Novel approaches to measuring knowledge among frontline health workers in India: Are phone surveys a reliable option?

Neha Shah, Diwakar Mohan, Smisha Agarwal, Kerry Scott, Sara Chamberlain, Aarushi Bhatnagar, Alain Labrique, Meenal Indurkar, Rajani Ved, Amnesty LeFevre, Agarwal Smisha Agarwal, Arora Salil Arora, Bashingwa Jjh Bashingwa, Bhatanagar Aarushi Bhatanagar, Chamberlain Sara Chamberlain, Chandra Rakesh Chandra, Chakraborty Arpita Chakraborty, Chauhan Vinod Chauhan, Dumke Neha Dumke, Dutta Priyanka DuttaGodfrey Anna Godfrey, Gopalakrishnan Suresh Gopalakrishnan, Indurkar Meenal Indurkar, Jairath Anushree Jairath, Kashyap Manoj Kashyap, Kumar Nayan Kumar, Honikman Simone Honikman, Labrique Alain Labrique, LeFevre Amnesty LeFevre, Mendiratta Jai Mendiratta, Miller Molly Miller, Mitra Radharani Mitra, Mohan Diwakar Mohan, Moodley Deshen Moodley, Mulder Nicola Mulder, Ng Angela Ng, Parida Dilip Parida, Penugonda Nehru Penugonda, Purty Nikita Purty, Rahul Sai Rahul, Rajput Shiv Rajput, Reddy Haritha Reddy, Sahore Agrima Sahore, Scott Kerry Scott, Shah Neha Shah, Sharma Manjula Sharma, Shinde Aashaka Shinde, Singh Aaditya Singh, Tiffin Nicki Tiffin, Ummer Osama Ummer, Ved Rajani Ved, Weiss Falyn Weiss, Whitehead Sonia Whitehead, Yadav Shalini Yadav

Research output: Contribution to journalArticlepeer-review


Background In 2017, India was home to nearly 20% of maternal and child deaths occurring globally. Accredited social health activists (ASHAs) act as the frontline for health services delivery in India, providing a range of reproductive, maternal, newborn, child health, and nutrition (RMNCH&N) services. Empirical evidence on ASHAs' knowledge is limited, yet is a critical determinant of the quality of health services provided. We assessed the determinants of RMNCH&N knowledge among ASHAs and examined the reliability of alternative modalities of survey delivery, including face-to-face and caller attended telephone interviews (phone surveys) in 4 districts of Madhya Pradesh, India. Methods We carried out face-to-face surveys among a random cross-sectional sample of ASHAs (n = 1,552), and administered a follow-up test-retest survey within 2 weeks of the initial survey to a subsample of ASHAs (n = 173). We interviewed a separate sub-sample of ASHAs 2 weeks of the face-to-face interview over the phone (n = 155). Analyses included bivariate analyses, multivariable linear regression, and prevalence and bias adjusted kappa analyses. Findings The average ASHA knowledge score was 64% and ranged across sub-domains from 71% for essential newborn care, 71% for WASH/ diarrhea, 64% for infant feeding, 61% for family planning, and 60% for maternal health. Leading determinants of knowledge included geographic location, age <30 years of age, education, experience as an ASHA, completion of seven or more client visits weekly, phone ownership and use as a communication tool for work, as well as the ability to navigate interactive voice response prompts (a measure of digital literacy). Efforts to develop a phone survey tool for measuring knowledge suggest that findings on inter-rater and inter-modal reliability were similar. Reliability was higher for shorter, widely known questions, including those about timing of exclusive breastfeeding or number of tetanus shots during pregnancy. Questions with lower reliability included those on sensitive topics such as family planning; questions with multiple response options; or which were difficult for the enumerator to convey. Conclusions Overall results highlight important gaps in the knowledge of ASHAs. Findings on the reliability of phone surveys led to the development of a tool, which can be widely used for the routine, low cost measurement of ASHA RMNCH&N knowledge in India.

Original languageEnglish (US)
Article numbere0234241
JournalPloS one
Issue number6 June
StatePublished - Jun 2020

ASJC Scopus subject areas

  • General


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