Relevance

The interviewed AWWs found the mobile phone useful and relevant for carrying out specific tasks such as weight monitoring, pregnancy care, and counselling of beneficiaries. However, it pose challenges for convincing beneficiaries to attend the VHSND. Although the theme of relevance may seem to be identical to usefulness, it specifically means the degree to which the technology in question will assist the worker in carrying out particular responsibilities they have been tasked as workers (Blanas et al., 2015). Technology that is available, easy to use, and potentially useful might not be used be by the worker if it is not related to their work. In the case of the CommCare application, it was envisaged to directly improve services AWWs needed to carry out and the majority of AWWs felt that the mobile phone application helped them. However, in the case of VHSND attendance, AWWs faced unintended adverse effects due to the cash transfer operational in the other two blocks.

Weight monitoring

AWWs felt that the weight grading of children was easier with the mobile phone because it was simpler and quicker. The mobile phone application automatically calculated the grade when the AWW entered it on the phone. AWWs felt it eased their efforts; otherwise, they needed to use growth charts, which most of them found difficult to use. They also felt the instant grade calculation helped them communicate the status of the child to his or her mother. Earlier, AWWs used to guess the grade of the child to communicate with the mother and fill the growth chart

later at home. The usefulness and relevance of using the mobile phone to undertake weight monitoring was appreciated more by AWWs who were well-versed with the mobile phone and application than the ones found it difficult. However, AWWs who faced difficulty in using the phone also found the growth chart difficult, and still preferred the phone.

Although AWWs felt ease in conducting the weight monitoring service, they did not conduct all weight monitoring using the phone. The phone was used to register all pregnant women at the start of the programme and women who got pregnant afterwards. AWWs only conducted weight monitoring of children of these women—which is a small group compared to the existing beneficiary cohort. AWWs used mobile phone weight monitoring for children born after the start of the programme (roughly from the start of 2015) and continued using paper growth charts for children who were born before the programme (i.e. monthly weighing of children who are below three years of age and quarterly weighing of children between three and six years of age). This was because the mobile phone application could only register women who are pregnant and then follow-up their children after birth. Directly adding children was not possible with the application. Moreover, the limitations due to lack of quality weighing machines still existed. Thus, mobile phone weight monitoring did not seem to have influenced the number of children weighed, rather it improved the motivation of the AWW to conduct the weight monitoring service and the quality of the service by improving the accuracy and responsiveness of the AWW in AWCs with access to weighing machines.

In that suppose, we want to know the weight. We ask the question and then after that press the button, we get to know from the information that appears whether the child is malnourished. So, it is easy for us. Earlier we had to weigh, [fill] the chart, plot it on the graph and then calculate. However, with the mobile it has become easy.

[…...] The growth chart is big. We have to take it out then match it and write at the bottom and put a mark. After that, we can tell that the child is coming in this particular grade. On the mobile, we get to know instantly and can then inform the mother in which grade the child is falling. We can tell by seeing the mobile”.

(AWW Interview)

Pregnancy care and counselling services

AWWs felt motivated using videos during counselling sessions (individual) and following the pre- set questions in the application while registering pregnant women. These features of the mobile

phone to an extent improved the perceived quality of services (case management of pregnant women and behavioural change counselling).

“We have also become aware due to this [the BCSP] …Like, I am a Sevika I learned to operate the mobile. I like it very much. After that on nutrition day the number of questions that are there I was not able to ask all questions before. Now it has become easy to ask questions on the POSHAN day (the VHSND), and I can get the information about children just by asking questions. Also, we can automatically get to know the grade of the child”. (AWW Interview)

“The change is that these things were not there before. When they [beneficiaries] used to come for immunisation and we used to write in the register. Now via the mobile, we have to send. We sit with them. We make them listen to what all they have to do, first we play songs for them on the mobile. That is why they understand fast. Earlier they were quiet”.

(AWW Interview)

AWWs who used videos in counselling felt the videos communicated effectively with the beneficiaries better than words—they were understood better by beneficiaries. They felt the beneficiaries showed a keen interest in viewing the videos during counselling sessions. One AWW mentioned that while registering pregnant women, the set of questions on the phone helped them to stick to all relevant information (such as last menstrual period, birth preparedness, and so forth) and it was more effective than before. AWWs who possessed decent levels of proficiency reported using the phone in counselling services.

VHSND attendance

Although improved VHSND attendance was one aim of the intervention, the interviews with AWWs suggest that they face difficulties in convincing beneficiaries to turn up for the VHSND. AWWs attribute this to the presence of the cash transfer programme in adjacent blocks as part of the wider BCSP. AWWs said beneficiaries in their block took vaccines and attended the VHSND in expecting to receive Rs. 250 per month. Beneficiaries complained that in other AWCs (in other blocks) pregnant women got money, but in their centres, AWWs were not giving them money. These beneficiaries were aware of the presence of the cash transfers in the neighbouring blocks and demanded their share. This strained the trust between beneficiaries and AWWs. AWWs needed to put in extra efforts to convince them about the absence of the programme in their block and assure that if the money comes for them, then she will pay. This factor also can impact

on beneficiary attendance at the VHSND. This spillover effect affects the trust between the AWW and beneficiaries and negatively influences the AWW motivation and service uptake. This is in line with negative spillover detected in Chapter 5.

“So, in their mind, they feel that they are not getting 250 rupees, and Didi (Anganwadi Sevika) pocketed it. They say 'is [the name of the block] second (step child)'? Yes, [the block] is. However, I say see, the state of health/nutrition is good here. Children, there are weak. There are weak

children here too, but compared to another block there it is less. [….] If it

comes from up (government) then the money will go to everyone’s account. Why will we keep your money? The day we get 250 rupees that day you will get it”.

(AWW Interview)