Satish B. Agnihotri

Arka Majhi, Satish B. Agnihotri, Aparajita Mondal

High and persistent child malnutrition levels with tardy reduction, seen in successive health surveys, continue to be a matter of concern in India, drawing attention to the need to revamp the four-decade-old Government program, Integrated Child Development Scheme (ICDS). ICDS field functionaries or Anganwadi Workers' (AWWs) capacity deficit was identified as a significant factor affecting ICDS's effectiveness. Considering rising numbers, over 1.4 million AWWs, and continuously advancing knowledge of community healthcare, conventional training pedagogy is ineffective in building and updating AWWs and their supervisors' capacity, which calls for rethinking, using the ICT approach. Over 6 lakh AWWs in India were smartphone equipped by 2020. An android based quiz app was designed, following AWWs training modules' content and need assessment results. The study investigates the quiz app's effectiveness and compares it with conventional classroom instruction, with a group of AWWs, and discusses ways to make it an adequate substitute.

Arka Majhi, Satish B. Agnihotri, Aparajita Mondal

Recent health surveys in India highlight the alarming child malnutrition levels and lower rates of complete child immunization in many parts of India. Previous researches report that the conventional training pedagogy of the CHWs (Community Healthcare Workers) or the ASHAs (Accredited Social Health Activists) in India is ineffective in enhancing their capacity. Considering that the CHWs are getting equipped with smartphones, it calls for a rethinking of their training pedagogy using the ICT approach. Two refresher training tools were developed to make learning the child immunization schedule more exciting and conceptually engaging for ASHAs. The physical and AR (Augmented Reality) versions of designed card games were compared for effectiveness and knowledge retention, pre, and post-intervention through questionnaire tests conducted immediately before and after playing multiple sessions. The AR-based play was found to be better in learning and knowledge retention with more engagement, mainly due to its interactive and intuitive nature of play.

Arka Majhi, Aparajita Mondal, Satish B. Agnihotri

In India, community healthcare workers are the primary touchpoints between the state and the beneficiaries, such as pregnant mothers and children. Their healthcare knowledge directly impacts the quality of care they provide through home visits and community activities. Classroom in-person or traditional ways of training are found ineffective in imparting knowledge and render poor knowledge retention, which needs reinforcements through short, frequent revisions. Smartphone games on healthcare topics could be a promising solution as a refresher, as they can be scaled and tailored as per players' requirements. This study aims to check the differences in knowledge gain, pre and post-intervention, and, secondly, to check knowledge retention after six months. 270 CHWs or participants were recruited to evaluate different modes of refresher training and assigned into three equal groups of 90 each. The control group (CG) (n=90) was trained using the standard classroom method, which is usually followed. Intervention Group-1 (IG1)(n=90) was trained in a physical card game format, and Intervention Group-2 (IG2)(n=90) was trained in a smartphone game format. 4 sets of questionnaires were made by shuffling 45 questions based on immunization of equal weightage. The questionnaires were filled out by CHWs by hand and collected, evaluated, and analyzed. Paired t-tests were conducted to compare pre-post knowledge increments and repeated measure ANOVA to check for differences in knowledge retention. Results suggest a significant difference in scores in all three groups. A significant difference was observed between the physical and digital gameplay modes. Pre-post knowledge increment was higher in the digital mode (p<0.05), but knowledge retained was not significantly different (p=.4) in digital and physical card versions.

Arka Majhi, Aparajita Mondal, Satish B. Agnihotri

India's recent health surveys have highlighted a worrying trend of incomplete child immunization rates across several district clusters in India. Conventional training methods for community healthcare workers (CHWs) in India are inadequate for improving their skills and knowledge. Smartphone games could be a viable and cost-effective method of refresher training specifically targeting immunization practices. A refresher training game was designed both as a physical card-based and digital app-based game, focusing on enhancing CHWs' knowledge and practices related to child immunization. A quasi-experimental study was conducted with 368 participants. Quantitative gameplay analytics and qualitative feedback from players were collected through interviews. The findings show that game-based refresher training significantly improves CHWs' knowledge gain and retention in the area of child immunization. The discussion highlights the study's implications and insights while developing effective digital tools for training CHWs. The research contributes to the growing body of work on digital tools for training CHWs in resource-constrained settings. The study underscores the potential of smartphone games as a scalable and effective method of refresher training for improving child immunization rates.

