System-level changes
The output-level results capture the voices of the implementing program and state officials from the highest levels down to the staff supporting the grassroots functionaries. These results are presented across five key domains outlined above, namely, a change in roles and responsibilities due to the layering of HNS activities, the role of BHNSI in supporting HNS layering, linking SHGs to existing health and nutrition schemes and services in villages, JEEViKA and JTSP’s specific role in supporting the layering efforts, and the current process of monitoring HNS layering as captured through JEEViKA’s internal MIS.
Roles and responsibilities of JEEViKA staff
Through the layering on HNS across JEEViKA, all staff took on additional responsibilities. State project managers and their associated project managers coordinated their activities and discussed how HNS activities could be layered onto their respective priorities. For example, the vertical on health and nutrition planned and rolled-out HNS trainings across 101 blocks in coordination with other verticals, such as institution- and capacity building. During the interviews, several staff members, especially the project managers and HN managers mentioned receiving guidelines detailing their revised roles and responsibilities. They also received additional key performance indicators detailing HNS activities to be layered onto their existing roles and responsibilities.
At the district-level, district project managers mentioned providing technical oversight and strategic guidance in the implementation of the HNS program. They assessed the progress of the program’s implementation in consultation with the HN manager and reviewed monthly block reports on HNS indicators to monitor the progress. Further, they served as a bridge between the blocks in their jurisdiction and the state project managers. On the other hand, the district HN managers who reported to them oversaw the trainings of the HNS modules in their district, generated awareness of HNS within JEEViKA during their meetings and field visits, coordinated closely with JTSP in program implementation, collated block reports into a district report and served as a liaison for the BHNSI, block project managers and district officials. An HN manager shared the impact of his work in the following words,
“I give HNS a lot of importance, as I believe it has long term impact. One of the important impacts of HNS is on the livelihoods of people.”
Block project managers seemed well versed with their new functions and responsibilities. They reported monitoring HNS trainings in their block, supervising the BHNSI and coordinating trainings with master trainers. They also accompanied BHNSI to the villages often to conduct unannounced field visits and interacted with CMs and SHG members to understand the ground reality of layering HNS.
Within the blocks, area coordinators had on average been in their current position for under 4 years and cluster coordinators for under 2.5. Area coordinators were primarily responsible for preparing area plans (90%) and executing them along with facilitating bank linkages for SHG members (79%). In addition, they were promoting HNS activities (58%) within their respective areas along with supportive supervision and monitoring of those activities (68%). Analysis of their time suggested that they carried out these additional responsibilities within their average eight working hours a day. On the other hand, cluster coordinators were primarily responsible for forming and strengthening VOs (83%) and training the members (83%). In addition, they organized community level health and nutrition activities (camps). A cluster coordinator covered, on average, around 11 villages, with about 89 CMs directly reporting to him/her. They were the first line of response to a CM’s request for guidance or assistance. They also collated HNS indicators at the village level and carried it forward to the block office. Analysis of the time they had spent working over the week preceding the survey suggested that they worked for ~7.5 hours/day over 6 working days and had managed to implement HNS activities during that time. Respondents said that they were motivated to include HNS activities due to encouragement and support from their supervisors, and had gained confidence to discuss HNS matters in the community. They were also satisfied with their work environment, primarily for receiving adequate opportunities to contribute ideas to improve services within JEEViKA, getting opportunities for training, and having supplies and equipment available for work, such as training materials.
Induction of BHNSI
BHNSI were staff at the block level who were appointed to support activities for HNS layering across the block. They were trained by JTSP prior to taking on their role in supporting JEEViKA’s implementation strategies. This staff’s salary was being paid by JTSP but they reported to the BPM as a JEEViKA block staff member. They organized trainings on HNS modules across the block, provided post-training support to the CMs, monitored the implementation of the modules and coordinated with various JEEViKA departments. In several interviews, block and district officials noted that BHNSIs were great support. Two BPMs stated,
“The BHNSI plays an essential role in sustaining the HNS activities in the block,” and,
“Due to the presence of BHNSI in the system, HNS activities are taken more seriously by JEEViKA staff.”
