# Introduction {#intro}

Project RISE is a mixed-methods collaborative project aimed at harnessing the power of ritual to improve the efficacy of frontline health-workers in Bihar, India.

I wrote this sentence in HackMD.

This document highlights a few of the main findings from ongoing quantitative analysis of the Project RISE questionnaire data collected by PCI in Bihar in 2019.

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In its present form, this report presents results from analysis of quantitative data. Other sources of data have been summarized elsewhere. Future version of this report will iteratively encompass the other project data streams until they are all synthesized in this report.
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This investment combines interdisciplinary social scientific anddesign research to conduct a comprehensive, mixed-methods assessment of the cultural and ritualized behaviors of FLWs, which will be used to co-design and rapidly test service solutions that target the psychological, social, and cultural barriers to frequent and high-quality health service delivery by FLWs. Human-centered design is a creative problem-solving process used across sectors, including increasingly in addressing complex health and development challenges in low-resource settings. Our versatile, multi-disciplinary team includes psychology researchers, design researchers, service designers, product designers, creative strategists, communication experts, in country researchers and issue expert partners as well as key Foundation staff, including from the in-country office. This diverse team will facilitate the pollination of new mixed-method approaches, ideas, and opportunities by integrating a range of expertise and knowledge in the project activities. A strong communication approach will play an integral role in effective engagement with key Foundation stakeholders and country partners. This will likely take the form of an internal communications strategy, rolled out alongside the creative forms of documentation and sharing that will occur throughout the program.This project seeks to achieve the following outcomes: 1) understandthe motivations, rituals, and social dynamics surrounding service delivery of FLWs, 2) use the research to co-designnew service solutionsthat directly address the psychological, social, and cultural roots of the current suboptimal delivery of services among FLWsand totestthe service concepts to develop clear proofs of concept, 3) articulate a strategyfor implementation and impact evaluationand disseminatekey learnings.

## Audience
The intended audience for this version of the report is Project RISE team members. This draft is not written for general distribution, in that it will omit details of the project's history and rationale, which can be added in subsequent drafts.

As this is a preliminary analysis intended to generate discussion and feedback to shape future drafts, sections will occassionally contain 'discussion questions' or other prompts to encourage feedback or to seek clarificaton on certain analysis decisions. That said, any feedback that comes to mind is welcome.

## Collaborative structure

The “RISE” in Project RISE signifies the goal of understanding and leveraging <u>**r**</u>itual to <u>**i**</u>mprove <u>**s**</u>ervice-delivery and <u>**e**</u>mpower health workers. More specifically, the purpose of project RISE is to understand the rituals, motivations, and social dynamics of Front Line Health Workers (FLWs) in Bihar, India.*

Project RISE is funded by the Bill and Melinda Gates Foundation (BMGF)
[(BMGF)][].

Project RISE is a collaborative effort of four institutions working
together: (need to add addresses and hyper links)

1. [The University of Texas at Austin: Evolution, Variation, and
Ontogeny of Learning Laboratory][]

2. [M4ID][]

3. [Project Project Concern International][](PCI)

4. [Ashoka University, Centre for Social and Behavioural Change][]

This report lays out the Project's Process and presents its major outputs, which include:

1. The human-centered-design intervention to improve ASHA motivation
and performance. All project components generate information that
will be synthesized and funneled toward this goal.

2. Datasets for the major data collection efforts that can be used by
RISE and future projects:

- Ethnography

- Qualitative interviews; focus group discussions (FGDs) and key
informant interviews (KIIs)

- Quantitative survey

- Human-centered-design

3. Written reports and publications that provide insights for relevant
target audiences on:

- The Project’s motivation, rationale, objectives, methods,
structure, and key findings. This includes how the project came
to be and what we learned in developing the mixed-methods
approach we are employing.

- Summary of the ritual landscape as experienced by ASHAs and
mothers during the pregnancy timeline

- Analysis of factors statistically associated with variation in
ASHA performance, maternal health behavior, and factors associated with perinatal health in Bihar.

- The design of the intervention

[(BMGF)]: https://www.gatesfoundation.org
[The University of Texas at Austin: Evolution, Variation, and Ontogeny of Learning Laboratory]:
http://www.cristinelegare.com
[M4ID]: http://scopeimpact.fi
[Project Project Concern International]: https://www.pciglobal.org/india/
[Ashoka University, Centre for Social and Behavioural Change]: https://www.ashoka.edu.in/page/CSBCC-73

## Motivation

Bihar, India, experiences globally high levels of infant mortality and has generally poor maternal and child health. In 2005 the Indian Government initiated program to help improve rural health in India, part of which included Front Line Workers (FLWs) who are tasked with helping with ameliorate risk and improve healthy behavior. However, sustainable heath improvements seem hampered by interactions between FLWs and beneficiaries that are insufficient with respect to quality and/or frequency. Many out-come oriented approaches to evaluating FLW efficacy have been attempted, but with variable results, hence the need to focus on the intrinsic motivations of FLWs.

