The National Rural Health Mission (NRHM) was initiated by the Government of India on April 12, 2005, with the overarching aim of improving access, accountability, availability and affordability of reliable primary healthcare, particularly for the underserved and vulnerable sections of the population. This program was designed by the Indian government towards the multiple determinants of health, including nutrition, sanitation and hygiene, as well as access to safe drinking water, taking a holistic approach to healthcare delivery [1]. A critical component of this mission was the creation of dedicated female health volunteers known as ASHA. These community-based health workers are deployed at the grass roots in rural settings and act as a liaison between the rural populations and health service providers thus playing an instrumental role in the attainment of the nation's health and population goals [2-3].

The major responsibilities of the ASHAs are a number of tasks aimed at improving health outcomes in their communities. These responsibilities include the provision of primary health care via a prescribed standard medical kit, promotion of disease prevention by education and surveillance, and maternal and child health services including antenatal, natal and postnatal care. ASHAs also counsel families on family planning, safe abortion practice, child immunization, and Vitamin A supplementation [4]. They also play an important role in advocating for health-related behavioural change, such as breastfeeding, birth spacing, gender equality, prevention of child marriage, and education of girls. In addition to that, they have an important role in doing household health surveys, collaborating with functionaries of health, and mobilizing the local communities towards effective health planning and the utilization of available health services [5].

In view of such heavy responsibilities provided to ASHAs, the present study aims at assessing the effectiveness of such workers in performing their assigned roles in their communities. It plans to find out how effectively such workers identify health problems and promote health interventions. More specifically, the focus shall be on the socio-demographic profile of ASHA workers, their exposure to maternal and child health centres in the Balangir region of Odisha and the knowledge, awareness, and practice in regard to their responsibilities at the field level. This will disclose how ASHAs work and will bring about improvements in the health condition of rural populations, which need them to achieve any level of integration of the NRHM and the overall goals of the public health strategy of India [6-7].

Study Design

This was a cross-sectional descriptive study designed for evaluating the functioning of ASHA workers attending Maternal and Child Health (MCH) Centre of Bhima Bhoi Medical College &Hospital, Balangir Odisha. The present study aimed to assess the socio-demographic profile, knowledge, and practices of ASHA workers regarding their roles in maternal and child health.

Study Setting

For the period of three months from January to March 2020, this study was conducted at the Maternal and Child Health Centre, Bhima Bhoi Medical College &Hospital, Balangir, Odisha. The chosen location provided a representative setting for assessing the impact of ASHA workers on community health, particularly in maternal and child health services.

Sample Size Calculation

Suppose the average performance of ASHA workers to be 50%, according to the report of Government of India, 2005. It can be calculated by a suitable formula for sample size calculation:

n=Z²pq/L²​

where:

• Z = Standard normal variate for a 95% confidence interval = 1.96
• p = Percentage of ASHAs with positive characteristics = 0.5
• q = 1 - p = 0.5
• L = Allowable relative error = 0.10 (10%)

Substituting the values into the formula, the calculated sample size was approximately 400. Therefore, a total of 400 ASHA workers were targeted for inclusion in the study.

Participants

All ASHA workers during the study period who visited the Maternal and Child Health Centre, Bhima Bhoi Medical College &Hospital, Balangir, Odisha were recruited for the study. The sampling method applied was simple random sampling. The study did not recruit the participants who declined participation. Recruitment was done until a sample of 400 participants was attained.

Data Collection

The data collection process was initiated after getting approval from the Institutional Ethical Committee (IEC) of Bhima Bhoi Medical College & Hospital, Balangir, Odisha. Informed consent was received from every research participant before enrolment. A self-developed semi-structured questionnaire was used for collecting information. The questionnaire has been designed to gather information concerning the socio-demographic profile of the ASHA workers, their knowledge and practices about antenatal care, immunization, general responsibilities, and other relevant health activities.

