‘[We] learned how to speak with love’: a qualitative exploration of accredited social health activist (ASHA) community health worker experiences of the Mobile Academy refresher training in Rajasthan, India

Introduction Mobile Academy is a mobile-based training course for India’s accredited social health activist (ASHA) community health workers (CHW). The course, which ASHAs access by dialling a number from their phones, totals 4 hours of audio content. It consists of 11 chapters, each with their own quiz, and provides a cumulative pass or fail score at the end. This qualitative study of Mobile Academy explores how the programme was accessed and experienced by CHWs, and how they perceive it to have influenced their work. Methods We conducted in-depth interviews (n=25) and focus group discussions (n=5) with ASHAs and other health system actors. Open-ended questions explored ASHA perspectives on Mobile Academy, the course’s perceived influence on ASHAs and preferences for future training programmes. After applying a priori codes to the transcripts, we identified emergent themes and grouped them according to our CHW mLearning framework. Results ASHAs reported enjoying Mobile Academy, specifically praising its friendly tone and the ability to repeat content. They, and higher level health systems actors, conceived it to primarily be a test not a training. ASHAs reported that they found the quizzes easy but generally did not consider the course overly simplistic. ASHAs considered Mobile Academy’s content to be a useful knowledge refresher but said its primary benefit was in modelling a positive communications approach, which inspired them to adopt a kinder, more € loving’ communication style when speaking to beneficiaries. ASHAs and health system actors wanted follow-on mLearning courses that would continue to compliment but not replace face-to-face training. Conclusion This mLearning programme for CHWs in India was well received by ASHAs across a wide range of education levels and experience. Dial-in audio training has the potential to reinforce topical knowledge and showcase positive ways to communicate. ASHAs are female CHWs who facilitate antenatal care, institutional deliveries, and immunisations; provide home-based newborn care; promote family planning, hygiene, and nutrition; and convene village health events.19 20 Current recruitment standards (released in 2012) dictate that ASHAs are required to have completed 10 years of formal education; ASHAs recruited in the first years of the programme (2005–2012) required only 8 years of education and educational requirements can be ‘relaxed’ in marginalised regions.21 While some ASHAs have attained education beyond high school, non-literate ASHAs are not uncommon in many states22; 17% of ASHAs surveyed in Madhya Pradesh were unable to read a full sentence,23 and 30% of ASHAs surveyed in Uttar Pradesh were low literate.24 ASHAs have been found to average over 20 work hours/week,25 and receive a small fixed monthly honorarium as well as performance-based remuneration with total monthly income ranging from 900 to 4250 rupees (US$14 to US$65) depending on state-level top-up payments and ASHA activity. ASHAs are also compensated 200 rupees (US$3) for attending face-to-face trainings. ASHAs have long asserted that they are underpaid.26 27 State governments aim to provide ASHAs with 23 days of initial training and 10 days of supplementary training, as well as monthly supportive supervision through the government primary healthcare system.28 Early evaluations identified curriculum inadequacies and low-quality training delivery as major issues facing the programme.28 29 Over time, trainings have sought to reorient towards a competency-based approach, with efforts to balance health knowledge, clinical skills, and communication and counselling ability.30 While the ASHA programme has been credited with bolstering antenatal care, increasing institutional deliveries31–34 and childhood immunisation,35 36 and improving community case management of childhood illness,37–39 studies have consistently identified gaps in ASHA knowledge and skills including on childhood illness and danger signs in pregnancy.37 39–46 Beyond gaps in knowledge and skills, shortcomings in ASHAs’ interpersonal and counselling skills have also been identified.30 47–49 Their communicative and counselling efficacy is influenced by their training on communication and counselling,48–50 as well as personal characteristics (eg, the ASHA’s confidence, empowerment, education), power hierarchies (eg, caste, class, religion, gender), other identity and relational factors (eg, geographic proximity, political affiliations, marital status, number of children and family relationship histories)43 51 52 and the health system more broadly (eg, the extent to which ASHAs are able to link to facilities that provide high-quality healthcare).53 54 Rajasthan is a majority Hindi-speaking state in northern India with a population of 78 million.55 In 2015, while 85% of men were literate, literacy among women was only 57%.56 The 2015/2016 maternal mortality ratio was 199 