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 Table of Contents  
Year : 2022  |  Volume : 7  |  Issue : 2  |  Page : 63-70

Empowering Accredited Social Health Activist (ASHA) in a rural communities of Pune (Maharashtra): Process evaluation of a community-based intervention for diabetes care

1 Public Health Foundation of India, Gurugram, Haryana, India
2 Chellaram Diabetes Institute, Pune, Maharashtra, India

Date of Submission25-Feb-2022
Date of Decision18-Mar-2022
Date of Acceptance18-Mar-2022
Date of Web Publication22-Jul-2022

Correspondence Address:
Ms. Shalini Bassi
Public Health Foundation of India, Plot No. 47, Sector 44, Gurugram - 122 002, Haryana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jncd.jncd_15_22

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Background: Diabetes is quickly reaching the status of a potential epidemic, with more than 74.2 million Indians diagnosed with the disease. With the majority of India's population residing in rural areas, the potential burden of diabetes is compounded by rising healthcare expenses, lower literacy, lack of awareness, limited access, and availability of healthcare.
Objective: The process evaluation of project diabetes with dignity (DWD) aimed to test the feasibility and effectiveness of a model of enhanced diabetes care for adults, empowering Accredited Social Health Activists (ASHAs) in rural communities of Pune, Maharashtra.
Methods: A community-based, quasi-experimental study was conducted with high-risk identified adults with Type 2 diabetes (n = 431, 30–70 years), in two Primary Health Centers of Baramati block of Pune district. ASHAs implemented six months' DWD intervention, including screening of subjects at risk of Type 2 diabetes using Indian diabetes risk score questionnaire, random blood glucose testing using glucometer, counseling, monthly house-to-house visits, and community-based awareness-raising activities about diabetes care-related issues.
Results: Results indicated that the delivery, and reach of DWD intervention were favorable. The intervention was delivered as intended with a high degree of fidelity with dosage delivery, high attendance, and good participation rates. The participants were satisfied with intervention strategies activities and recognized to scale it up further. The engagement of ASHAs as a protagonist in the successful project implementation was emphasized.
Conclusions: The findings on DWD intervention satisfaction, reach, and participation favored the capacity-building of ASHAs for diabetes screening, prevention, management, and referrals in rural Indian settings.

Keywords: Accredited Social Health Activist, community health workers, diabetes, process evaluation

How to cite this article:
Bassi S, Rawal T, Nazar GP, Dhore PB, Bhatt AA, Deshpande SR, Unnikrishnan AG, Arora M. Empowering Accredited Social Health Activist (ASHA) in a rural communities of Pune (Maharashtra): Process evaluation of a community-based intervention for diabetes care. Int J Non-Commun Dis 2022;7:63-70

How to cite this URL:
Bassi S, Rawal T, Nazar GP, Dhore PB, Bhatt AA, Deshpande SR, Unnikrishnan AG, Arora M. Empowering Accredited Social Health Activist (ASHA) in a rural communities of Pune (Maharashtra): Process evaluation of a community-based intervention for diabetes care. Int J Non-Commun Dis [serial online] 2022 [cited 2023 Feb 1];7:63-70. Available from: https://www.ijncd.org/text.asp?2022/7/2/63/351743

  Introduction Top

Diabetes is fast gaining the status of a potential epidemic in India, with 74.2 million people diagnosed with the disease.[1] While previously considered a problem of the urban affluent, it has become a serious concern among the rural population contributing to widening health inequalities.[2]

In India, the primary health care system since long has been the key provider of healthcare in rural settings through primary health centers (PHCs) and community health workers (CHWs). The successful engagement of nearly 1 million Accredited Social Health Activists (ASHAs), a female cadre of India's CHWs under the National Health Mission, is proof of the potential and effectiveness of CHWs in community participation and empowerment.[3],[4]