Hence, the presence of BHNSI was of great help in supporting HNS activities at the block level.
Linking SHGs to health and nutrition schemes and services
Our interviews revealed that within JEEViKA, efforts to layer HNS programming were focused on two key components – one, generating demand for health services through increased interactions with frontline health workers and seeking health services in public facilities, and two, increasing knowledge of the practice of healthy maternal, neonatal and child behaviors among SHG women. In line with the first objective, JEEViKA was making several efforts to link SHGs to health and nutrition schemes and services. To this effect, project and HN managers along with BHNSI said that they were interacting with external agencies such as the Integrated Child Development Scheme and community health system, to leverage support for HNS layering. In addition, block project managers stated that they interacted with block development officials and representatives of the primary healthcare system, to seek their support for HNS programming. In order to achieve the second objective, CMs were trained on key maternal, neonatal and child behaviors that they were encouraged to share in SHG meetings at least once a month and through home visits of SHG members’ households especially where there was a pregnant woman or a child under two present. They were also encouraged to advice SHG women to accompany pregnant and lactating mothers to health services, visit Angadwadi centers (where nutritional foods were distributed), attended village health sanitation and nutrition days (VHSNDs) which were held monthly for immunizations and nutritional camps, and, invited frontline workers to SHG and VO meetings. CMs described these tasks as part of their routine activities and reported on them to their supervisors.
Supporting HNS layering at SHG level
With JEEViKA’s encouragement and support, JTSP identified interventions that are effective and acceptable to the community. They then developed the interventions and its individual components using human centered design and concurrent measurement, and ensured quality by providing handholding support, mentoring, supervision and review. These interventions include the development and introduction of training modules on HNS ranging from an orientation module highlighting the importance of HNS, to early initiation of breastfeeding, complications during pregnancy, antenatal care, birth preparedness, iodine deficiency, basic newborn care, complications in mothers and newborns, family planning, and maternal and child nutrition, among others. Trainings are conducted by master trainers for all staff of JEEViKA and the implementation is supported by quality assessment and support teams who regularly support JEEViKA in monitoring the progress of the implementation of the modules; both master trainers and the quality assessment and support teams are paid staff of JTSP but seconded to JEEViKA. More than 40% of all JEEViKA cadre interviewed mentioned being trained at least on the first module which is an overarching introduction to the key healthy maternal and child health behaviors and the significance of practicing those behaviors at the population level. HN managers who attended the trainings and workshops stated that it helped them build self-confidence and further encouraged them to establish community links for generating HNS awareness. They further highlighted that they interact with JTSP staff, i.e. the regional manager and quality assurance support coordinator, every month to plan and monitor the trainings. BPMs reiterated that they regularly conducted field visits with master trainers and BHNSIs to speak with CMs and discuss implementation on the ground. In addition, JTSP assisted JEEViKA in incorporating the key objectives of HNS within the community operational manuals; hence, new groups being formed have the layering of HNS programming as an integral part of their functioning.
At the decentralized level, JEEViKA, on the other hand, lso contributed significantly to the layering of HNS programming on the ground. They mandated the layering of HNS programming across the entire organization with great emphasis put on building the capacity of CMs and supporting them in every way possible. Select VO members were invited to form a health sub-committee which assists JEEViKA in the village in carrying out its health-related activities. Following the formation of the sub-committes, the members were oriented on their roles and responsibilities by BHNSIs. A government order issued in this regard directed the sub-committee to act as an interface between frontline workers and the community thus mobilizing the community to access health services. Sub-committee members carried out home visits to pregnant women and mothers of young children; encouraged women to attend Annprashan days (when information and food was distributed at Angadwadi centers), VHSNDs; held special seminars and rallies in the village when called on to do so, etc. JTSP officials informed us that by August 2016, 73% of the VOs (across the 101 blocks) reported participation of FLWs in their monthly meetings. In addition, the state’s commitment was highlighted in their financial support rendered to the layering of HNS programming. For example, JEEViKA supported the logistical arrangements and bore the financial costs of HNS trainings, costs for printing modules and other materials, travel and daily allowances for BHNSI when visiting the field along with monthly stipends (INR 300/USD 4.5) to the CMs who have received the training and were carrying out additional tasks. One BPM noted the secondary effect of this support, saying
“JEEViKA funding for HNS training serves as a monitoring mechanism of HNS activity progress in my block.”