A pilot test was conducted with 10 subjects before actual implementation to check on the readability and understandability of the questionnaire. Any modifications along with suggestions from the pilot test were made to clarify the questionnaire and provide options to answer any questions that may have arisen. Initial drafting was done in the English language, which was then translated into Odia and back translated into English to check for authenticity.

Data collection was held for some of the following areas:

• Socio-demographic profile: Age, education, experience, etc.
• Antenatal care knowledge and practices Early detection, safe practices, and follow-up measures.
• Immunization practices Immunization schedules and practices related to children.
• General health responsibilities ASHA's role in health education, disease prevention, and other community health interventions.

Statistical Analysis

The data obtained from the study was tabulated in a Microsoft Excel spreadsheet for keeping and preliminary analysis. The statistical analysis was done through the SPSS software (Version 21.0). Percentages and proportions were used to interpret the data to understand the knowledge and practice of the ASHA worker while working. Through this analysis, it represented the successful handling of their job by the ASHAs and also areas where improvement can be called upon them in terms of training and support

Socio-Demographic Profile

The study included 400 ASHA workers, of whom the majority, 206 (51.5%), were aged 31–40 years, with a mean age of 33 years. Educationally, most participants (308 or 77.0%) had completed high school, while 48 (12.0%) studied up to middle school. Regarding their occupational status, 295 participants (73.8%) were housewives. A majority (250 or 62.5%) lived in nuclear families, and most were married (363 or 90.8%), with 35 (8.8%) being widowed.

In terms of religion, 388 participants (97.0%) were Hindu. Caste distribution showed that more than half (212 or 53.0%) belonged to Other Backward Classes (OBC), while 172 (43.0%) were from Scheduled Castes (SC), and 16 (4.0%) were from Scheduled Tribes (ST). According to the Modified B.G. Prasad Socioeconomic Classification, 363 participants (90.8%) fell into Class V (lowest economic class).

Knowledge of Roles and Responsibilities

Among the participants, 326 (81.5%) exhibited good knowledge of their roles and responsibilities, while 70 (17.5%) had fair knowledge, and 4 (1.0%) demonstrated poor knowledge. ASHA workers displayed strong knowledge in key areas such as:

• Diarrhoea: 95.0%
• HIV/AIDS:92.0%
• Health Insurance Schemes:91.0%

However, gaps were observed in specific domains:

• Neonatal Care:40.0%
• Breastfeeding Practices:59.0%

Table 1 and Table 2 summarize the responsibilities and knowledge of ASHA workers, highlighting areas where improvement is needed.

Factors Influencing Knowledge Levels

The study identified several factors influencing the knowledge of ASHA workers:

1. Participation in Village Health and Nutrition Day (VHND): Active participants scored significantly higher (p < 0.05).
2. Involvement in Village Health and Sanitation Committee (VHSC) Meetings: Regular attendees had better knowledge (p < 0.01).
3. Refresher Training: Workers attending these sessions were more knowledgeable (p < 0.05).
4. Performance in Postnatal Visits: Superior performance correlated with higher knowledge (p < 0.05).

Knowledge Gaps

Despite commendable knowledge in many areas, specific gaps in neonatal care (40.0%) and breastfeeding practices (59.0%) emphasize the need for focused training interventions.

Tables and Figure

Table 1: Socio-Demographic Characteristics of ASHA Workers

Table 2: Knowledge Levels of ASHA Workers

Figure 1: Knowledge of ASHA Workers About Specific Health Topics

The findings demonstrate that while most ASHA workers possess strong knowledge about their roles, targeted training programs addressing neonatal care and breastfeeding are necessary. Strengthening participation in VHNDs, VHSC meetings, and refresher training sessions can further enhance their effectiveness.

This study assesses the knowledge and practices of ASHA workers in terms of their job responsibility factors that influence their performance in maternal and child health care. The findings provide valuable insight into their socio-demographic profile, knowledge levels, and areas that need improvement in order to enhance the effectiveness of community health worker systems [8].

