’[We] learned how to speak with love’: a qualitative exploration of accredited social health activist (ASHA) community health worker experiences of the Mobile Academy refresher training in Rajasthan, India

Introduction Mobile Academy is a mobile-based training course for India’s accredited social health activist (ASHA) community health workers (CHW). The course, which ASHAs access by dialling a number from their phones, totals 4 hours of audio content. It consists of 11 chapters, each with their own quiz, and provides a cumulative pass or fail score at the end. This qualitative study of Mobile Academy explores how the programme was accessed and experienced by CHWs, and how they perceive it to have influenced their work. Methods We conducted in-depth interviews (n=25) and focus group discussions (n=5) with ASHAs and other health system actors. Open-ended questions explored ASHA perspectives on Mobile Academy, the course’s perceived influence on ASHAs and preferences for future training programmes. After applying a priori codes to the transcripts, we identified emergent themes and grouped them according to our CHW mLearning framework. Results ASHAs reported enjoying Mobile Academy, specifically praising its friendly tone and the ability to repeat content. They, and higher level health systems actors, conceived it to primarily be a test not a training. ASHAs reported that they found the quizzes easy but generally did not consider the course overly simplistic. ASHAs considered Mobile Academy’s content to be a useful knowledge refresher but said its primary benefit was in modelling a positive communications approach, which inspired them to adopt a kinder, more ‘loving’ communication style when speaking to beneficiaries. ASHAs and health system actors wanted follow-on mLearning courses that would continue to compliment but not replace face-to-face training. Conclusion This mLearning programme for CHWs in India was well received by ASHAs across a wide range of education levels and experience. Dial-in audio training has the potential to reinforce topical knowledge and showcase positive ways to communicate.

before there should be an acknowledgement that ASHAs cultivate more complex relationships in their communities than just ones reducible to a relationship between a "health worker" and "beneficiary". • ASHAs being women from underprivileged backgrounds, their work, training and established contacts in governmental public health sector significantly increase their social capital and enable their social mobility. A possible future research could look into whether and how engaging with mobile phone training and other technologies enable women's aspirations to be socially mobile and "digital" (Quermezi 2017). • Section 5 of the article seems to be very general and depart from the article's focus on the ASHAs' learning on Mobile Academy Platform. I would suggest to omit it and instead expand the section on the main argument of the paper, especially discussed in the sections 3 and 4he implications in the discussion section. Alternatively, a link with the main argument should be established.  However, I would like to draw attention to a number of comments and points for revision. Given my own background in cultural anthropology and medical anthropology, the comments and suggestions below relate to conceptual, epistemological and qualitative research questions. Reviewer 1, comment 2: My main comment is related to the research problem, state of the art and the main argument of the paper which would benefit from more precise formulation. At the current stage, the article introduction has an extensive literature review, mainly focusing on the effectiveness of the mLearning among frontline health workers. However, the research problem and its relationship to the article findings remains vague. The article states that it examines ASHAs' "perceptions" of the Mobile Academy. Engaging with literature on ASHA's and CHW's perceptions, everyday and work experiences, and motivations would be useful and perhaps would help to articulate the contributions in a more nuanced way. For instance, is there a relevant bodie(s) of literature that study community health workers' perceptions of training activities or technologies, and what new insights this article brings to such bodies of literature? The abstract claims it contributes to "global understandings of how mLearning programs are experienced by frontline health workers and the potential of future mLearning programs". I would suggest to spell out the contributions in a more specific way.