A few instances of delayed payments to the community cadre workers were reported by block officials; as it affected motivation to work, these delayed payments were being addressed and efforts were being made to prevent such activities from happening in the future. JEEViKA also established several funds at the VO level to support HNS layering; these included a health risk fund primarily used for community development and toilet construction, and food security fund used to procure food for SHG households.
Layering HNS indicators into the MIS
Indicators to capture the implementation of HNS activities were added to JEEViKA’s existing MIS system. Hence, at all levels across the institution, JEEViKA staff collect, collate, analyze and review a set of additional indicators in relation to their existing monitoring tasks. Examples of indicators are, numbers of: SHG meetings where HNS messages were shared, VO meetings where frontline workers were present, VOs that received food security funds and VOs that purchased rice, wheat and other food items from it, VOs that received health risk funds, VHSNDs in which health sub-committee members participated, Annprashan days at which VO/SHG members participated, numbers of households where kitchen gardens were started, and households visited by health sub-committee members to check on a pregnant woman/child under the age of 2.
CMs compile data in HNS-designated forms and registers on a monthly basis. Cluster coordinators, with the assistance of bookkeepers, collate the data at the VO level which is then further compiled by area coordinators and shared with BHNSI monthly. BHNSIs prepare monthly reports shared with district officials and JTSP. From the district, updates are shared with the HNS vertical at the state office. In state quarterly review meetings, the CEO is present where HNS indicators along with different livelihood and capacity-building parameters are also assessed. Data at the block, district and state-level are reviewed against planned targets to monitor progress, identify areas for further improvement and target efforts accordingly.
Layering onto CMs
A key indicator for layering HNS programming on the CMs was having received at least one training on HNS topics. During those trainings, CMs learned about key messages they were expected to share and were also informed of the additional tasks they would undertake to layer HNS programming into their daily SHG activities. Staff trained highlighted that the classroom instructions were enhanced through sharing of real life examples, such as case studies, supplementary materials, etc. District level officials highlighted the need for continued training to prevent a dilution of knowledge from the mater trainers to the CMs to the SHG members over time.
We present various analyses highlighting the differences in the CMs of those who were trained and those who were not, such as their background characteristics and levels of knowledge on HNS-related messages they learned in the trainings. We then further analyzed the work-related tasks they carried out during the week and how they spent their day in an attempt to understand how they layered HNS activities onto their existing responsibilities. In addition, we identified key determining factors that were associated with CMs’ increased knowledge of HNS topics, interacting with BHNSI, capturing HNS indicators, and time spent on any HNS activity in the past week.
