Bringing men into the conversation around family planning and contraception has always been challenging in India. However, with the correct information and awareness, dedicated staff like Rina Devi in Bokaro, Jharkhand, serve as an example that male engagement is possible.

Rina was recently recognized as one of the best community health workers for mobilizing four non-surgical vasectomy (NSV) clients during the country’s NSV fortnight in November 2022.

Urban ASHAs
Bokaro, Jharkhand

However, her journey as an Accredited Social Health Activist (ASHA) was not easy, as she recalls that she came across several men who were reluctant to talk to her in general, let alone about family planning. Faced with this, Rina sought the support of her husband to visit the households and talk to men.

She learned these techniques from her auxiliary nurse midwife (ANM) mentor and the TCI team in India. Rina said both have always supported her, be it for one-on-one counseling, or conducting interventions where men gather, such as ‘Chauraha’ meetings (meaning ‘crossroads’ in English) for men seeking odd jobs as laborers.

As the world anxiously awaited the development of COVID-19 vaccines, there was also growing concern about vaccine hesitancy and even anti-vaccine attitudes in people that could significantly dent the government’s nation-wide coronavirus vaccination campaign. Not that vaccine hesitancy was without a reason: from vaccine side effects and safety, lack of trust in the process, and fear amongest high-risk individuals like diabetics and hypertensive patients – there was a long list of reasons why people were reluctant to be vaccinated. Jagdish Verma, 66, was one of them.

Retired from government service and a resident of Indore, Jagdish was also a diabetic (Diabetes Mellitus). The Samagra team, during a visit to the community, met Jagdish where he confessed his apprehension about the vaccine, especially since he was told it could interfere with his diabetes medication.

Urban ASHAs
Aligarh, Uttar Pradesh

To address Jagdish’s hesitation, the team felt it necessary to talk to him about the added risk in contracting COVID 19 given his underlying diabetic condition. This was part of the overall strategy by Samagra to disaggregating populations by their reasons for hesitancy and then address these barriers, often by making them part of support groups to bring about behaviour change in those hesitating to take the vaccine.

Thus, not only was Jagdish convinced about visiting the UPHC, but the Samagra FPA and ASHA continued their follow-up visits to further motivate him for vaccination.

After two weeks of follow-up by the ASHA, Jagdish agreed to take the vaccine. Today, Jagdish is a COVID-19 vaccine champion in his community and encourages his friends and neighbours to get vaccinated. It is this team work like this that has made Indore the first million-plus population district in the country to achieve 100 per cent coverage by the first-dose of the COVID vaccine.

A critical outcome objective of the Samagra project is to improve acceptance of the COVID 19 vaccine among the slum population of Indore, through improved knowledge of COVID vaccines, improved risk perception, and self-efficacy. The project’s coaches, field program associates (FPA) work with FLWs to conduct extensive and well-managed community engagement. One of the strategies that the Samagra team advocates with the FLWs are to proactively release timely information on vaccine modalities to disaggregated populations in the community, including high-risk individuals undergoing care for comorbidities.

As a staff nurse at the Laxminagar urban primary health center (UPHC) in Mathura, Uttar Pradesh, Kashmiri is paving the way for women there to learn more about reproductive health and make family planning decisions. Her passion for her work can be felt as she tells the following story:

“When Poonam came to UPHC seeking medical treatment, I talked to her about family planning. She wanted to space her next pregnancy, but because of myths and misconceptions she never did. I clarified each of her myths and explained the effectiveness of various contraceptive methods from the basket of choice. I also shared videos of satisfied family planning users over her WhatsApp number. Later, Poonam opted for a method of her choice.”

Kashmiri, Staff Nurse
Laxminagar UPHC, Mathura, Uttar Pradesh

Poonam returned to the facility a few days later, this time accompanied by her younger sister Devaki, who received a long-acting reversible contraceptive (LARC) method from the Laxminagar UPHC.

Kashmiri continued:

Manju persuaded her next-door neighborUsha also. But her husband was apprehensive. Kashmiri counseled and persuaded them to use a family planning method of their choice. Manju also accepted a family planning method.

Kashmiri feels proud that her sincere efforts of counseling clients, dispelling myths and giving clear information about each method has spread the word about the benefits of family planning in the surrounding community.

Vijay Sekhar Reddy lives in Chintapenta village, Penumurumandal in Chittoor district in the south Indian state of Andhra Pradesh. Along with his own family, his elderly parents also live with him.