Project RISE harnesses the power of ritual to...

Many of the health-compromising behaviors that contribute to high infant mortality and poor maternal-child health outcomes areintertwined in the rich traditions of local cultural practices, shared across social networks, and are potentially deeply integrated into ritualized behaviors of FLWs. The specific rituals surrounding health-service delivery byFLWs are notwell understood,making it difficult to improve quality of care ([@riseteam2018]).

Though there are many potential target health promoting-behaviors of interest for Project RISE (i.e., use of modern spacing contraceptives, consumption of 90+ Iron Folic Acid tablets, planning for institutional delivery, kangaroo care, delayed bathing, exclusive breastfeeding, diverse/frequent complementary feeding, oral rehydration for diarrhea, care seeking for severe diarrhea and pneumonia), the research team will work with in-country partners to identify 3-4 of these that would be most feasible to improve within the context of this initial investment time frame. By building on existing research and employing an innovative mix of research methodologies, the project aims to generate new understanding of FLW behaviors, needs, and service-related rituals.

One study found that ASHAs in rural India are under a great deal of stress [@mannapur2019]

### The identified behaviors
**Say why for each** **Move to ExecSum**

+ The avoidance of healthy food and/or intentional caloric restriction during pregnancy or while breastfeeding Fasting during pregnancy or post partum

+ The frequency and quality of ANC visits

+

## Goals and objectives

The goals of Project RISE are to understand the motivations, rituals, and social dynamics of FLWs and to use this knowledge to devise solutions for sustainable improvements in the frequency and quality of FLW services to new and expectant mothers and women of reproductive age. Specifically, this project will research the community-specific social, psychological, and environmental barriers to health-promoting behavior among FLWs which we will use to design and pilot a set of service solutions to improve the quality of care among FLWs (Make a citation for the RISE proposal).

Our aim is to develop an understanding of FLW behaviors, perception, and patterns rooted in context. We will use this knowledge to co-design and test service solutions that more directly target the psychological, social, and cultural roots of the problems related to health-service delivery of FLW.

## Data streams

## Project timeline

## Structure of this report

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**Summary**

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The blue summary boxes are especially useful for summarizing the regression analysis in the quantitative sections, but are used throughout the report to highlight key messages for any of the data streams.

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**Query**

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Most of the yellow text boxes contain queries to the Project RISE core team to help develop the content of the report, but they also contain ponderous larger scale questions.

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The 'alert' boxes contain information that may help interpret a result or remind the reader of an important caveat

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**Reflexivity**

* Text in orange boxes like this will contain notes for reflexivity, or of lessons learned, during the process of putting Project RISE together.

* The concept of reflexivity has many definitions in the philosphy of science and in sociology. Here we are taking it to mean a reflection on how the research process, the researcher techniques, or the presence of researchers affects the nature, quality, and extent of data collected. In this sense, it is a critical review of our process and suggestions for future improvements.

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The 'reflexivity' boxes are used throughout to note places where key decision points were made or where, upon reflection, greater continuinity among parts of the project could potentially have been achieved.

## Bihar overview

Bihar India is a largely rural state in that a lot of the livelihood comes from farming activities and most of the population does not live in large dense cities. However, rural in this case does not mean sparsely populated, in terms of typical population densities found globally. Bihar has a population density of just over 1,100 persons/$km^2$, which is higher than Kerala (at about 860) and higher than any US state (excluding Washington DC, which is pretty much a big city), and of course much higher than Finland (39 people/$km^2$). In area, Bihar is over 94,000 $km^2$, which is a little larger than the country of Hungary and has about $1/10th$ the population.

Bihar is the poorest state in India Gross State Domestic Product. Both its population and domestic product are rapidly growing. Many of the health indicators tracked by international development organizations would place Bihar in a zone of concern, with high levels of infant and maternal mortality and low levels of female literacy. The overarching desire to see Bihar improve in some of these metrics is a background motivator for Project RISE. More in the foreground is developing a novel and more nuanced perspective on ASHA motivation and performance so that maternal and newborn health can continue to improve.

include_graphics('Bihar2.png')

## Rituals and health behavior

This approach of targeting the psychological and cultural rituals that contribute to a behavior (i.e.,. the quality of FLW services) is novel for work in this sector of global health, and will allow this investment to have a deeper, lasting effect on the behavior and outcomes of the target beneficiaries. Given that past work with the target population has produced only short-term results rather than sustainable change (e.g., the temporary increase in antenatal care visits by Front Line Workers that leveled-off once external support was removed), this novel approach seeks to improve upon the challenges faced by past work in Bihar (RISE proposal).

