs encountered certain difficulties towards recruiting a large number of community dwellers with arthritis like lack of regular incentives; focus on the alternate job, environmental barriers and attitude of the community towards ASHAs. The experiences of the ASHAs will in turn help us determine areas to be addressed by rehabilitation professionals when empowering the community health workers.