Of the 594 CMs’ interviews conducted, 418 were from JTSP blocks and the remaining 176 were from non-JTSP blocks. Of those from the JTSP blocks, 89% (372) CMs had received at least one HNS training till the time of data collection. The most common topics included the introductory module on the importance of HNS (70.3%), antenatal care (54%), basic newborn care (53.2%), immunization (25%), child nutrition (21.8%) and sanitation practices (15.9%). Of those trained, almost two-thirds (61%) had received training on four/more topics. Table 1 presents key background characteristics of the CMs, by those who received training and those who didn’t. Majority of the CMs are 25-34 years old (39.9%), women (99%), belonged to the Hindu religion (95.8%) and were from other backward castes (68.9%). Furthermore, majority had completed high school/more (88.9%), were married (81%) and owned a mobile phone (89.9%) which was a basic brick phone. On average, CMs had been carrying out their duties for the past 2.5 years and worked an average of four hours/day five days a week. Test of proportions suggested that CMs trained on HNS topics from the JTSP blocks were older, more likely to own a mobile phone and had been associated with JEEViKA a year and 3 months longer than the CMs who had not received the training. Hence, these characteristics were adjusted for while conducting multivariate analyses to understand the individual effects of training of CMs’ knowledge on HNS topics and related activities.
Table 1
Background characteristics of community mobilizers (CMs), by receipt of training/not
Background Characteristics | Percentage (%) |
Total (N = 594) | Did not receive HNS training (N = 222) | HNS training (N = 372) |
Study Arm | JTSP blocks | 70.4 | 20.7 | 100.0* |
Non-JTSP blocks | 29.6 | 79.3 | 0.0* |
Age | 18–24 years | 33.3 | 44.6 | 26.6* |
25–34 years | 39.9 | 35.6 | 42.5 |
35 years and above | 26.8 | 19.8 | 30.9* |
Mean (SD) | 29.2 (7.9) | 27.1 (7.1) | 30.4 (8.1) |
Gender | Male | 0.8 | 1.8 | 0.3* |
Female | 99.2 | 98.2 | 99.7* |
Religion | Hindu | 95.8 | 96.4 | 95.5 |
Others | 4.2 | 3.6 | 4.6 |
Caste | SC/ ST | 20.2 | 18.0 | 21.5 |
OBC | 68.9 | 68.9 | 68.8 |
Others | 10.9 | 13.1 | 9.7 |
Education | 0–8 years | 11.1 | 6.8 | 13.7* |
9–10 years | 33.7 | 34.7 | 33.1 |
11–12 years | 32.2 | 32.9 | 31.7 |
13 + years | 23.1 | 25.7 | 21.5 |
Marital status | Others | 19.0 | 20.3 | 18.3 |
Currently married | 81.0 | 79.7 | 81.7 |
Own a mobile phone | Personal | 89.9 | 84.7 | 93.0* |
Shared | 10.1 | 15.3 | 7.0* |
Type of mobile phone | Basic brick phone | 75.8 | 77.5 | 74.7 |
Featured phone | 16.2 | 14.4 | 17.2 |
Smart phone | 6.4 | 4.5 | 7.5 |
Duration of association | Duration of association with JEEViKA in months (mean, SD) | 31 (21) | 22 (16.2) | 37* (21.8) |
Work duration | Weekly working hours (mean, SD) | 18.4 (13.8) | 17.2(13.3) | 19.2 (14.1) |
* = p-value < 0.05 |
Table 2 compares the knowledge of CMs on HNS messages by those who received training and those who did not. Results suggest that those who received training had more knowledge across all the domains than those who did not receive training. These included topics related to healthy maternal practice during pregnancy (registration of pregnancy, antenatal care check-ups, delivery preparedness), institutional delivery, timely post-natal checkups, neonatal care (skin to skin care, clean cord care, delayed bathing), emergency contact numbers for ambulance services, diarrhea care management, maternal and child nutrition, and services available at Anganwadi Centres, VHSND and Annaprashan days.