Vijay Sekhar is the sole breadwinner for his family, earning a small living from farming; it is not surprising, therefore, to see him make repeated trips to Chittoor to buy seeds, manure and other agriculture-related inputs for his farm. So much so he was even forced to travel to Chittoor during the COVID-19 pandemic, since his livelihood depended on ensuring timely agricultural inputs to the crops throughout the cropping season.

Vijay Sekhar
Chintapenta, Penumurumandal, Andhra Pradesh

So, it was with a great sense of relief that he met a PSI India Hygiene Volunteer during his house-to-house calls for awareness generation in communities on COVID-19 preventive behavior (like handwashing, etc.). Vijay Sekhar says while he was already aware of preventive aspects like using masks, sanitizer, hand washing, and social distancing from watching television, he rarely took the recommended precautions seriously and did not practice them in his everyday routine.

That is why the conversation with the PSI India Volunteer was all the more revealing – not only did his knowledge about transmission of COVID-19 increase, he was convinced that following desired preventive behavior like maintaining social distance, using masks, and hand washing frequently, etc. More importantly, Vijay Sekhar came to realise that the best way to keep himself and his family safe was hand washing using soap, not just hand washing with water. Following the discussion with the PSI India Volunteer, everyone in his family practices hand washing with soap several times a day, especially if they have travelled outside their home. As an added precaution, all his family members have also got themselves vaccinated.

T Vennela, Panchayat Secretary of Athuru village, Reniguntamandal in Chittoor district the south Indian state of Andhra Pradesh, has always been a big supporter of PSI India’s work in the district.

When the coronavirus struck the state, she was therefore quick off the mark in organizing trainings for all government functionaries in her village on handwashing for prevention of COVID-19 transmission in the village with the help of PSI India.

T Vennela
Athuru, Reniguntamandal, Chittoor, Andhra Pradesh

Vennela also developed hard copies of all the flash cards with her on COVID-19 preventive behavioural practices for sharing with all the government functionaries in the village by leveraging panchayat funds. To ensure optimum coverage, she divided the total number of households amongst each government functionary in the village, like, for example, entrusting Village Volunteers to conduct IPC activities related to handwashing and COVID-19 prevention in the village.

Vennela adds people in the village had fallen prey to several myths about COVID-19, such as only people in cities would be infected while those living in villages were ‘strong’ and thus would not be affected by the disease, etc. the villagers also thought merely washing their hands with water was enough for clean hands. Realizing the gravity of the problem, Vennela - from April to June, 2021 – ensured blanket coverage of all households in the village through IPC activity; this activity was repeated at least three times in the aforementioned period. This helped clear the myths and misunderstandings that prevailed earlier in people’s minds, especially since the trainings and awareness generation was conducted by both government and PSI India functionaries. Vennela is convinced her approach has helped the community view the pandemic and related prohibitive behaviour from a very positive perspective and adopt the behavioural changes so quickly and readily.

ASHAs (accredited social health activists) are voluntary community health workers who work in all health areas in Indian communities. With multiple priorities, family planning was often the last thing on their mind. ASHAs were also not equipped to identify and counsel family planning clients. The Challenge Initiative (TCI) worked with the Indian government to coach and mentor ASHAs about family planning and prioritizing young low-parity women (15-24 years). During household visits, ASHAs provide informed-choice counseling on all family planning methods.

An ASHA in Prayagraj is empowering women to take family planning decision. TCI supports the Prayagraj government in strengthening urban family planning and adolescent and youth sexual and reproductive health services for its urban poor population.

ASHAs
Prayagraj, Uttar Pradesh

Tell us something about yourself, your family background, your education, etc.?
My name is Annapurna Kesarwani, I am 40 years old. My husband is a street vendor, sells snacks on a pushcart (chaatkathelalagatehai).  I hold a bachelor’s degree in Arts. I have two kids, 17 years old daughter and 16 years old son.  I always aspired to have a career that would allow me to educate others. I considered teaching at first but perhaps fate had something else in store for me. My in-laws want me to stay at home to take care of the family. My husband’s income was not enough to fulfill the family requirements. To provide financial support to my husband in 2011, I applied for the ASHA (Accredited Social Health Activist) position. Luckily I got selected and for the last 10 years I have been working as an ASHA in the Gaughat slum area, which is under the DharikarBasti urban primary health center (UPHC). In the Gaughat slum area women mostly work as rag pickers and are illiterate.