Response to comment 2: Thank you. Your suggestions are well received. We have edited the introduction to better frame our focus on FLHW perceptions of the program (we do not focus on the actual impact of the program, since assessing changes in knowledge and behavior was outside the scope of our research.) While there is an extensive literature on ASHA motivation and perceptions of their work overall, in light of the word count and need to focus the article on training specifically, we have added relevant literature on CHW perceptions of trainings specifically, with the following text: "User perceptions and acceptability of digital training have broadly been found to be positive. FLHWs have found digital training programs easy to use and the content easy to understand15-17 and relevant.18 However, few studies have conducted indepth examination of FLHW perspectives on mLearning, including how FLHWs with different profiles engage with the technology and content, motivation and hesitation around a new form of training, appropriateness of content, perceived impact, and how they compare them to face-to-face options." We have also edited the abstract to be more specific, with the following text in the first paragraph: "This qualitative study of Mobile Academy explores how the program was accessed and experienced by community health workers, and how they perceive it to have influenced their work." Reviewer 1, comment 3: While the main argument in the introduction could be elucidated, the compelling title of the article seems to suggest its main findings are about the affective value that may ASHAs found in the Mobile Academy's training platform. ASHAs valued a gentle and polite tone and appropriate pace, which, it seems, they found respectful when using the Mobile Academy training. Interestingly, ASHAs compare and contrast this affectionate and likable style of communication to inperson training and encounters with higher-ranking health workers and their supervisors. This points to a curious paradox, where technology is valued for appropriate feelings, kindness and regard, whereas actual human interactions are experienced as inciting fear, anxiety and being unpleasant.
Could it be that Mobile Academy here inadvertently subverted the hierarchical, and authoritative atmosphere in India's public health sector? These imbalances can also be linked to gender inequalities, since ASHAs are women, whereas some of the higher-ranking health workers to whom they are accountable, are men. To pursue this direction of inquiry, I would advise to situate these discussions within the literature on user experience, emotions and technology in the context of ASHAs' experiences of regular training and interaction with supervisors. Response to comment 3: Thank you for this insight, situating our findings within the power (and gender) hierarchy of the Indian public health sector. We have edited the discussion section as follows: "ASHAs reported that Mobile Academy's lasting impact on them was both informational and affective -ASHAs spontaneously and frequently focused on the "loving" communication style and their intention to incorporate this into their interactions with beneficiaries. A few ASHAs contrasted the kind tone in Mobile Academy to a more intimidating teaching style used at some face-to-face trainings. Power hierarchies in the Indian health system (e.g., by education, caste, professional status, gender, urban-rural residence) can be reproduced in trainer-ASHA dynamics and in ASHA-beneficiary interactions, ultimately limiting communication and trust throughout the system.54,66 The capacity for digital trainings to improve communication within this hierarchical space require further exploration: to what extent does Mobile Academy subvert hierarchies versus engage with them in a productive manner? Can face-to-face trainers learn from Mobile Academy's tone and approach? And what is the actual impact of this "loving" tone on ASHA-beneficiary interactions? Ultimately, it is important to note that strengthening ASHA-beneficiary relationships will require ongoing ASHA capacity building (of which mLearning can play a role), community engagement, and quality improvements in the government health services themselves. Response to comment 4: Yes, thank you for your thoughtful comments on this finding. One thing worth pointing out, is that we don't really know if Mobile Academy influenced their interaction with beneficiaries. We only know that they said it didwe have clearly noted this limitation now in the article discussion.
We have added content in the introduction about training attempts to teach counselling and communication skills to ASHAs, and in the discussion about how Mobile Academy appears to be (according to ASHA self-reports) an mLearning approach that quite powerfully influences these soft skills.
Reviewer 1, comment 5: ASHA payments should be discussed in the article and reflect the terminology used in the article. Accredited Social Health Activists are termed "activists", not workers, because they do not receive regular salaries, differently from other health workers. A vast literature has pointed out to this exploitative aspect of ASHA programme and Community Health Work more generally. Across India, ASHAs, who come from underprivileged background, have been engaging in social protest and mobilisation due to low payments and incentive system. ASHAs receive incentives for different tasks, including for training. As far as I understand from the article, ASHAs are not paid for their Mobile Academy training completion, but use their personal time to complete this training. How does this affect ASHAs' willingness and reception of the training platform, especially in comparison to the regular training sessions, for which ASHAs receive payments? What facets of Mlearning contributed to this positive reception of this training platform despite ASHAs not being paid for their working time? Response to comment 5: This is a very good question and the ASHA payment issue is major. I do think calling them workers is appropriate since "community health workers" refers to many unpaid (and paid) cadres and because ASHAs receive a form of monthly payment for routine activities, although not a salary.