Table 2
Knowledge scores of community mobilizers (CMs), by receipt of training/not
A. Knowledge Indicators (Average scores) | Average knowledge score of CMs (For each indicator, knowledge score can vary from 0 to 1) |
Total (N = 594) | Did not receive HNS training (N = 222) | Received HNS training (N = 372) |
1. Skin to skin care | 0.7 | 0.5 | 0.8* |
2. Delivery preparations for birth (home/hospital) | 0.6 | 0.3 | 0.7* |
3. Tests during ANC check-ups | 0.5 | 0.4 | 0.7* |
4. Registration of pregnancy | 0.5 | 0.3 | 0.6* |
5. Proper nutrition during pregnancy | 0.5 | 0.4 | 0.6* |
6. Benefits of institutional delivery | 0.4 | 0.3 | 0.5* |
7. A pregnant/ lactating woman eating in comparison to a non-pregnant woman to provide good nutrition to her baby and help baby grow | 0.4 | 0.2 | 0.5* |
8. Services provided at the Anganwadi Centre | 0.3 | 0.2 | 0.4* |
9. Clean cord care | 0.3 | 0.1 | 0.4* |
10. Post-natal check-ups of the new born | 0.3 | 0.2 | 0.4* |
11. Making child’s food nutritious and energy dense | 0.3 | 0.2 | 0.4* |
12. Services provided under VHNSD | 0.3 | 0.1 | 0.4* |
13. Immediate new born care | 0.2 | 0.1 | 0.3* |
14. Health complications faced by new born within the first month of birth | 0.2 | 0.1 | 0.2* |
C. Knowledge Indicators (Proportions) | Proportion of CMs who answered correctly to binary knowledge indicators |
Total (N = 594) | Did not receive HNS training (N = 222) | Received HNS training (N = 372) |
1. Incentives of INR 1400 under Janani Evam Bal Suraksha Yojana (JBSY) on delivering at government health facility | 97.8 | 96.4 | 98.7 |
2. Timely initiation of breastfeeding | 95.1 | 90.5 | 97.9* |
3. Check-up of the new born baby within 1 hour of birth | 94.6 | 92.4 | 96.0 |
4. Initiation of semi solid food at six months | 93.9 | 91.9 | 95.2 |
5. Knows whom to call for assistance during pregnancy related emergency | 93.4 | 86.0 | 97.9* |
6. Institutional delivery | 90.4 | 85.1 | 93.6* |
7. Two or more TT injections during pregnancy | 84.0 | 72.5 | 90.9* |
8. Infant under six months of age should not be given water | 82.5 | 68.5 | 90.9* |
9. Pregnancy registration in the first trimester | 80.6 | 68.5 | 87.9* |
10. Annaprashan Divas is held on 19th of every month | 78.1 | 62.2 | 87.6* |
11. Emergency number for the ambulance service | 76.4 | 50.9 | 91.7* |
12. Inclusion of tricolored food items during pregnant woman | 76.3 | 46.9 | 93.8* |
13. A 6–24 months old children should be given semi-solid food only | 74.8 | 77.0 | 73.4* |
14. Delayed bathing for 72 hrs | 73.9 | 55.9 | 84.7* |
15. 100 or more tablets during pregnancy | 72.1 | 46.9 | 87.1* |
16. Availability of 24-hour ambulance during emergency | 70.5 | 59.5 | 77.2* |
17. Minimum birth weight | 68.7 | 65.8 | 70.4 |
18. ORS treatment during diarrhea | 66.2 | 52.7 | 74.2* |
19. Initiation of water, animal/formula milk, semi-solid or solid food like khichri after six months of birth | 65.2 | 43.2 | 78.2* |
20. At least three antenatal check-ups | 28.6 | 9.5 | 40.1* |
* = p-value < 0.05 |
A detailed weekly time use analysis of the CMs showed that the most common tasks that CMs reported working on and spending the most time on included: conducting SHG meetings and sharing HNS messages when possible, maintaining books of records where they documented savings and other progress indicators such as HNS indicators, prepared micro-plans for the groups, and facilitated bank linkages for the members (Table 3). A comparison of the time spent on the various activities over the course of the week by the CMs trained in HNS versus those not trained further highlighted that those who trained spent more time doing HNS-related activities, such as capturing HNS indicators, and sharing HNS messages in SHG meetings and through home visits. Hence, this suggested that when CMs layered HNS activities onto their existing responsibilities, they replaced the time they were spending on non-HNS activities by HNS activities thus contributing the same time to their SHG responsibilities. This was highlighted further in the 24-hour time use analysis of their previous day where CMs were most likely to carry out their SHG-related activities in the morning and early afternoon (Fig. 2). This pattern did not differ for those who were trained on HNS topics versus those who were not and there were no other significant differences across geographies or characteristics of the CMs. The rest of the time, the CMs were pre-occupied with household responsibilities and a small proportion of them were also engaged in other income generating activities, such as non-farm economic activities, raising animals, etc.
