The highway between Lucknow and Delhi is long, flat, and smooth. We roll down the freshly paved section between the Indira Nagar Colony in Lucknow and Sitapur in luxury with Parul from Catholic Relief Services (CRS), who will be acting as our interpreter as well as an all around resource due to her experience working with all parties involved in today’s visit. The CRS hired car service boasts all wheel drive, air conditioning, and a customized car horn with a less-obtrusive, echoing honk that actually changes in rhythm each time it blows, which occurs on average around once a minute during our two hour ride.
We meet the District Community Mobilizer and his assistant at their office along with some refreshments. It’s the first time I’ve had orange soda since high school and I don’t think I’ve ever appreciated it as much. As a foreigner in India, one will never go thirsty. Upon every new encounter either a cold glass of water, cola, or hot tea is served, or sometimes all three alongside small plates of cookies, chips, or a spicy mix of crunchy snacks. The show us some photos from events that they host for Community Mobilization Coordinators whose job it is to build disease and treatment awareness in their communities and act as a resource for those in need of healthcare. We take them along with us for the rest of today’s meetings and they instruct the driver where to go.
A cow is walking slowly down the street in front of the National Rural Health Mission (NRHM) office and leads us directly into the driveway and straight up to the front door. I take this as a sign of good luck. The District Program Manager, Anubha Pandey, is sitting in the back corner of the office, surrounded by a group of other workers. We introduce ourselves then step back into a side office for some more refreshments while we wait our turn, where we meet an IT officer who is dutifully verifying the data in the excel file where the monthly reports of the regional Accredited Social Health Activists (ASHAs) are compiled. We will soon find out that these monthly reports are actually rather difficult to enter electronically and compile as each ASHA writes up her own custom paper report without any standard format.
As soon as Anubha is free, we take our places in the splay of chairs around his desk and boot up our CommCare presentation on a laptop. Around the desk are four other workers from the District Program Management Unit, as well as the full team from our car: the District Community Mobilizer, his assistant, and Parul. The presentation is short and smooth and is followed by looks of genuine interest, especially as we pull out our CommCare equipped mobiles and give a brief demo of the existing literate version as well as a rudimentary mock-up of what the illiterate version may look like. Anubha takes the mobile and clicks through a few screens. The interest is clear and we are offered any help that the office may offer in further coordination with the ASHAs.
An important thing to note in a country filled predominantly with similar model Nokia phones: upon leaving a meeting make sure you walk away with your mobile, and not someone else’s… After a quick detour back to the NRHM office to return a mistakenly placed mobile we are on the road to the next and final visit of the day, our meeting with the ASHAs themselves.
The clinic is filled with people. A room is cleared out to make space for all of us and we are greeted by the chief clinician and a handful of other employees whose roles remains unclear. Five ASHAs enter, each of them in a different colored dress, and sit down together on a long bench. We get started with introductions and meet the women: Vinuto, Somyan, Meena, Snelata, and Madhuri and ask them for details about their work. We find a few interesting results: firstly, that their reports are not standardized and that one of their biggest problems in compiling the reports is that they have no mechanism for reporting newborn children that have not been immunized, only those that have received their immunizations. Secondly, that one of the major difficulties they find in household visits is conveying credibility. Some families are not convinced that immunizing their child is helpful. The ASHA explains to them that the immunization itself may cause a mild fever, but will help prevent future sickness, but the family retorts that if the immunization itself can cause sickness, then why would they do it? Another difficulty mentioned is the cost of transportation to the local clinic. ASHAs are volunteers and quite poor themselves. In the case where a visit to the clinic is necessary, even if the family is convinced, they nor the ASHA may not have the means to make it possible.
As we are talking two of the AHSA’s mobiles ring and they, embarrassed, try to silence them. Meena has trouble unlocking her phone and passes it to one of the staff, who unlocks it and silences it for her. As we move on to the topic of technology and mobile phones themselves, two more ring, answering one of our questions without ever having to ask it. All of the ASHAs carry mobile phones and are comfortable with rudimentary use (making phone calls, receiving phone calls, and receiving text messages). They also seem familiar with the address book/contact list, however when I ask Madhuri to show me her contact list, she has trouble navigating the menu to find it. Once she gets there however, she happily scrolls through the names listed and reads them off to me.
One of the most interesting discoveries is not the fact that all of the mobile phones are set to English, but that they all have the option of being set in Hindi and have never been changed. I show Madhuri that I can change her phone to Hindi and ask her if she would like to keep it that way. She tells me no, she’d rather have it in English, citing that she is more familiar with the system in English and that it will help her learn. She also mentions that the Hindi text on the cell phone screen is too small to read (all her phone book entries are in capital Roman letters) and I agree with her. Devanagari script, in which Hindi is written, is much more detailed than Roman script, and when squeezed into the same size space on a small Nokia screen can be very difficult to read even if the reader has good eyesight. When the other ASHAs are asked about changing their mobile language to Hindi, most respond in a similar fashion, citing that they are already used to seeing Roman letters and prefer it that way and that it will help them learn English.
All but one of the the ASHAs have been taught how to use their mobiles by either a son or a daughter, the exception being a brother-in-law. When asked hypothetically if it would be useful to bring their helper offspring in for training with the system as well, the unanimous response was no. The ASHAs are very proud of their work and their position and seem to be wary of jeopardizing their level of responsibility by bringing someone else into the picture. When asked if it would be better to train their husbands as opposed to their sons, the response is a vehement no. Parul tells us that she believes that the woman do not want to show weakness and would therefore prefer to be trained alone and possibly feign comprehension and then ask for help from sons or daughters later at home.
After a short break we start our game of charades. The women are supposed to be mothers that are sick and cannot talk and must use their bodies to display the symptoms of pain, fever, headache, and being pregnant but unable to feel the baby moving. Without a hint of shyness, they get up and act out the symptoms. I try to draw a simple representation of their actions in black and red ink on notepad paper, which they then review and comment on. The symptom we expected to be difficult to show, being pregnant but unable to feel the baby moving, was acted out without a moment’s hesitation by one woman laying face-up on the bench and another pressing her ear to the belly, clearly reinforcing how important this meeting and interaction is to the design process.
We thank the ASHAs for their cooperation, are careful not to steal anyone’s mobile phone as we are leaving, and bid them farewell. Back on the long road home to Lucknow, we promptly pass out to the soft lullaby of our driver’s echoing horn.