When and from whom did you hear about family planning for the first time?
Until my second pregnancy, family planning was completely a new thing for me; as both my pregnancies were unplanned. Within one year of marriage I got pregnant. After the birth of my daughter, my in-laws evicted us from the property and house because they wanted a male heir. We had no savings at that time, hence we started living separately in an affordable rented house near the slum area. After a year, I was pregnant again – those were the hardest days of my life.  It was during my second pregnancy’s prenatal check-up, I heard about family planning from a gynecologist and soon after delivery, I adopted a long-term contraceptive method of my choice.

How important do you think family planning is for your community?
Before I became ASHA, I wondered why do undernourished poor women die during childbirth. I used to note the cases of stillborn/premature births due to multiple pregnancies. I learnt that it is the lack of education and awareness amidst other factors that prevents women from accessing contraceptive information and services. Family planning is very important for the community. I associate family planning with women’s empowerment because the range of barriers – like lack of access to family planning information and services, lack of support from their husband and family – restricts them to build a healthy future for themselves.

How do you promote family panning in your catchment area?
I work in an area that mostly has rag picker women who are illiterate and poor. There are many barriers that impact these slum women’s motivation and ability to access contraception – for instance, lack of knowledge, financial constraints, restricted mobility, distance to district hospitals, fear of side effects, lack of support from family, social stigma, myths and misinformation. Initially, it was difficult to motivate them for family planning. With the support of TCI and my supervisor (an Auxiliary Nurse Midwife), I enhanced my counseling skills.  I learnt about the importance of establishing a rapport and cordial relation with women of my catchment area. Apart from health services, I make efforts to address family planning barriers and also help them to avail benefits of other government schemes.

Now, I start with family planning counseling of a woman during the gestation period itself so that she is aware of post-partum family planning services and prepares herself to make an informed decision to make use of family planning methods post-partum. That is the most suitable and the recommended period by doctors as well. In the case of young couples or first-time parents, I involve decision-makers of the family (husband, mothers-in-law) in counseling sessions. I have identified 20 champions, one in each cluster of the ward. These champions are smart educated women, active members of MahilaArogyaSamiti (MAS or women’s support groups) and Anganwadi Workers. Each champion covers 10 households and creates awareness among poor women on the economic and health benefits of family planning, nutritious diet, antenatal and prenatal care, immunization, COVID vaccination, hygiene etc. The fixed day static (FDS) service, which was initiated at DharikarBasti UPHC by the city government, with the technical support of TCI, is helping these counseling efforts. (The FDS approach is a collaborative effort whereby trained manpower, equipment, commodities and supplies at the facility are made available on a pre-announced day and time known to the community.) Woman who make up their mind do not have to wait for a long time to access family planning services. MahilaArogyaSamiti members promote FDS service, and at times escort women on FDS day as well. They also organize group meetings in their cluster area where I create awareness and counsel women and mothers-in-law on the advantages of family planning.

I help them with the school admission of their children. As a result, women in my area understand the importance of family planning, they themselves (in few cases along with mother-in-laws) visit UPHC on FDS days and make use of family planning services. They value family planning, education, and health overall. Most of all, today they listen to me, respect me and seek my advice in many things.

What kind of progress would you like to see in the area of family planning?
Family planning is a key factor in the development of society and nation. Each and every eligible couple should have access to short-term and long-term family planning services since this will help them to avoid unintended pregnancies and plan the size of family as per their choice.  Apart from creating awareness on family planning methods, the correct and consistent use of contraceptives should also be emphasized. Furthermore, there is a need to motivate men to adopt family planning methods.

What message or statement you would like to make for other women?
Family planning is not only beneficial for mothers and children, but it is for the entire family. Family planning provides an opportunity to woman to give more time to her family and herself. Women who have fears or believe myths associated with contraceptives should seek correct information from service provider. And women who are using contraceptives should promote the benefits among their peer groups.

Employed as a staff nurse at the Sant Nagar urban primary health center (UPHC) in Firozabad, Manisha is tasked with supporting all government health programs being implemented by the UPHC. She, however, considers her role in facilitating access to FP services one of her more significant responsibilities.

“I was trained by The Challenge Initiative (TCI) project on family planning counselling, Antara as well as intrauterine contraceptive devices (IUCDs). I am committed to my FP-related work since my UPHC is visited by a large number of women who depend on me for their FP needs. I cannot afford to miss even a day of work and try hard to be there for every one of my clients,” says Manisha.

Manisha
Sant Nagar, (UPHC) Firozabad, Uttar Pradesh

The COVID-19 lockdowns and the resultant closure of the UPHC was a situation she no one had every anticipated – or something her training had ever prepared her for.