Table 3
Key tasks and activities performed by community mobilizers (CMs) in past 7 days and average time spent on these activities
Key tasks and activities | % of CM who report carrying out specific activity in past 7 days (N = 594) | Average time spent on these tasks and activities in seven days |
Total (N = 594) | Did not receive HNS training (N = 222) | Received HNS training (N = 372) |
Meeting facilitation and conducting a meeting for non-health topics | 40.1 | 11.9 | 13.5 | 11.1* |
Maintaining books of record | 43.3* | 2.1 | 2.6 | 1.9 |
Maintaining health and nutrition register | 23.7* | 1.5 | 1.4 | 1.5 |
Training to SHG members | 23.7* | 2.3 | 2.0 | 2.3 |
Preparing micro plan for SHG | 19.9* | 2.1 | 2.0 | 2.1 |
Facilitation of bank linkages | 12.8* | 0.9 | 1.2 | 0.8 |
SHG formation | 12.0 | 3.0 | 4.6 | 2.1 |
Facilitation of opening bank accounts | 11.6 | 0.5 | 0.6 | 0.4 |
Conducting meetings where health, nutrition and sanitation modules are rolled out | 6.1* | 1.3 | 0.9 | 1.4* |
Attend village organization, cluster and administrative meetings | 6.7 | 0.5 | 0.8 | 0.5 |
Conflict resolution at SHG level | 2.9 | 0.3 | 0.3 | 0.3 |
Average working hours: 18 hours/week |
* = p-value < 0.05 |
Table 4
Bivariate analysis showing association of background characteristics by outcome indicators
Background Characteristics | Knowledge and Awareness score | Interacting with BHNSI | Maintain HNS registers | Spent time on HNS activity in past week |
Average score | No | Yes | No | Yes | No | Yes |
| 21.0 (N = 594) | 45.6 (N = 271) | 54.4 (N = 323) | 40.1 (N = 238) | 59.9 (N = 356) | 73.1 (N = 434) | 26.9 (N = 160) |
Received training on HNS | Yes | 23.7 | 24.7 | 94.4* | 18.1 | 92.4* | 54.4 | 85.0* |
No | 16.5 7 | 72.3 | 5.6* | 81.9 | 7.6** | 45.6 | 15.0* |
Study arm | CMs in JTSP blocks | 22.9 | 35.8 | 99.4* | 30.3 | 97.2* | 63.4 | 89.4* |
CMs in non JTSP blocks | 16.5 | 64.2 | 0.6* | 69.8 | 2.8* | 36.6 | 10.6* |
Age | 18–24 years | 19.2 | 42.4 | 25.7* | 41.2 | 28.1* | 34.8 | 29.4 |
25–34 years | 21.6 | 35.1 | 44.0* | 37.0 | 41.9 | 38.5 | 43.8 |
35 + years | 22.4 | 22.5 | 30.3* | 21.9 | 30.1* | 26.7 | 26.9 |
Mean (SD) | - | 27.7 (7.5) | 30.3 (7.9) | 27.8 (7.4) | 30.1 (8.0) | 29.1 (8.1) | 29.4 (7.3) |
Gender | Male | 18.5 | 1.5 | 0.3 | 1.7 | 0.3 | 1.2 | 0.0 |
Female | 21.0 | 98.5 | 99.7 | 98.3 | 99.7 | 98.9 | 100 |
Caste | Scheduled castes/Scheduled tribes | 21.6 | 19.9 | 20.4 | 19.3 | 20.8 | 20.1 | 20.6 |
Other backward castes | 21.1 | 66.1 | 71.2 | 68.9 | 68.8 | 69.4 | 67.5 |
General | 19.6 | 14.0 | 8.4* | 11.8 | 10.4 | 10.6 | 11.9 |
Education | 0–8 years of schooling | 22.3 | 9.6 | 12.4 | 8.4 | 12.9 | 10.1 | 13.8 |
Completed 9th /10th grade (high school) | 20.9 | 32.8 | 34.4 | 38.7 | 30.3* | 34.3 | 31.9 |
Completed 11th /12th grade (higher secondary school) | 20.8 | 32.8 | 31.6 | 30.7 | 33.2 | 32.7 | 30.6 |
Completed 13 + years of schooling | 20.7 | 24.7 | 21.7 | 22.3 | 23.6 | 22.8 | 23.8 |