We have added the following in the section on ASHAs (now in the methods section): ASHAs have been found to average over 20 work hours a week,22 and receive a small fixed monthly honorarium as well as performance based remuneration with total monthly income ranging from Rs 900 to Rs 4250 (USD$14 to $65) depending on state-level top up payments and ASHA activity. ASHAs are also compensated Rs 200 (USD$3) for attending face to face trainings. ASHAs have long asserted that they are underpaid.23,24 In section 2: ASHAs were not paid for completing Mobile Academy, and when asked about payment they tended to say it was not necessary. Instead, they framed the course was a means to remain in their positions and excel at their work. It was only when discussing future mLearning opportunities (section 5) that several ASHAs mentioned that they ought to be paid for these activities.

And in section 5:
When asked directly about incentives to complete future trainings most but not all ASHAs requested payment. One noted that they are paid for face-to-face trainings and said that mLearning ought not to be different: "We get money for every training. So if we get in this one, it is good" (ASHA_11). However, several said that no money was needed, explaining that the knowledge itself is desirable ("Because we have to learn something, so why should they pay money?" ASHA_29) and instead requested other incentives such as certificates or the opportunity for promotion.
Reviewer 1, comment 6: The article states that ASHAs have difficulties in interacting with their "beneficiaries". However, the programme design and formal emphasis on the rights-based approach entails that people they engage with are from their own communitiestheir neighbours and community members. While such difficulties were reported before there should be an acknowledgement that ASHAs cultivate more complex relationships in their communities than just ones reducible to a relationship between a "health worker" and "beneficiary". Response to comment 6: You're absolutely right. We have added the following text in the introduction "Their communicative and counselling efficacy is influenced by their training on communication and counselling,42-44 as well as personal characteristics (e.g., the ASHA's confidence, empowerment, education), power hierarchies (e.g., caste, class, religion, gender), other identity and relational factors (e.g., geographic proximity, political affiliations, marital status, number of children, and family relationship histories),37,45,46 and the health system more broadly (e.g., the extent to which ASHAs are able to linked to clinics that provide high quality health care).47,48" Reviewer 1, comment 7: ASHAs being women from underprivileged backgrounds, their work, training and established contacts in governmental public health sector significantly increase their social capital and enable their social mobility. A possible future research could look into whether and how engaging with mobile phone training and other technologies enable women's aspirations to be socially mobile and "digital" (Quermezi 2017). Response to comment 7: This is a very valuable suggestion. We have added the following to the conclusion: "Fourth, ASHAs and health system actors understood Mobile Academy as an internal accreditation rather than an achievement that could bolster community trust. Other studies from South Asia have found that women's engagement with mobile phones enables "modern" aspirations for education and socially mobility but requires reputational risk management.57,59 The ways in which ASHA use of digital technology affects their social identities and relationships warrants further research." Reviewer 1, comment 8: Section 5 of the article seems to be very general and depart from the article's focus on the ASHAs' learning on Mobile Academy Platform. I would suggest to omit it and instead expand the section on the main argument of the paper, especially discussed in the sections 3 and 4he implications in the discussion section. Alternatively, a link with the main argument should be established. Response to comment 8: We have now removed this section. Reviewer 2, comment 1: This is a very well researched and articulated manuscript on an important topic: use of mobile health technology to improve community health work in India. The introduction is very concise and gives a clear background and strong justification for the study. The qualitative methods used were well described in a such a manner that would facilitate reproduction of the study while the results were also well presented. Although the discussion is brief, it captures most of the findings of the study. I would suggest inclusion of the summary of the key policy recommendations of the study after the conclusion section. Response to comment 1: Thank you very much for your positive assessment of our manuscript and methods. We greatly appreciate your review. While we tried to add a paragraph on recommendations, we have found ourselves badly over the allowed word count. We hope that the current summary of findings in the discussion provides adequate directions for policy makers and we have edited the conclusion to synthesize the overall message to policymakers: "Policymakers can note Mobile Academy's high acceptability among users, as well as its potential to not only reinforce knowledge but also encourage positive beneficiary-FLHW communication style. These findings position the Mobile Academy model as a viable mLearning option for many LMIC contexts to reinforce ongoing face-to-face training." Reviewer 2, comment 2: What were the limitations of your study and what did you do to mitigate them? Please include a paragraph on this at the end of the discussion section. Response to comment 2: We have added the following paragraph: "This study was limited to the experiences of ASHAs in the Indian state of Rajasthan. Given that Mobile Academy has been scaled up across 13 states, additional localized research would be beneficial. Another limitation of this study is that we only present ASHA and supervisor perspectives on how Mobile Academy influenced ASHA knowledge and communication with beneficiaries.