“I quickly realised how difficult it was going to be for me and my clients when it came to service delivery. So, when my mother was hospitalized for cancer, it was a very difficult moment for me, torn as I was between my love for my mother and the need to be with her at her bedside, and my commitment to my clients to make sure they were not left unattended either. I then decided that I would carry my family planning client register with me when I was in the hospital with me mother at the cancer hospital,” says she.

True to her form, Manisha worked on her client every day she was by her mother’s bedside, reminding her Antara clients of their next dose falling due, ceaselessly working her mobile phone throughout the day to counsel family planning clients who had visited her at the UPHC earlier.

“I am happy that in my absence none of my family planning clients had to return without availing the services they sought from me,” says Manisha with a smile.

“I remember when a frail woman – and a mother of seven - visited our UPHC to for STI (sexually transmitted disease) treatment. She was in poor health, and I tried counselling her on various options available for family planning so she could focus on the well-being of her children as well as her own health. She was amenable to the idea herself, but was obviously reluctant because she knew her husband staunchly refused to adopt any FP method, either for himself or for her,” says Manisha.

Manisha decided to continue the dialogue with her client whenever she came to the UPHC for follow-up visits.
One day, seeing her accompanied by her husband, Manisha plucked up the courage to speak to him directly, despite the woman’s discomfort at the idea. Manisha was determined, though, and she took the couple aside and gently told him about his wife’s poor health and how it affected the well-being of the whole family, including their seven children at home. “I explained the benefits of family planning in detail to both of them, especially the husband,” says Manisha.

It was not easy, but after a number of counselling sessions, Manisha was able to persuade him to consent to his wife and himself adopt family planning. “It was then that I felt a sense of satisfaction. I had learnt first-hand how reluctance of husbands and in-laws was arguably the biggest obstacle to women adopting family planning to limit the size of their families,” she says.

For the last three years, 34-year-old Mohsina has overseen ward number 45 as a ward “corporator” in Muzaffarnagar, a city located in Uttar Pradesh, India. In this role, she ensures that the health, education, housing, transportation and other needs of the ward’s urban population are adequately addressed. Although she holds a position of power politically, she was hesitant and a bit uncomfortable to speak up about women’s reproductive health issues. Until she met an Accredited Social Health Activist (ASHA) named Haajra.

Mohsina was just 19 when she married Mohammad Yakub, who is now a primary school principal in Muzaffarnagar. She has five children and was interested in adopting a family planning method since her last two pregnancies were unplanned but she feared possible side effects from family planning methods.

Mohsina
Muzaffarnagar, Uttar Pradesh

She attended many community meetings in her ward where she heard firsthand about women’s health concerns for themselves and their families. She would encourage women to get their children immunized and counsel them on nutrition, but she was unable to speak to them about family planning. Her encounter with Haajra changed all that.

Mohsina fondly recalls that meeting and what took place afterwards with pride: “In a community meeting, I heard an ASHA educating and counseling women on reproductive health issues. That day, I felt an overpowering urgency to do something about my fears and I called that ASHA to meet me after the event was over. I inquired about all the family planning methods and shared my concerns hesitantly. Haajra [the ASHA] explained in detail how each method works and told me something that changed my perception of contraceptives that ‘side effects are temporary and not life-threatening.’ She gave me the number of the nearest urban primary health center (UPHC) where during fixed day static services (FDS) day, assured and quality FP services were provided. I was impressed with her and learnt that she had received hands-on coaching under the PSI-TCIHC project. I decided to adopt a long-acting reversible family planning method and availed services during an Antral diwas/FDS day organized at the UPHC. I did not have any serious side effect.

After overcoming my fear, I realized there are many women in my ward who are ignorant or have myths and misconceptions associated with contraceptives. I decided to empower women with correct information. With ASHA Haajra I organized group meetings exclusively on family planning in various locations in the ward. I encouraged women to attend group meetings and openly discuss their problems with the ASHA. We also involved MahilaArogyaSamiti members in organizing the meetings to ensure women’s turnout. During these sessions, we talked at length about why family planning is critically important for the health of the child and mother and emphasized limiting the family size and maintaining a gap of at least three years between births. We advised choosing a method of their choice and availing services from the nearest UPHC as there was no longer the need to visit the faraway district women’s hospital.

It is critical that women not only have access to credible information and good counseling on family planning, but also role models and champions, like Mohsina and ASHA Haajra, in their communities that can help create an enabling environment for the uptake of family planning services.

A tailor by profession, Lakshmipathi lives in Scheduled Caste (SC) colony in Chinnakampalli village in Chittoor district in the south Indian state of Andhra Pradesh.

