Rekha, an ASHA from our pilot site in Rajasthan, called me tonight. “I missed you and wanted to talk. When are you coming back to Kishangarh, sister?” she asked. I felt a warm and fuzzy feeling inside. It’s quite endearing to get calls from the ASHAs.

Will the novelty wear off with time?

We spoke about progress in her village, both with and without CommCare. She had only good news to share. She said women love the information they can see and hear in the program and aren’t bored by it. They pay attention and ask questions.

For the past few months, Rekha’s had the highest number of form submissions of the pregnancy checklist. This is a multimedia-enabled mobile form, which asks questions about antenatal care check-ups, tetanus immunizations, contains reminders for the women to take their iron pills daily. The form also disseminates information (both through audio and visuals) about dangers signs a woman can experience at different stages of pregnancy, encourages the woman and her family to prepare for cost and transportation in advance, in case of an emergency. New information is displayed based on the stage of pregnancy. It changes about every 3 months or so.

In addition to highest form submissions and she also is one of the ASHAs with high case activity percentages, which means she’s covering 100% of client base very often. When I spoke to her three months ago, she said that she circulates the pregnancy checklist and shows the information in her mobile phone to the pregnant woman in her village every two weeks!

So I asked, “Are the women getting bored? They see the same information over and over. Is it not a novel tool anymore?”

Her answer was simple, “No, they still come and listen and watch. But they do ask, ‘Does she [woman in the mobile] always say the same stuff?’ ‘Yes’, was her answer. And that was it.

More immunizations for both women and children

All of the ASHAs say there’s benefit in using CommCare and that they’ve experienced some kind of kind. I tried to get her to quantify the change. She said, all of the children in her village are coming out for immunization now. Before she used CommCare, at least 50% would be missing.

She also said more women are getting their tetanus immunizations completed than before. On Immunization day, one or two women would be missing.

Please let me step back for a bit. What I’ve learned is woman will happily (if they feel pressured enough) get immunized themselves for tetanus while they’re pregnant, but they resist bringing their children for immunizations. Typical reasons are my baby will cry, it will hurt my baby, it results in swelling and pain for the baby.

The application that Rekha is using only has an antenatal application, and not a newborn module, which would contain information on children’s immunizations. Perhaps the cycling of the information to the women of her small community has resulted in greater uptake of immunizations for children? As I mentioned earlier, the pregnancy checklist contains information about the importance of getting tetanus immunizations for the woman. I’m not sure, but I’d like to believe it. Naturally an informed and aware woman will understand what’s necessary for the health of her baby, isn’t it?

ASHA adapts CommCare in an unexpected way!

Rekha’s also doing something very innovative with the multimedia stored in her phone. It blew me away when she first told me. After two months of using CommCare, one day during Immunization Day in her village, Rekha decided to play the audio files through the media player for small groups of women who were waiting to get immunizations for themselves or their children.

The audio played without pause actually sounds like a conversation between two women about antenatal care topics. The way we named the files results in the following playlist: 1) a woman says, she does not know about topic xyz; 2) a health worker gives information about this topic; 3) a woman says, yes, she knows about topic xyz. And this flow repeats for 45 antenatal topics!

A couple women came up later to ask the ASHA more questions about topics raised in the “radio show”. According to another ASHA in our pilot, the audio-visual information available on CommCare is similar to the way information about health is shown on television or heard on the radio. Not only is it an interesting and engaging medium, but a convincing medium for villagers, who believe and trust information from media sources like TV or radio (more-so sometimes that what their ASHAs tell them).

[Only recently, after my work in Bihar, did I realize why this is. Some people in villages are skeptical of the information the ASHA gives about having an institutional delivery, going to the hospital to get antenatal care checkups completed, or opting for sterilization as a method of permanent family planning because they know ASHAs get incentives for all of that work. They believe the ASHA works for the money and not for the people. (I will write another post about on this issue at a later date)]

One woman’s story

Three months ago, I felt especially connected of a story Rekha told me of one woman in her village. This woman’s husband is an alcoholic and forbids her from going to the Anganwadi center, or speaking to the ASHA. This woman heard about ‘the program Rekha was given in her mobile phone for pregnant woman’ through word of mouth. This could happen when women go to fetch water, or walking to the fields. This woman snuck away from the home without her husband knowing to the Anganwadi center on several occasions to learn the information and benefit from the program. She had heard there’s information about pregnant woman that Rekha has to share, and she also felt like she should hear it!

My first takeaway: A novel tool can attract people and want to access information through it.

I asked about this woman today. Rekha said, she came to learn the information from CommCare (which was a big step on its own), but never took up the practices as they was forbidden by her husband. This woman was the only woman in her village, who experienced complications during pregnancy, was transferred to Ajmer for emergency care and lost lots of blood there. Her newborn died within 4 days. She’s recovered now.

Rekha said, the main problem was the husband hadn’t arranged for transport in advance, didn’t allow her to take the pills, let her get looked at by an ANM (auxiliary nurse midwife) or get immunized. I wonder what he’ll decide to allow/disallow for their next pregnancy after being the only family that did not follow the practices encouraged in the application.

My second takeaway: People learn from real stories and do what other people do right.

I wonder if Rekha will cite this example as a behaviour change weapon along with CommCare. Rekha was among the top performers for form completions and case activity rates. Every single pregnant woman who saw CommCare in the past 6 months had a healthy pregnancy and are now breastfeeding, except one (she’s only had an about 7-8 pregnant woman in the past 6 months). By way of example of that one woman’s story, I wonder how people’s opinions have formed for the information in CommCare and the credibility of the ASHA. Through CommCare, ASHAs are able to share information, comprehensively, correctly and with credibility. Now, let’s hope it can motivate service uptake and break down barriers.

On that note, I think there’s so much value in filling out the counseling type forms within the home, where there is a higher probability of a (resistant) family member being present and at the very least half-listening.

My third takeaway: Encourage ASHAs to complete all counseling forms at the home, instead of at the Anganwadi Center, where household decision makers may also tune in and learn.

 

Check out Rekha in action on YouTube. Courtesy Daniel Pepper.

YouTube: Rekha