Evaluating these assertions was beyond the scope of our research but would be very beneficial.

GENERAL COMMENTS
Dear authors and the editor, Thank you once again for this needed and interesting article, and for excellent revisions. I believe the article is ready for publication. I have a few minor comments that would help to finalise it.
• The authors have considered and enhanced and contextualized the debate on ASHA training in relationship to the debates and their preferences on payment. I would suggest to also very briefly in one sentence -to flag this debate up in the discussion section, for instance, as an important policy recommendation along with the general need for such programmes. If they are used repeatedly and regularly, the incentives for this training would be recommended in order to reward their labour and to sustain motivation and an interest.
• As the section five was too general and deleted, I would suggest to add a one-two sentence summary of it into the discussion or conclusion. This could also be an outline of a future possible research on the challenges to implement training knowledge that ASHAs face.
• Some of the discussion points could be generalized and liked with each other. For instance, ASHAs felt that Mlearning increased their confidence and knowledge, and that the tone of the learning programme was appropriate. Could this also be that these are linked outcomes, as the acceptable tone and repetitive pedagogy enabled learning and increased their confidence? • I would suggest to rephrase the following sentences/phrases and find generalized descriptions that are more precise and closer to the ASHAs' responses: o "Initial fear replaced by happiness"perhaps satisfaction and being content with a course? o Line 57 -"they quickly relaxed"they felt comfortable with technology/course content/task….

VERSION 2 -AUTHOR RESPONSE
Comment 1: The authors have considered and enhanced and contextualized the debate on ASHA training in relationship to the debates and their preferences on payment. I would suggest to also very brieflyin one sentence -to flag this debate up in the discussion section, for instance, as an important policy recommendation along with the general need for such programmes. If they are used repeatedly and regularly, the incentives for this training would be recommended in order to reward their labour and to sustain motivation and an interest.
Response to comment 1: Thank you for this suggestion. We have added the following as the last sentence of the first paragraph of the discussion: "If mLearning becomes a repeated and regular part of ASHA training, many respondents noted that financial incentives would be required to compensate ASHAs for their time and sustain motivation." Comment 2: As the section five was too general and deleted, I would suggest to add a one-two sentence summary of it into the discussion or conclusion. This could also be an outline of a future possible research on the challenges to implement training knowledge that ASHAs face.
Response to comment 2: Great idea. We have added the following to page 15, in the discussion, in the paragraph on hierarchy in the Indian health system: "A few ASHAs contrasted the kind tone in Mobile Academy to a more intimidating teaching style used at some face-to-face trainings. And although many ASHAs expressed sympathy towards families that did not abide by their recommendations, others expressed frustration. ASHAs noted persistent barriers to change, including resistance from mothers-in-law, fear of poor quality care and financial costs at hospitals and shame and secrecy around reproduction. But several ASHAs described families that did not adhere to their guidance as stubborn, lazy and careless, and felt little shared identity the populations they served." Comment 3: Some of the discussion points could be generalized and liked with each other. For instance, ASHAs felt that mlearning increased their confidence and knowledge, and that the tone of the learning programme was appropriate. Could this also be that these are linked outcomes, as the acceptable tone and repetitive pedagogy enabled learning and increased their confidence?
Response to comment 3: Thank you. We have edited the first paragraph of the discussion as follows: "They felt that the warm and friendly tone and their ability to repeat content refreshed their knowledge and showcased a positive communication style that they could apply to interactions with beneficiaries." Comment 4: I would suggest to rephrase the following sentences/phrases and find generalized descriptions that are more precise and closer to the ASHAs' responses: o "Initial fear replaced by happiness"perhaps satisfaction and being content with a course? o Line 57 -"they quickly relaxed" -they felt comfortable with technology/course content/task…. Response to comment 4: Thank you. We have changed the heading on page 11 to "Initial fear replaced by enjoyment". The concept of "fear" and "enjoyment" emerged strongly from the data so we thought it would be appropriate to retain these terms. We have changed "quickly relaxed" to "quickly felt comfortable with both the technology and content."