The interesting thing, however, is Lakshmipathi lives with his family in a partially constructed house – but one that has a fully-functional toilet! This has made him a household name in the community – not only for his commitment to safe and dignified sanitation in his house, but also for working hard, day in and day out, to educate his children till graduation - and even beyond.

, Lakshmipathi
Chinnakampalli, Chittoor, Andhra Pradesh.

What is even more astonishing about Lakshmipathi is he constructed the household toilet by taking a loan from a private lender on interest, something which is unheard of in this small habitation where most households did not have a toilet as recently as April 18, 2022, when the Swachh Bharat Mission (SBM) implemented the toilet construction programme with the help of the panchayat and local administration.

Strangely, as this was happening, Lakshmipathi realized for reasons unknown to him, his name was missing from the list of beneficiaries for toilet construction, and despite his best efforts, he was ignored during the process of construction of toilets. He confesses initially, he had never thought of constructing a household toilet since he was barely able to meet his children’s college fees, even though, ironically, his own grown-up daughter had asked him many a time to construct a household toilet seeing how difficult it was for her to walk long distances in search of privacy every time she had to relieve herself in the fields. He says the constant hand-to-mouth existence made it very difficult for him to heed her request, though he was fully aware of her predicament.

It was only when PSI India Sanitation Counselors met Lakshmipathi and his friends during a group session in the village that Lakshmipathi first realized how vital it was to have a safe and hygienic household toilet in his house. He says the PSI India Sanitation Counselor showed him videos on toilet construction and use, and he was struck by the message in the video – that if a father uses a toilet, then the children will also learn from him and follow his example, and a responsible father will always use a toilet.

Moved by the example in the video, Lakshmipathi realized while he was doing his best to be a responsible to his children, his had however failed them in one aspect – by not constructing a toilet at home. But to his credit, Lakshmipathi was torn between his modest means and the large number of priorities vying for his little savings, most importantly his incomplete house.

But he did understand the importance of having a toilet in the house for the family and the importance of setting a good example to his children by being a responsible father. He thus decided to give priority to toilet construction rather than wait to complete his house. Because of lack of funds, he decided to take a loan from a private lender in the village to construct the toilet as a priority.

He beams with satisfaction when people tell him not only is his family regularly using the toilet since the day it was constructed, but his example has made him immensely popular in the village. People tell him others in the village speak highly about his progressive attitude and want to emulate his example by making toilets at home also.

Lakshmipathi modestly credits his popularity to the effort of the PSI India Sanitation Counselors who gave him insights and knowledge about the significance of sanitation for every household and every person. He doesn’t stop here: he says the PSI India Sanitation Counselors taught him how to maintain and keep the toilet clean through the video. He says he is especially proud of the fact his “children use the toilet at home with dignity and do not waste time in open defecation; instead they now use their time productively in studies”.

Today, not only he, but even his family members help keep the toilet clean.

PSI India Sanitation Counselors today reach out to every household in our project villages to motivate them to not only construct household toilet but also to use them regularly.

In the three years of Project SAVERA in Chittoor district, PSI India endeavours to change the behavior of 2,00,000 households towards sanitation in 400 project villages in the district.

Pinki, 35, a resident of the Bastauli slum in the Indira Nagar of Lucknow, Uttar Pradesh. Pinki, a homemaker, works part-time at stitching and sewing to supplement her income for the schooling of her three daughters. Her first encounter with cervical cancer occurred two years ago when her beloved older sister passed away from the disease. Her uncontrollable sobs show the suffering her family went through. A year after this unfortunate incident, Pinki met a member of the PSI India outreach team while participating in a door-to-door outreach campaign for cervical cancer awareness.

Pinki herself got screened for cervical cancer at a camp organized by PSI India, and she was tested positive. She was treated with cryotherapy at a nearby PSI India network private facility for a very small fee. She had the full support of her three daughters and husband Rajendera since they did not want to lose another family member.

Pinki
Indira Nagar, Lucknow, Uttar Pradesh

As a result of the services, she got inspired and motivated to mobilize other women, her family, and friends for screening during her free time. She frequently participates in community meetings organized PSI India, helps outreach workers by sharing her own example with community women to dispels screening myths, and helps fellow women move from ignorance to awareness. She has carved out her own life and is now paving the way for their better health.

As a responsible mother, she has also committed to bringing her three teenage girls to the District Women Hospital in Lucknow for the free HPV vaccination.She says, "Once my daughter receives the HPV vaccine, I will be better able to counsel mothers of other girls in my community and would handle any types of preconceived notions about cervical cancer prevention vaccination”. She believes that she has found her life's purpose and that by working on the cause of cervical cancer prevention she is trulyhonoring her late sister.

