To the best of our knowledge, this is one of the first studies that has evaluated the life skills training and financial literacy of ASHAs (community health workers) in India. There was a statistically significant improvement in the post-test scores of the participants in the intervention group across all four domains of life skills (communication skill, self-confidence, problem-solving and decision-making skill, time and stress management skill) and financial literacy. Three distinct change patterns were found post-training in the intervention group. The enhanced change in perceptions was positively associated with health workers aged more than 38 years and with experience of ≤12 years. On the contrary, the change in financial literacy and self-confidence scores was common among health workers with more than 12 years of experience.
As stated in the national guidelines and previous literature, ASHAs should be between 25-45 years of age and have completed 8 years of schooling at the time of selection [12,13]. The participants from the intervention group in our study had similar age and education distribution. A higher presentation of ASHAs from the scheduled caste or tribes is reflective of the system’s response to enhanced coverage and quality delivery of services to poor and marginalized people by skilled workers from their own community [14]. Furthermore, one-third of the participants in the present study had more than 12 years of experience. The increasing years of experience not only bring to ASHAs an increased social capital and networking within the health system but increased skills and performance in delivering outcomes [15]. Started in 2005, the ASHA program is still evolving in India and has been viewed from different lenses. The empowering views of the program are improved respect and dignity to health workers in the community, and the disempowering lens finds a lack of support and political contradictions from the health systems [15].
Life skills, essential for professional practice, help health workers in dealing with patients face-to-face, making correct decisions in difficult situations, and improving their performance and career prospects [16]. Community health workers, acting as agents of social change, need to feel empowered and equipped with life skills such as communication, problem-solving, etc. [17]. However, the life skills gap in community health workers has been poised as a critical challenge with an impact on their performance and lack of motivation, self-worth, job satisfaction, and a high attrition rate [16,18,19]. Building on the need to address this gap, the present study provided evidence of the effectiveness of a structured training program in improving the life skills and practices in the community of ASHAs. We observed a significant improvement in all the life skills and financial literacy post-training. P.A.C.E training program conducted for another set of professionals (non-health workers) in India and neighbouring countries reported similar results with improved gender issues/relations, productivity, confidence, and better time management and communication skills [20]. Other studies have evaluated the life skills training program for community health workers with different training structures or strategies and found considerable improvement in their performance, decision-making capacity, patients dealing, time management, self-confidence, and interpersonal skills [16,19].
P.A.C.E. training program gains an advantage over other programs by being holistic, that is focusing on woman’s work and personal advancement and sustainable, that is integrating the program into existing internal operations [20]. Moreover, the program has been designed to be flexible, adaptable, and contextualized for the setting in which it is implemented.
Financial literacy is the ability to make informed judgments and to take effective decisions regarding the use and management of money. It can help health workers avoid financial distress and achieve financial security with improved physical and mental well-being [21]. However, there is a huge gap in the levels of financial literacy among health workers [22]. Previous studies highlighted that financial literacy is poor, even among educated and working women [23,24]. We found a significant increase in the financial literacy scores in the intervention group from the baseline. However, some increase was noted in the control group as well. The plausible explanation for such an increase in the control group could be that they might be exposed to some other training program [25]. However, further inquiry is required to better explain the increase in the level of financial literacy in the control group.
Female health workers experience unequal gender relations with the community and other health cadres and need to exercise agency to deftly balance the demands and supply of essential services in the community [15]. The training on gender dynamics and relations help community health workers to navigate and negotiate the difficulties and dilemmas at all levels, personal, community, and workplace. Our findings accord with this thought, and ASHAs realised that their understanding of gender improved after the training program.
Finally, in highlighting the socio-demographic attributes of the change patterns observed, our findings demonstrate that ASHAs elder in age but with experience ≤12 years have increased probability of acquiring life skills and change in perceptions related to practice at personal, community, and workplace levels. This clearly affirmed the observation in the previous studies that health worker’s performance is often related to increasing age and experiences regarding relations and power [15,26, 27]. Greater probability of increased financial literacy and self-confidence scores among ASHAs with more than 12 years of experience may reflect the need and outcome of savings in the last 10-12 years.
Contrary to the published literature, we could not find the effect of increasing years of education on any of the three change patterns [26]. However, we concur with the findings from a review, which demonstrated that health workers with low levels of formal education could be trained effectively for acquiring skills and knowledge [28]. We could not find statistically significant improvement in financial literacy or life skills among ASHAs with higher incomes. David McCoy and his colleagues’ work on adequacy of incomes for health workers demonstrates that low pay can cause decreased retention, increased dissatisfaction, and loss of motivation among health workers [29]. The ASHAs in the study did not receive a salary and depended on performance-linked incentives [15]. We argue that regular monthly income and secured salary would improve performance and job satisfaction [30].
Similar studies globally have identified the importance of communication skills to improve the patient-provider relationship and enhance service delivery. Moreover, such trainings have been found to improve patient outcomes [31]. There is a highlighted need for building the life skills of community health workers besides improving health literacy and technical information [32]. Improved self-confidence emanating from increased knowledge and support will further ASHAs interpersonal relationships and enhanced trust and social standing in the community [10].
Limitations of the study: The results of the study should be interpreted in view of certain limitations. Firstly, the assessment of the immediate effects of the training (knowledge, practices, and perceptions) was done without assessing its effect on the end-users to whom ASHAs serve in the community. Secondly, the study was conducted on a small scale in localized settings that may limit the generalization of findings. Lastly, due to budgetary and time constraints, more specific models of life skill training evaluation were not undertaken, such as Kirkpatrick’s model and People Styles model [33].