Marital status | Currently married | 19.3 | 79.7 | 82.0 | 80.7 | 81.2 | 80.9 | 81.3 |
Currently not married | 21.4 | 20.3 | 18.0 | 19.3 | 18.8 | 19.1 | 18.8 |
Own a mobile phone | Personal | 18.7 | 85.6 | 93.5* | 87.0 | 91.9 | 88.9 | 92.5 |
Shared | 21.3 | 14.4 | 6.5* | 13.0 | 8.2 | 11.1 | 7.5 |
Type of mobile phone | Basic brick phone | 20.8 | 74.9 | 76.5 | 79.8 | 73.0 | 75.4 | 76.9 |
Featured phone | 21.2 | 16.2 | 16.1 | 12.6 | 18.5 | 16.4 | 15.6 |
Smart phone | 23.0 | 5.5 | 7.12 | 4.2 | 7.8 | 6.0 | 7.5 |
Length of association | Average months of association with JEEViKA | - | 22.6 | 38.6* | 23 | 37* | 30.1 | 34.5* |
Work duration | < 18 hours | 20.7 | 52.4 | 48.0 | 58.0 | 44.7* | 54.8 | 36.9* |
≥ 18 hours | 21.3 | 47.6 | 52.0 | 42.0 | 55.3* | 45.2 | 63.1* |
* = p-value < 0.05 |
Table 5
Multivariate regression showing effect of HNS training, and other characteristics on HNS knowledge and activities
| | Model A: Knowledge Scores | Model B: Interaction with BHNSI | Model C: Maintain HNS register | Model D: Spent time on HNS activity in past week |
| | Beta coef. (SE) | OR (95% CI) | OR (95% CI) | OR (95% CI) |
Received training on HNS (Ref: No) | 0.96* (0.06) | 1.61* (1.46–1.77) | 2.03* (1.79–2.31) | 1.15* (1.08–1.22) |
Age (Ref: 18–24 years) | 25–34 years | 1.13* (0.46) | 1.77* (1.00–3.14) | 1.20 (0.66–2.18) | 1.24 (0.73–2.12) |
35 + years | 1.28* (0.53) | 1.11 (0.58–2.13) | 1.13 (0.57–2.24) | 0.99 (0.53–1.83) |
Caste (Ref: Scheduled castes/Scheduled tribes) | Other backward castes | -0.33 (0.43) | 1.22 (0.73–2.05) | 0.95 (0.53–1.69) | 0.98 (0.60–1.59) |
General | -0.79 (0.64) | 0.90 (0.40–2.00) | 1.75 (0.77–3.97) | 1.43 (0.70–2.91) |
Education (Ref: 0–8 years of schooling) | Completed 9th /10th grade (high school) | -1.05 (0.59) | 0.86 (0.43–1.72) | 0.48 (0.22–1.03) | 0.62 (0.33–1.18) |
Completed 11th /12th grade (higher secondary school) | -0.24 (0.61) | 0.97 (0.48–1.97) | 0.98 (0.44–2.14) | 0.62 (0.32–1.21) |
Completed 13 + years of schooling | -0.25 (0.65) | 0.86 (0.40–1.86) | 1.00 (0.43–2.29) | 0.67 (0.33–1.37) |
Marital status | Currently married | 1.17* (0.51) | 0.72 (0.38–1.35) | 1.00 (0.51–1.95) | 0.90 (0.50–1.62) |
Own a mobile (Ref: Shared mobile) | Personal mobile | 0.74 (0.57) | 2.06* (1.03–4.11) | 1.09 (0.54–2.20) | 1.19 (0.59–2.37) |
Duration of association: Average months of association with JEEViKA | 0.03* (0.01) | 1.04* (1.02–1.05) | 1.02* (1.01–1.04) | 1.00 (0.99–1.01) |
Weekly work duration (Ref: <18 hours) | 18 hours or more | 0.12 (0.34) | 0.90 (0.60–1.37) | 1.67* (1.07–2.59) | 2.10* (1.42–3.10) |
* = p-value < 0.05 |