Shiva, 39, a clerk with a private company in the small town of Ramnagar led a simple life; eating mostly vegetarian food with the only vice of smoking 4-5 cigarettes a day. His father had high blood pressure; he died young, at the age of 58.

He stopped studying after he crossed 17 years of age, and became the sole bread winner of the family. He did not know if his father had diabetes along with high blood pressure and he never considered himself to be at risk of these diseases. He lived happily in oblivion until one day his close friend tested borderline positive for diabetes.

Shiva
Ramnagar, Uttar Pradesh

With this discovery in his friend's life, he noticed his friend was advised to take regular medication, exercise and restrict his food habits. He remembered the doctor mentioning to his friend that if any member of the family has metabolic disease such as diabetes, the immediate family may be at higher risk of developing diabetes or passing risk factors on to future generations.

He had just become aware of the complications, effects and risk factors of diabetes and high blood pressure.

How many of us are lucky enough to learn of the warning signs on time! Well, we can be, if we understand the signs and symptoms of non-communicable diseases and understand that we can change potentially unhealthy habits such as leading a sedentary lifestyle or using tobacco to delay or prevent onset of non-communicable diseases

Kavita Devi, 42, is a TB survivor; tragically, she lost her husband, Kapil, only recently. Kavita admits it is difficult to make ends meet, "but somehow, I manage.”

But now she has bigger concerns: "The lack of a toilet in our house is my biggest priority today. At stake is our dignity; every time my daughter had to go to the fields to defecate, I don’t rest till she’s back. During the monsoons, it is even more troublesome to go out of the house with so many mosquitoes and the danger of snakes biting us," says Kavita.

Kavita Devi
Uttar Pardesh

She admits finding a private spot to defecate was getting increasingly difficult and risky. "Every time we saw people; we would shrink away in shame. Sometimes, people just stared at us, forcing us to quickly move away and look for a more secluded place," says she.

Initially, when Kavita’s husband was alive, her neighbours shared their toilet with the family, but soon after his passing, they grew reluctant. Kavita’s meagre earnings from selling beedi’s were too little to support even the family’s basic needs, let alone constructing a toilet.

One day, Kavita happened to attend a community meeting organized by PSI India’s Saadhan Sanitary Mart (SSM), where she was intrigued to learn how quality toilets could be built at affordable prices. With the help of a family friend, Kavita submitted an application for a loan; her application was forwarded to the SaadhanSuvidha microfinance agency and very soon, the loan was sanctioned.

To her surprise, SaadhanSuvidha also sent their technical expert to her house to supervise the construction of the toilet.

Kavita is delighted with her new toilet. "I am happy, but my daughter is the happiest," says a beaming Kavita

Usha, 40, lives with her husband and four children in Lalbangla slum, ward No. 32 in Indore. It was in January 2020 when Asha Gaikwad, ASHA assigned to Usha’s ward and accompanied by Samagra team’s Field Program Associate (FPA), were on a routine visit to the community.

It was a routine weekly visit; FPAs usually met ASHAs in small groups to coach them in developing the planned journey cycle (PJC) using data from the urban health index register (UHIR), better known as the ASHA diary. ASHAs were also encouraged to include visits to nonusers of FP in their weekly PJC, reassurance and reminder visits to users of Anatra and IUCD, as well as supply replenishment visits to users of condoms and OCPs.

Usha
Lalbangla, Indore, Madhya Pradesh

Because her UHIR showed Usha as a user of condoms, Asha visited Usha’s house to inquire how she was and if she needed more supplies, etc. It was during their discussion that the FPA noticed that Usha’s abdomen was unusually large; when asked, Usha divulged she had missed her periods in the last four months. This led Asha to inquire about issues like her sexual relationship with her husband, and frequency of monthly menstrual cycle, etc. Based on what they had gleaned from the conversation, the FPA suggested Usha to take a pregnancy test.

Though reluctant at first, Usha finally consented to the test after being counselled by Asha, who then accompanied her to the nearest UPHC for the test. Once there, Usha was again counselled by the Medical-Officer-in-charge (MOIC), before she finally agreed to the test.

The MOIC gently counselled her about the risk of aborting an almost five-month-old foetus; he also asked Usha’s husband to come to the UPHC for a joint counselling session.