Socio-demographic analysis revealed that the majority of the ASHA workers were between 31–40 years, with a mean age of 33 years. It is an ideal age for community health interventions that would combine experience with the ability to be physically active. The vast majority had completed high school (77%), which was at the minimum eligibility level required for recruitment [9]. However, a relatively smaller percentage with middle school will face the problem of understanding complex ideas related to health and the translation of such ideas. So, training methods have to be developed specifically for lesser qualified workers [10].

The number of ASHA workers was substantial and largely comprised housewives (73.8%). They have assimilated women of the locality in the healthcare delivery system that uses their natural familiarity with the community. Most of the participants were of an economically backward class, residing in a nuclear family (90.8% belonged to the lowest class). These findings align with the rural profiles of ASHA workers and underline their crucial role between communities and health services [11].

In terms of knowledge, 81.5% of the ASHA workers had a good level of awareness about their responsibilities and roles and had strong knowledge of important health-related topics such as the management of diarrhoea (95%), HIV/AIDS (92%), and health insurance schemes (91%). Significant gaps, however, were found in neonatal care (40%) and breastfeeding practices (59%), critical areas for reducing infant morbidity and mortality. These areas highlight the need for focused training and capacity-building programs to enhance knowledge in these critical areas.

All this summed together played a significant part to their knowledge levels among ASHA workers. Active participation in VHNDs and regular attendance in VHSC meetings were essential factors towards scoring knowledge. This was mainly because the two mediums facilitate exposure to peers, honing skills, and awareness concerning what is happening in these health programs. Similarly, the attendance at refreshment training sessions was positively associated with improved knowledge, which underscores the need for continuous education in order to keep ASHA workers abreast of the changes that are happening in health guidelines and practices. Furthermore, high knowledge levels were strongly associated with effective performance in postnatal visits, indicating that hands-on experience is important in developing competence [12].

Although promising in general, the findings indicate gaps in neonatal care and breastfeeding practices that need more specific training. Focused interventions can be made to improve retention and application of knowledge with culturally sensitive educational materials, practical demonstrations, and interactive sessions. Further strengthening the role of ASHA workers as community health advocates will be community health platforms enhancing engagement through regular refresher courses [13-14].

The results of this study are in consonance with previous studies that documented high knowledge among ASHA workers on topics such as diarrhoea management and immunization, while underlining similar deficits in neonatal care and breastfeeding. Comparative studies point out the need for training programs that are structured and have community involvement to enhance the performance of ASHA workers. These similarities lend strength to the conclusions drawn by this study and highlight the importance of targeted, evidence-based strategies for training [15].

Although the ASHA workers showed a very satisfactory perception of their role and job, lacunas noticed in neonatal care and breastfeeding practices indicate that attention to such issues would be of utmost importance. The upgradation of training programs should be done further with more avenues for community participation in maximizing the contributions of ASHA workers toward maternal and child health services. Targeted research can further enhance this critical workforce and subsequently lead to better community health outcomes.

The ASHA workers have played an important role in the delivery of rural health care. Their knowledge regarding a general health responsibility is impressively good and they have effective practices pertaining to maternal and child health care. Nevertheless, some of the areas left as glaring gaps are neonatal care and practices related to breastfeeding. Active participation in VHNDs and refresher training sessions has greatly impacted knowledge levels, which is an emphasis on continuous education and skills enhancement. These interventions improve retention of knowledge but also facilitate stronger community engagement, a very important aspect of sustainable healthcare delivery. Addressing the gaps in training, capacity building, and support mechanisms is vital to optimizing the effectiveness of ASHA workers. Tailored training programs, combined with culturally relevant educational materials and interactive sessions, can bridge knowledge gaps and empower ASHA workers to deliver high-quality health services. Strengthening these efforts is essential to ensure better health outcomes in underserved rural communities and to maximize the impact of ASHA workers as key agents of change.

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