An analysis of the key outcomes of interest among CMs showed that average knowledge score was 21.0. In addition, just over half (54.4%) had interacted with BHNSI over the past year, three-fifths (60%) were capturing HNS indicators, and around a quarter (26.9%) had carried out HNS related activities in the past week. Average score for knowledge was higher for those who received training (23.7) versus those who did not (16.5). Also, those who have received training on HNS-related topics, were working in the JTSP blocks, were 25 years/older, had a longer association with JEEViKA, were more likely to have greater knowledge on HNS topics and were carrying out various HNS-related activities as compared to their counterparts. Furthermore, CMs who were currently married, had feature/smart phones and reported working for more than 18 hours/week had more knowledge of HNS than their counterparts. We then ran multivariate analyses for each of the outcomes of interest in order to identify key factors associated with the uptake of HNS knowledge and behaviors.
The multivariate analyses suggested that CMs who received HNS training were positively associated with having better knowledge around HNS topics (β = 0.96, SE = 0.06) and had significantly higher odds of interacting with BHNSI (OR = 1.61; CI = 1.46–1.77; p < 0.001), capturing HNS indicators (OR = 2.03; CI = 1.79–2.31; p < 0.001 ) and carrying out HN activities in the past week (OR = 1.15; CI = 1.08–1.22; p < 0.001). Also, knowledge around HNS topics increased with age and duration of association with JEEViKA. CMs who were currently married were likely to have 1.17 points of higher score of knowledge on HNS topics. CMs who were 25–34 years and owned their own mobile phone have greater odds of interacting with BHNSI than younger CMs and those not owning their own phone. For every one month increase in association with JEEViKA, the odds of interacting with BHNSI (OR = 1.04; CI = 1.02–1.05; p < 0.001) and capturing HNS indicators (OR = 1.02; CI = 1.01–1.04; p < 0.001) routinely increased. Similarly, those who worked more than the average 18 hours a week had higher odds of capturing HNS indicators routinely (OR = 1.67; CI = 1.07–2.59; p < 0.025) and spending time on HNS activities over the past week (OR = 2.10; CI = 1.42–3.10; p < 0.001) than those working fewer hours.
During the survey, CMs were asked as to the factors that motivated them to layer HNS onto their existing tasks. They cited that additional trainings had boosted their confidence in guiding others and thus experiencing the joy of benefitting others; another motivating factor was increased remuneration they were receiving as a result of the added tasks. CMs also stated that they were satisfied with their work environment, primarily for receiving adequate opportunities to contribute ideas to improve services within JEEViKA, getting opportunities for training, having supplies and equipment available for work such as training materials, and having a balanced workload relative to their available time. One block project manager sums up the effort saying,
“Overall time allocation in HNS related activities has increased”.