A detailed discussion followed, wherein the MOIC, Asha and the FPA explained the pro’s and con’s of taking the pregnancy forward. They assured Usha she was in safe hands with Asha and explained how a meticulous antenatal care schedule would be developed to ensure she had a safe pregnancy. The FPA also coached Usha on the antenatal care schedule for Usha for good measure. Together, they also visited Usha’s house to counsel her first-hand on the importance of prenatal care, including medicines she was advised (vitamins, iron, calcium, etc.). The Samagra team worked with Asha to ensure Usha received antenatal care at the urban health and nutrition day (UHND) designated for the purpose.

All the meticulous planning and pre-natal care bore fruit when, on June 8th, 2021, Usha gave birth to a healthy baby. Soon after discharge from hospital, she was visited by the Samagra team to make sure she and the new born were well. Meanwhile, Asha visited Usha regularly at home to follow-up on her ante-natal care; she also took the opportunity to counsel Usha and her husband on family planning options available for them, including long-term methods like IUCD, Antara, vasectomy, and tubectomy.

Usha opted for tubectomy since she already had four children to look after and both she and her husband were clear they did not want any more children. Supported by Asha’s, Usha underwent the procedure in the first week of September, 2021, and says she is now looking forward to providing the best care and education to all her four children.

From assisting a high-risk pregnancy to guiding young mothers on breastfeeding, nutrition, family planning, and safe hygiene practices, Samagra is coaching ASHAs and ANMs to help women in Indore look forward to a healthier tomorrow.

Pooja Kumari works as a janitor at the Aurangabad urban primary health center (UPHC) in Lucknow, Uttar Pradesh. Recently, she participated in a whole-site orientation (WSO), a TCIHC proven approach that targets all staff working in a health facility to become advocates for family planning.

All staff receive an “orientation” to gain a basic understanding of family planning and its benefits. At Pooja’s facility, the Medical Officer In-Charge conducted WSO for the entire staff on how to provide adolescent-friendly health services. Pooja was overjoyed to be sitting in the same hall as everyone else working for the facility.

Pooja Kumari
Aurangabad, (UPHC) Lucknow, Uttar Pradesh

With a sparkle in her eyes, she shared: “Since 2015, I am working in Aurangabad UPHC. As a janitor, my role is limited to facility housekeeping duties and responsibilities. When I was invited for WSO, I was somewhat astonished. I thought trainings are meant for medical staff only. At the same time, I was excited to have been counted for this training opportunity. It was a new experience for me. Whole-site orientation helped me to reflect on my adolescence, as back in those days there were hardly any services available for adolescents. In my teens, I could only approach my mother to discuss about menstruation and I don’t remember visiting any facility or hospital without any guardian.

"This story describes how unmarried adolescents face socio-cultural prejudices and stigma when they visit a facility alone. Their fear of being judged inhibits them to seek sexual and reproductive health care information or services. Due to insufficient and inaccurate information, they are left with much curiosity and unresolved issues. The participatory discussion followed by the story helped me to realize the health needs of adolescents and also equipped me with a know-how of how a non-clinical staff [like myself] can also create a conducive environment for adolescents by being non-judgmental and unbiased, regardless of their age and marital status.” I have learned so much from this orientation, both professionally and personally. Today, as a facility staff and as a mother I believe that the environment of a health facility and home should be adolescent-friendly so that they can fearlessly share their problems and get correct information related to sexual and reproductive health issues. In fact, after attending WSO, I have noticed a change in myself as immediately a few days later when some adolescents had visited the facility, I greeted them with a smile. I had never done this before. I am glad that I was considered as an important facility staff who can play a substantial role in creating enabling environment for adolescents.”

K. Mamtha, an Anganwadi worker in KodandaRamapuram village, Karvetinagaram, in Chittoor district of the south Indian state of Andhra Pradesh, says she is proud to have attended the training on handwashing organized by PSI in GramaSachivalayam, which was also attended by other government functionaries in the village.

In her opinion, she feels the training was very helpful, especially for her, since it was for the first time she came to realise the value of hand washing to keep COVID-19 at bay, both for herself and her family; she in fact used the videos and flash cards she received from PSI volunteers to show her children the correct way to wash hands with soap every time they ventured outside their home.

K. Mamtha
KodandaRamapuram, Andhra Pradesh

This has led to unprecedented behavioural change in Mamtha’s village - children now wash their hands before eating; not only washing hands with water, the children having learnt the value of washing hands with soap, now regularly wash their hands with soap as a habit, more so because they now understand that washing hands can protect them from COVID-19 also.

Mamtha is now using the videos and flash cards to share with other families in her community as well. She has also insisted on installation of a digital wall-painting on handwashing in her anganwadicenter, and says her effort to improve handwashing behavior during COVID-19 is being appreciated by her superiors in the mandal (district). Key opinion leaders in the village – including the Panchayat Secretary – have expressed their happiness about improvement in handwashing practices in the village, especially amongst children. Encouraged by the response, Mamtha says with the easy availability of vaccines in her village now, she is now motivating her community to come forward to get themselves vaccinated.