Ways RITUAL might be harnessed and leveraged include:

1) existing health-related rituals that should be altered, 2) new health-related behaviors that can be introduced and ritualized, and 3) non-health related rituals that can be used to reinforce positive health behaviors

ritual-based behaviors reinforce social affiliation, thus leading to long-term maintenance of behaviors.Engaging in shared ritual practices in the context of a group increases social group bonding and increases preference for ritual behavior.For example, people who participate in group rituals identify more strongly with their group, and are more likely to continue to affiliate with the group over time than people who have not participated in group rituals. Rituals promote the high fidelity maintenance and transmission of group behavior over time. People are also more likely to continue to engagein behavior over time if it is a ritual group practice. RItuals are thus critical for understanding the motivation to engage in group-level behavior.14151617Health-related behavior is also heavily ritualized. For example, behaviors ranging from tooth brushing to hand washing are culturally transmitted and normative. Across diverse global populations, rituals are used to promote health, cure illness, and solveattempt to solve problems. By focusing on rituals, we can address the deep-rooted barriers to health-promoting behavior and create long-term sustainable solutions for behavior change.

### Ritual-Based Behavior Change Principles

1. Establish a stable, supporting environment: Long-lasting behavior change requires a supportive environment, such that the tools needed to enact the desired behavior are effortlessly and consistently available. For example, do FLWs have all of the tools –both tangible items and knowledge-based tools–to provide the quality of care that is desired? Is their pattern of service delivery behavior characterized by a habitual action sequence into which new health-promoting behaviors can be easily integrated? Because the nature of FLWs’ work is characterized by a changing, inconsistent environment (i.e., by providing their health services in different homes of beneficiaries), it is essential that other aspects of their service delivery (e.g., their educational tools, products, and behavior sequences) are kept consistent, stable, and supportive.

2. Capitalize on existing rituals: Research shows that new behaviors can be more effectively established if introduced in connection to existing habits or rituals8.For example, people are more likely to take their daily vitamin when connecting this practice to another ritualized practice (i.e., eating breakfast)9. By identifying the existing ritualized behaviors of FLWs in Outcome #1, we will be able to capitalize on these existing habits to more successfully implement the new target behaviors.

3. Eliminateperceived effort fordesired behaviors: When new rituals are introduced to improve FLW quality of care, it is essential that these tasks are perceived as easy and that effortful decision-making is kept to a minimum. When new tasks are introduced or when extensive decision making is involved, this “friction” makes it easier for individuals to relapse into oldhabits. In a recent study of habitual health-promoting behavior (hand washing with soap) in 11 developing countries (including India), the authors showed that a primary barrier to this health-promoting behavior was the competing, religious ritual-based habit at a young age (hand washing with plain water10).

4. Provideownable cues: Behaviors can be motivated by the desire for either the presence of positive cues orthe absence of negative cues, so behavior change can be achieved by making these cues more explicit.For example, hand-washing interventions can bemore successful when the cue of removing germs (usually invisible and non-explicit) is made more obvious through products that make hands smell and feel more clean after washing or through media campaigns that illustrate how germs are removed during the washing process.11This could potentially apply to motivating FLWs to improve their service delivery by improving interactions with beneficiaries and improving beneficiaries’ perceptions of FLWs, thus associating the cue of engaging, positive social interactions with FLWhealth service delivery tasks.

5. Support repetition: Practice is essential for engaging neural areas implicated in habit formation. Allowing FLWs to physically engage in role playing or actual practice the target behaviors will utilize procedural memory mechanisms, allowing the target behavior to become more ingrained into FLW behaviors. In an intervention study with hand-washing, supervising children to actively practice the correct hand-washing technique was effective in increasing the behavior and improving health outcomes.

6. Promotemeaning-making: Even when behaviors are ritualized or so ingrained that they become automatic, encouraging FLWs to make the target behaviorspersonally meaningfulis important for sustaining the behavior and promoting the behavior to others to establish new social norms. This method has been successfully implemented in India in past work, when behavior change around hand-washing behavior was achieved by facilitating mothers tounderstand hand-washing as being an integral part of being a “good mother”.In this intervention, mothers had regular meetings and were encouraged to share tips with one another to effectively encourage hand-washing with their children.

## Cross-stream research objectives

1. Identify and describe the role of individual motivation in the degree to which FLWs perceive that frequent and high quality visits with beneficiaries are important

2. Identify and describe FLW rituals, both those that may be harnessed to encourage high quality health service delivery and those that pose a barrier to health-promoting behavior among FLWs.

3.

## Design goals
Using the results of the research objectives, the main goal of Project RISE is the design of service solutions to improve quality and frequency of FLW interactions with beneficiaries. This process will involve a process of co-design with FLWs and community representatives, then testing, refining, testing, and refining until we have established several options with proof--of--concept.

par(mar = c(4, 4, .1, .1))
plot(pressure, type = 'b', pch = 19)

Reference a figure by its code chunk label with the `fig:` prefix, e.g., see Figure \@ref(fig:nice-fig). Similarly, you can reference tables generated from `knitr::kable()`, e.g., see Table \@ref(tab:nice-tab).

knitr::kable(
  head(iris, 20), caption = 'Here is a nice table!',
  booktabs = TRUE
)

You can write citations, too. For example, we are using the **bookdown** package [@R-bookdown] in this sample book, which was built on top of R Markdown and **knitr** [@xie2015].