Arka Majhi, Satish B. Agnihotri

POSHAN Abhiyan envisages capacity building of AWWs or frontline health workers through 21 training modules of ILA (Incremental Learning Approach), modularising the net learning content into smaller learning topics to help them perform their daily activities. It envisions building skilled AWWs, strengthening supervisory hierarchies, and improving coordination between AWWs (ICDS) services and health programs to achieve common goals such as increasing awareness, improving access to health and nutrition services, and reducing deaths and malnutrition. To better understand the contents of ILA literature, we conducted a content analysis by further breaking down the modules into content types such as facts, concepts, procedures, and principles. Then we framed learning objectives for teaching AWWs. We applied CDT (Component Display Theory by David Merrill) to map the contents with the desired learning objective, following the Specification of Objective chart. In this way, one can easily develop pedagogies from a new training literature. The challenges in framing learning objectives and pedagogies are: The AWWs do not have a (formal/scientific) nutrition and epidemiology background. Therefore, it is important to teach them through examples, familiar to them. AWWs are not evenly and structurally trained across districts. Training materials should be customized based on language, location, and prior knowledge. Delayed refresher courses render them underprepared for their jobs. To overcome these problems, we are developing an Android app based on gamified learning to provide refresher training to AWWs. Conducting content analysis, framing learning objectives, and developing pedagogical approaches will help conceptualize the gamified application.

Arka Majhi, Aparajita Mondal, Satish B. Agnihotri

Digital health technologies are increasingly used to improve healthcare access and delivery worldwide. However, many healthcare applications are designed for environments with stable infrastructure, high digital literacy, and strong institutional support. These assumptions often do not hold in low-resource contexts where healthcare delivery often depends on community health workers, caregivers, and informal care networks. Designing effective healthcare applications for such environments requires attention to infrastructural constraints, cultural contexts, language diversity, and usability challenges. This Birds of a Feather session aims to bring together researchers, designers, and practitioners interested in healthcare application design in low-resource contexts. The session will provide an informal forum for discussing challenges encountered in the design and deployment of digital health technologies in underserved settings, sharing field experiences, and identifying opportunities for collaboration within the Interactive Health (IH) community.

Arka Majhi, Aparajita Mondal, Satish B. Agnihotri

In India, Community Healthcare Workers (CHWs) serve as critical intermediaries between the state and beneficiaries, including pregnant mothers and children. Effective planning and prioritization of care and services necessitate the collection of accurate health data from the community. Crowdsourcing child anthropometric data through CHWs could establish a valuable repository for evidence-based decision-making and service planning. However, existing platforms often fail to maintain CHWs' engagement over time and across different spatial contexts, resulting in spatially misrepresented and outdated data. This study addresses these challenges by conducting a co-design exercise to develop innovative methods for collecting anthropometric data over time and space. The exercise involved analyzing data to create hotspot and density distribution maps. We implemented a trial of the developed game with two groups (n=94 per group) from various states across India, comparing the game-based and non-game-based data collection methods. Our findings reveal that the game-based approach significantly improved measuring efficiency (p<0.05) and demonstrated superior engagement and retention compared to the non-game-based method. This research contributes to the expanding literature on co-design and Research through Design (RtD) methodologies for developing geospatial games, highlighting their potential to enhance data collection practices and improve engagement among CHWs.

Arka Majhi, Aparajita Mondal, Satish B. Agnihotri

Community Health Workers (CHWs) play a critical role in delivering primary healthcare services in low-resource settings, yet sustaining their training and performance remains a persistent challenge. Prior research has explored digital and game-based approaches for CHW training. However, limited work has synthesized longitudinal design insights into generalizable guidelines for interactive health interventions. Building on a four-year design-based research program involving multiple game-based refresher training systems, including quiz-based mobile apps, physical and augmented reality games, card-based games, and location-based games, we examine which design guidelines support sustained engagement, learning transfer, and contextual appropriateness in CHW training. We conducted a mixed-methods analysis across deployments with Accredited Social Health Activists and Anganwadi Workers in India, including interviews, field observations, and usage logs. Through thematic synthesis, we derive eight design guidelines addressing contextual realism, adaptive learning, hybrid interaction, social motivation, explainability, professional identity, and ethical considerations. Our findings contribute actionable design knowledge for researchers and practitioners developing interactive health interventions in low-resource healthcare contexts.