Table 2 Key Operational Challenges in the pre-intervention phase and strategies used to overcome them

I

Individual Level

1

Low motivation of some ASHAs to participate in the project

Some ASHAs were not motivated to be part of the project. They felt involvement in the project had led to an increase in their work burden

In AP, due to significant increase in remuneration of ASHAs, several of them did not find additional income from the project as an attractive incentive and were unwilling to take on project related tasks in addition to their regular work

Some resorted to avoiding contact with field staff and tried to postpone screening individuals’ multiple times

Persons senior to ASHAs, who were likely to convince ASHAs to be part of the project were approached. These included the PHC medical officers, District and Block ASHA co-ordinators. They explained to the ASHAs that participating in the project would equip them for government mental health programmes in the future and was a good opportunity to learn using tablets

In some places ASHAs were replaced with other local women with similar educational background. They were trained and provided support by field staff for the data collection

Unsupportive attitude of some stakeholders

In one site an ASHA facilitator asked all ASHAs in her locality to stop working on the project because she was dissatisfied with the amount being paid by the project

In one site some Auxiliary Nurse Midwife (ANMs) were not happy with ASHA’s involvement in the project. ASHAs report to ANMs and work closely with them. Some ASHAs wanted to withdraw from the project since they did not want to displease the ANM

Persons senior to ASHAs were approached. They were requested to convince ASHAs to work in the project

The medical officers of PHCs where the ANMs worked were approached. They were requested to call ANMs and convey the need to provide support to the project

Dissatisfaction related to remuneration among some ASHAs

Several ASHAs in Haryana were dissatisfied with the incentive amount offered to them to undertake screening of high-risk individuals

In Andhra Pradesh, there was a significant hike in salaries being paid to ASHAs by the government. Remuneration for time through the project was small compared to their monthly salary. Therefore, many ASHAs were not motivated to work for the project and opted out

Meetings were held with ASHAs to address their concerns. It was explained that fee being paid to them was at par with existing government rates for similar tasks. Details of how the time commitment and remuneration were at par with government rates was discussed

Field staff approached the PHC Medical Officers on specified days when ASHAs came to the PHC for their weekly meeting. They were requested to talk to ASHAs and convince them

Low performance by ASHAs in some clusters

There was variation in performance of ASHAS in different clusters. In some clusters ASHAs took much longer than expected, to complete screening of high-risk individuals

A teleconference was organised for ASHAs of high performing and low performing clusters. This provided them an opportunity to interact and learn from their peers and motivated ASHAs of low performing clusters to improve

Reaching all individuals in the sample

In Haryana the sample for high-risk screening was randomly selected. Many individuals lived in areas far from the ASHAs home. As majority of ASHAs did not have private means of transport and found it difficult to collect data

Some individuals selected in the sample were migrants who were not available when the ASHA visited them

Regular contact with ASHAs and on-site support for any difficulties arising in the field was provided by project staff to ensure that all individuals in the sample were reached by the ASHA

Where possible the ASHAs travelled with the field staff on their motorbikes to respondent households

II

Interpersonal Level

1

Objections by family members of some ASHAs

In Haryana, due to the cultural context very few female field staff were recruited. Therefore, male staff were required to work with ASHAs. Several ASHAs were reluctant to move around the village with male field supervisors. Family members of some ASHAs expressed displeasure at having male staff travel with ASHAs

Male staff were sensitive to adopt culturally appropriate behaviour in their interaction with ASHAs. Senior field supervisors reached out to family members and explained the project goals and need for supervision

2

Creation of anti-stigma video of person with lived experience (PWLE)

One of the campaign materials was a video of a PWLE of mental illness, sharing his/her story. In Haryana it was not possible to find any PWLE who was willing to share his/her lived experience on camera. Family members objected due to fear of stigma from relatives and neighbours

The video from Andhra Pradesh site was dubbed in local language and used in Haryana

III

Institutional/Organisational Level

1

Approvals and permissions

Getting permissions before the start of the project was a long-drawn process and took more time than was anticipated. Permissions were taken from state level health directorate and the district level

Repeated visits were made by the project staff to concerned officials

Other stakeholders who could discuss the project with concerned officials (like elected representatives), were approached for their support

2

Transfer of key health officials

Before start of the project, efforts were made to explain project objectives and have buy-in from district level health officials. In one site the health official who had been approached at the start of the project was transferred

Some planned trainings with ASHAs were delayed because the district health official was transferred, and permissions needed to be taken from the new appointee

Senior project staff visited the newly appointed official and shared relevant information about the project and prior permissions that had been granted

3

Delay in communication between departments

There was delay in sharing information about the project to the PHC doctors by district level authorities. Without formal communication from the district level, PHC doctors were unwilling to permit ASHAs to participate in the project

In Haryana additional permissions were needed to conduct training of ASHAs. PHC doctors needed office orders issued from the CMOs office before allowing trainings

Contact was made with PHC doctors in all the PHC clusters by project staff. The project objectives were explained, and their co-operation requested

Copies of formal permission letters from the state and district level authorities were shared with the PHC doctors

