The P.A.C.E. training program’s goal was to equip ASHAs with life skills education and financial literacy for seeking improvement in their personal and professional outlook. There were four major modules in the P.A.C.E. program, apart from introductory and consolidation modules. The four major modules included were communication skills, problem-solving and decision-making skills, time and stress management skills, and financial literacy.
The flow chart of the key activities in the training program is given in Figure 1. We followed a cascade model of training (P.A.C.E. trainers created master trainers to train ASHA). We did pre-and post-test assessments for the master trainers (n=19). Further, master trainers trained ASHAs on the six modules, and each training session lasted 6-7 hours. A gap of 20 days between two sessions was kept purposively to let the contents of one be imbibed properly in the attendees. Hence, we covered all the modules in 6-7 months. All the trainings for ASHAs were done in the health facilities. The interactive modules had visuals, pictorials, games, and plays to understand the content better. The modules imparted 40 hours of education, followed by enhanced technical training intended to help health workers to become more effective at work and improve their personal lives.
2.2 Study design and sampling
We conducted a quasi-experimental, non-randomized, controlled study with pre-and post-test assessments among ASHAs of two selected districts. In each of the two selected districts, two control and intervention blocks were selected. The selection of intervention blocks was carried out randomly; simultaneously, control blocks were selected adjacent to the two intervention blocks in the respective districts. As this was a panel study, the same sampled respondents were provided training, and the same individuals were interviewed during the baseline and end line rounds. The individual outcomes’ trajectories in the intervention group could be assessed and compared with those of the control group due to the panel design. We adopted systematic random sampling. To have heterogeneity within the sample, the study delineated the sampling frame into a group, namely years of experience. The sample was distributed proportionately in each group for case and control arms, respectively. The training program was started in November 2018 in two districts of Uttar Pradesh in India, namely, Prayagraj and Varanasi. These two districts were selected because they had poor maternal and child health indicators . The details of the training program are provided in supplementary file 1.
2.3 Sample Size and participation
N= 2(Zα + Zb)2 × p(1-p)
Where N = Sample size required for each group
P1= Probability of event in the intervention group = 75%
P0= Probability of event in the control group = 50%
p= (P1 + P0)/2
Zα = Standard normal deviate corresponding to the level of significance (type I error rate)
Zb = Standard normal deviate corresponding to the chance of not detecting the relative risk as significant (type II error rate)
A sample size of 60 per group was derived assuming that 50% of ASHAs had knowledge on life skills during the baseline and hypothesized that this would increase to 75% after the intervention at 95% confidence level and power of study as 80%. The sample size was equally divided in each intervention or control block. Within each block, we selected respondents randomly for the interview.
2.4 Data collection
Ten trained investigators collected data. The baseline assessment was done in November 2018 and the end line in August 2019. We developed a structured questionnaire for the study to collect data in both survey rounds (supplementary file 2). The questionnaire had the following sections: a) socio-demographic characteristics; b) knowledge and practices related to life skills (communication skills, self-confidence, problem–solving and decision-making skills, time and stress management skills), and financial literacy; c) change perceptions on gender-, life skills-, and savings-related practices at personal, community, and workplace levels (only during the end line survey). The socio-demographic characteristics included age, years of schooling, years of experience working as ASHA, monthly income from the job, and social class ASHA belongs to.
2.4.a. Life skills
The life skills were assessed through different scales. The communication skills scale consisted of 7 questions with scores ranging between 0-17. The self-confidence scale had six questions on a five-point Likert scale (‘no confidence’ to ‘very confident’) with scores ranging between 6-30. There were four questions in the problem-solving and decision-making scale, and the minimum and maximum scores were 0 and 11, respectively. Similarly, the time and stress management scale had five questions, and the scores ranged between 0-20. We summed up the individual questions’ scores in the life skills’ scales to calculate their aggregate scores. The reliability scores (Cronbach’s alpha score) of all the scales were found more than 0.7.
2.4.b. Financial literacy
Assessment of financial literacy was based on five questions with minimum and maximum scores of the scale ranging between 0 and 24, respectively. The Cronbach’s alpha score of the scale was 0.76.
2.4.c. Change perceptions
Additionally, during the post-test assessment, current practices and related perceptions of ASHAs from the intervention groups were also captured. Here, we specifically assessed general perceptions on P.A.C.E. training modules and change perceptions on gender-, life skills- (problem-solving, communication, and time management), and savings-related practices at the personal, community, and workplace levels. Separate scales for assessing change perceptions were developed. The questions in all the scales were based on a four-point Likert-scale. The responses varied from ‘completely agree’ to ‘completely disagree’. The questions’ responses on every scale were aggregated with ‘completely agree’ given a score of 2 and ‘agree’ a score of 1 and rest 0. The maximum and minimum scores of changes at the personal level varied between 0-22, community-level between 0-18, and the workplace between 0-14. The reliability scores (Cronbach’s alpha score) of all the scales were observed more than 0.85. For assessing general perceptions on P.A.C.E. training modules, the participants were asked to rate the quality of the training on a scale from 1 to 10.
The questionnaires were standardized, translated into the local language (Hindi), and field-tested before data collection. We used Computer Assisted Personal Interview (CAPI) for collecting quality real-time data during both survey rounds. To collect quality data, two supervisors, one in each district, were assigned to randomly back-check and spot-check 10% of all interviews during both rounds.
2.5 Data analysis
The data were analyzed using the IBM SPSS Statistics for Windows version 24.0 (IBM Corp., Armonk, N.Y., USA). Descriptive data were expressed as frequency or percentages for categorical variables and mean (Standard Deviation, SD) or median (Interquartile Range, IQR) for continuous variables. The paired t-test (or Wilcoxon signed-rank test for medians) was conducted to assess the differences between average pre-and post-test scores in the intervention and control groups of life skills and financial literacy. Given that there were eight outcomes in which we sought the change, namely, four life skills, financial literacy, and change perceptions at three levels, we considered factor analysis. The factor analysis helped us derive different change patterns in the participants due to training. We used this method to assess the degree to which life skills, financial literacy, and change perceptions in the intervention group were correlated and derive a new set of composite variables. These new set of composite variables, not related to each other, represent discrete change patterns due to training. Only the change patterns with eigenvalues >1.0 were included in the analysis. The variables that loaded highly (|>0.30|) in varimax rotated change patterns were shown in the analysis. The Kaiser-Meyer-Olkin (KMO) measure reached the acceptable limit of 0.6, and Bartlett’s test of sphericity was significant (p<0.001), meaning thereby that the data were suitable for factor analysis.
We performed a general linear regression model to assess the association between the change pattern scores and socio-demographic variables using main-effect analysis. Standard regression coefficients (β) and 95% confidence intervals were used to depict the strength and precision of associations. A two-sided p-value <0.05 was considered statistically significant.
2.6 Ethical considerations
MAMTA Ethical Review Board granted ethical approval for the study. We obtained written informed consent from all the study participants.