Accredited Social Health Activists (ASHAs) are empowering women like Rani Burman living in Madhya Pradesh, India, to seek a better tomorrow. The Challenge Initiative for Healthy Cities (TCIHC) supports local governments in Indian states like Madhya Pradesh to strengthen the capacity of urban ASHAs to provide quality family planning counseling and referrals to meet the needs of women like Rani. I was flying on my new scooty; my dreams were turning into reality. Life was a Bliss! All thanks to Pooja Didi. Yet I clearly remember the day when Pooja Didi first visited me. I was eating only rice. She had asked, ‘Why are you eating only rice? You have small children; you must eat a healthy and balanced diet.’ My eyes had welled up and she sat there quietly. Once I felt better, I shared that ever since the birth of my second daughter financial hardships increased for us. My husband and in-laws wanted a male child so my husband did not spare money for us; instead, he spends most of his earnings on alcohol. Today I at least had rice to eat. Pooja Didi comforted me and left with a promise to return.”

From that day, she would visit me often, sometimes to give iron-folic tablets or to immunize my children or to just inquire about my health. One day, she cited her example and encouraged me to work and earn for the family. I told her that I had completed my secondary education but my husband does not like the idea of my working outside of the house.

Rani Burman
Madhya Pradesh

From that day, she would visit me often, sometimes to give iron-folic tablets or to immunize my children or to just inquire about my health. One day, she cited her example and encouraged me to work and earn for the family. I told her that I had completed my secondary education but my husband does not like the idea of my working outside of the house.

She checked about children’s health and started a conversation around the importance of family planning and also prodded upon the idea of my working outside of the house. She reasoned without fear that these two decisions will only make life better for us. My husband was moved. A few days later, I asked my husband if I could look for a job. To my surprise, he gave his nod. I soon found one and gradually found a better one as a receptionist at a hospital. Pooja Didi was elated!”

Financial independence boosted my confidence. I started expressing myself. I told my husband that I know that the family desires to have a male heir but given that we already have two daughters and our income is also not sufficient to support this current family of six members including his parents. Thus, we must do something about family planning as we cannot bear the cost of upbringing one more child. My husband approved and asked me to inquire all about family planning from ASHA Didi. Next time, when Pooja Didi visited us, she explained all the family planning choices and clarified our doubts. We decided to adopt a permanent family planning method as we wanted to be free.”

These two decisions have changed my life. Not only am I free from the constant pressure of producing a male child but I have become independent too and also gained respect from my family and society. I am determined that my daughter will do advanced studies and become a doctor or a police officer. I have learnt not to fear life but to live life.”

Poonam Batham, who is 23 years old and lives in Nadi Paar Taal, a slum of almost 2,000 people in Gwalior. She lives with her husband Sujit Batham,has their two-year-old son and her mother-in-law, depends on daily labour to make ends meet.

Her community strongly believes that TB is a result of a person being under the influence of black magic or an evil spirit. Additionally, the community elders believe women under the influence of this black magic cannot become mothers again and, therefore, must be isolated from family.

Poonam Batham
Nadi Paar Taal,Gwalior, Madhya Pradesh

People also believe TB can only be treated by traditional healers. Poonam’s mother-in-law believe Poonam was under the influence of black magic, coughing all day and losing weight. As a result, Poonam was isolated from her family members and the community avoided her.

They discussed government schemes for free medication and care from qualified doctors at medical facilities closer to their home. The AHSA convinced Poonam’s husband that she needed medical care and accompanied her to the district hospital. At the hospital, the doctor observed that Poonam was undernourished, weighing just 25 kilograms, and tested her sputum. Once the test results confirmed pulmonary TB, the ASHA supported Poonam in adhering to her treatment plan and making sure she had access to nutrition and care from family during her weekly household visits. Grateful for the ASHA’s intervention and follow-up with her and her family, Poonam said, “I have realized the life of hell and heaven in very short span of time.”

The coaching the ASHA received from PSI India team helped her to effectively support Poonam. The ASHA also dispelled myths about TB affecting fertility in the community. Because Poonam dreams of her son getting a good education and having a successful career away from the poverty of the slums, she and her husband decided that she would use an intrauterine contraceptive device (IUCD) so they would have time and resources to make her dream a reality. Poonam credits the AHSA’s counseling for the decision to adopt a family planning method.