Senior project staff met the CMOs, nodal program in-charge, and district ASHA co-ordinators to seek permission and get the office order issued

4

Selection and mapping of clusters

For selection of PHC clusters several inclusion and exclusion criteria (eg. rural PHCs, contiguity) needed to be considered. However, obtaining PHC level data was a challenge

Obtaining official map for districts in Haryana was a challenge

All PHCs were physically visited by staff to verify they met the inclusion criteria

Several sources were explored to obtain district map and other relevant data (eg. district handbooks, census data, surveys done by ASHAs, and municipal corporation)

Time spent making changes in the apps

Any existing modifications of the applications needed to be done manually

Remote online modifications of applications were introduced

Data Safety

Family members of some ASHAs were able to bypass the AppLock feature and were misusing the tablet for downloading videos

More stringent data safety measures were put in place

ASHAs were informed about the importance of not using the tabs for personal downloads as it could compromise the functionality of the tabs

Additional data encryption measures were added so to ensure data safety in case of the tab being lost or stolen

IV

Community Level

1

Winning community support and trust

In Haryana the intervention area was new for the implementing agency. During household listing, field workers noted distrustful attitude in some villages. Some villagers had past negative experience with other NGOs. Some villagers thought that field enumerators could be thieves gathering household information

Relevant information about the organisation, office location and contact details of supervisory staff who villagers could contact for more information were shared

Local staff who belonged to the same area proved helpful in building initial rapport and trust with the community

Key village administrators and village leaders including religious leaders contacted wherever needed to discuss the project objectives

2

Socio-cultural norms

In both states ASHAs belonging to Scheduled Caste community were hesitant to go to homes of non-Scheduled caste and talk to them. (Scheduled Castes are castes recognised as socially vulnerable and provided constitutional protection [55]

ASHAs were counselled about the importance of their role and the need to reach out to all households. Field staff accompanied them to such households

3

Mental Health Stigma

During rescreening of high-risk individuals, several individuals expressed displeasure at having a repeat visit from the project staff. Due to the stigma associated with mental health, they feared being labelled as someone with mental health issues in their village

Clear information was provided in the informed consent forms about the nature of the study and possibility of repeated visits to the same households

It was explained that primary purpose of the project was to gather information in the initial stage. However, in the later phase of the project some village level medical camps would be organised, and efforts will be made to make medicines available at the PHC

4

Explaining technicalities of research design to community members

During data collection, it proved difficult to explain the research methodology to the community. Some individuals who were selected as part of the random sampling wanted to know why they were being screened and not everyone in their village. They were afraid of being stigmatised as someone with mental health issues

The study required repeated visits to the community respondents (screening, re-screening, baseline survey). Several respondents expressed displeasure at having repeated visits

There was expectation of some form of benefits from the project like free medicines

All efforts were made to provide information about the research, explain its objectives and selection criteria. Project team used simple and culturally relevant analogies to explain simple random sampling technique, i.e. while steaming rice, to check if it is cooked, only a small portion is checked

V

Policy/Environment Level

1

Protests against the Citizenship Amendment Act (CAA) and National Register of Citizens (NRC)

Challenges were also faced during the anti CAA-NRC protests in early 2020. Due to mistrust for the government, members from the Muslim community in some villages did not want to sign any official looking documents. The villagers were distrustful of signing the information consent form and suspected that the field workers were from a government department

Despite taking permission from local village leaders, field workers in Haryana who were collecting data for the baseline survey faced refusal and even verbal and physical threats in several villages

There were similar refusals in some villages in Andhra Pradesh

Help was solicited from elected village representatives (Sarpanch). The objective of the research, the need for signing the informed consent form and detailed information about the implementing agency was provided. In some cases, the village sarpanch accompanied the enumerators or sent his representatives to convince the villagers who were distrustful of the data collection process

The local religious leader (maulvi) in some villages were approached to solicit co-operation

2

COVID Pandemic

The pandemic and resulting lockdown from March 2020-May 2020 led to delays in the project

In Andhra Pradesh where screening of high-risk individuals was resumed after easing of restrictions, villagers expressed displeasure at having outsiders (project staff) come to their village. This made it difficult to supervise work of ASHAs

In AP training of staff for baseline and training of ASHAs for rescreening could not be organised face to face due to COVID restrictions

To counter the unpredictability due to COVID, the project team developed three alternative scenarios with three different timelines (Plan A, Plan B, Plan C) with necessary adaptations

Risk assessments done periodically at project and at institutional level

Monitoring was done through telephonic follow-up with ASHAs. Any missing data or suspected discrepancy in data was checked by calling up the respondent

The field teams monitored the official COVID risk classification in the project area and resumed work in designated green zones after the lockdown

Online training was organised with small batches spread over a larger number of days than planned earlier

To maintain regular communication and monitor work of field staff, a group calling plan was acquired by supervising staff. Regular meetings were held using group calls

3

Strike by ASHAs

The pre-intervention training was planned for the ASHAs in Haryana was delayed because the ASHAs went on a strike due to grievances against existing government norms

Regular communication was maintained with the ASHAs and they were requested to participate in the trainings as soon as they could