per 100 000 live births57 and the rural under-five mortality rate was 54.4 per 1000 live births.56 Only 39% of women received the recommended four antenatal care check-ups, but 84% of deliveries took place in health facilities.56 As of January 2018, there were approximately 44 900 ASHAs in the state’s rural areas, which is 88% of the targeted recruitment and amounts to 1 ASHA per 1147 rural people. We received permission to conduct this qualitative study in three districts (Ajmer, Sikar and Pali) of Rajasthan, selected by government authorities. Data collection took place in October and November 2018. ASHAs were selected purposively using data generated by Mobile Academy’s technical system and guidance from block-level ASHA facilitators. We interviewed ASHAs who had completed Mobile Academy when it was officially launched (2016, early 2017), as well as ASHAs who completed Mobile Academy more recently (late 2017, 2018). This decision was made to explore possible differences between early and late completers of Mobile Academy. We also hypothesised that late completers would be more likely to recall specific details of the course, since it would be fresher in their minds. We sought ASHAs with varied Mobile Academy engagement profiles. We considered the number of minutes an ASHA was engaged in the course (while most ASHAs in Rajasthan completed the course in approximately 240 min, we sought 11 ASHAs who took 270 min or more), their scores (while most ASHAs in Rajasthan had a score in the 40s out of a maximum of 44 points, we sampled 15 ASHAs with scores less than 40/44) and ASHAs who had repeated the course (we sampled four ASHAs who went through the course twice). Our focus group discussions (FGDs) included a mix of ASHAs by Mobile Academy completion data, nature of Mobile Academy engagement (quiz scores, etc) and education level. We also interviewed auxiliary nurse midwives (ANMs) and ASHA supervisors, who work closely with ASHAs, and other government health system stakeholders at the block, district and state levels (table 1). Mobile Academy respondent sample ANM, auxiliary nurse midwife; ASHA, accredited social health activist; IDI, in depth interview. Interviews and FGDs were conducted by four female qualitative researchers (authors MS, DG, BM and NC), supported by a male research manager (OU) and female research coordinator (KS). All researchers were trained over a 1-week period, which included pilot testing the detailed ASHA interview guide, and had a master’s level social science education or higher. They approached the respondents first by phone to explain the study, identify themselves as working for a Delhi-based research company, explain that they had governmental approval to conduct this study, and ask if they could meet face to face to learn more and, if the respondents agreed, to participate. The interviews took about an hour and were conducted in ASHA homes and in other stakeholder’s offices and health facilities; the FGDs took just over an hour and were conducted in empty school buildings, clinics, and courtyards. ASHA family members were often around the home during the ASHA interviews but did not actively listen to or engage with the interviews. Only the researchers and participants were present during the other data collection. The study information and informed consent was read to each potential participant and then summarised in conversational language to ensure comprehension. All respondents provided informed oral consent. Two people who we approached for the study refused: one ASHA who had a family emergency and one state-level actor citing lack of interest. All respondents who agreed to participate in the study also allowed audio recording. The research domains explored are presented in box 1. Analysis began with daily debrief meetings, where the field team (MS, DG, BM, NC, OU and KS) drew from interview notes to discuss emerging themes and adjust elements of the guide and sampling based on saturation and emergent subtopics without the study domains. After data collection, all audio files were transcribed and translated into English and uploaded into Dedoose, a qualitative data management software. Guided by the principles of thematic analysis, KS and OU developed and applied a coding framework with nine code clusters that echoed the topics explored in the interviews and FGDs. The clusters consisted of between three and 11 codes which were primarily drawn from a priori areas of interest. After coding, we generated code reports that enabled us to read all text tagged by the same code. We present our findings thematically, grouped under the five components of our framework for understanding CHW engagement with mobile learning courses (figure 1). Framework for understanding community health worker (CHW) engagement with mobile learning courses. The research was shaped by ASHA and other health system actor priorities, experiences and preferences through iterative probing and flexibility within our research domains. Results were disseminated to Government of India stakeholders and actors involved in developing Mobile Academy.