There is a literature base from developed and developing countries that community-based interventions involving CHWs are a promising strategy for improving diabetes awareness and outcomes.[5],[6],[7],[8] The role of ASHA has been specified for population-based screening, following up with patients, and providing lifestyle-related behavioral intervention through house-to-house visits under the national health program.[9] However, limited research from India has focused on the evaluation of ASHA's role in diabetes care. This paper presents the findings from the process evaluation of Project Diabetes with Dignity (DWD) intervention. DWD is a model of enhanced diabetes care for adults in the rural Indian setting of the Pune district through the empowerment of ASHAs. The process evaluation of health intervention is important to measure the extent to which an intervention was delivered or received as planned, participants' interactions and responses to intervention, effectiveness, its suitability, and sustainability for translation into routine practice.[10],[11] DWD was effective in improving the quality of life and diabetes knowledge among adults with diabetes in the intervention compared to the control group.[12] The comparative clinical and behavioral measures related to diabetes and lifestyle between intervention and control groups were also collected as part of DWD and will be presented through a separate research paper. In this paper, only the findings of process evaluation have been presented.

  Methods Top

Study design, participants, and setting

DWD is a community-based, quasi-experimental study conducted with the high-risk identified adults (30–70 years) with Type 2 diabetes in two PHCs from one block of Pune district (Maharashtra, India). The intervention area was Pandare, and the control area (conventional care) was Shirsupal PHC.

Project diabetes with dignity intervention

Project DWD (2016–2017) aimed to test the feasibility and effectiveness of a model of enhanced diabetes care for adults in a rural Indian setting. The 6 months' DWD intervention embraced multiple strategies empowering ASHAs for prevention, management, and referral of diabetes. The intervention involved monthly home visits, patient/caregiver, and community-based awareness-raising activities by the trained ASHA workers. In both intervention and control areas, ASHAs were involved in baseline screening and mobilizing the enrolled diabetes subjects for baseline and end-line assessments.

A house-to-house survey was conducted by the trained ASHAs in both intervention and control areas to identify at-risk diabetes participants. The screening was done using the Indian Diabetes Risk Score (IDRS), a validated high-risk screening questionnaire for screening of undiagnosed diabetes in India.[13] The participants at high risk (score ≥60 by IDRS) were subjected to random blood glucose (RBG) testing using a glucometer. The participants with RBG ≥200 mg/dl were diagnosed as diabetes cases. Both newly and prior diagnosed diabetes subjects were included in the study. Those with severe systemic illness, advanced diabetes complications, mental instability, and those unwilling to participate were not included in the study. ASHAs referred the at-risk participants and known cases of diabetes for further evaluation and treatment to the medical officers of the respective PHCs.

The capacity of ASHAs from the intervention area was also built to support self-care, management, monthly home visits to enroll diabetes subjects, and their engagement in activities to improve diabetes awareness in the community. This capacity was built through a 3-day structured training program conducted in the local language (Marathi). The modules developed in the local language (Marathi) and focused on various aspects of diabetes management including a general overview of diabetes, early symptoms identification, managing complications, pharmacological and nonpharmacological management, the importance of interpersonal and group communication, were used during the training [Table 1].
Table 1: Modules and content covered during training conducted for Accredited Social Health Activists

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Each subject with diabetes from the intervention area received a monthly home visit by trained ASHA over 6 months [Table 2]. No intervention except educational leaflets was given to participants in the control area. ASHAs in the intervention area were also involved in formulating and organizing meetings of support groups and committees in respective villages and creating awareness about diabetes care-related issues. The Village, Health, Sanitation, and Nutrition Committee, Diabetes Selfhelp Groups, and community leaders such as village Sarpanch (head of the Panchayat and the Gram Sabha) were also involved in awareness-raising activities.
Table 2: Structure of monthly visits by Accredited Social Health Activist to patients with diabetes

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The 6 months' DWD intervention was followed by a post intervention evaluation. A well-staffed and equipped Mobile Diabetes Clinic (MDC) was used to perform baseline and end-line investigations.

Data collection

Multi-staged comprehensive process evaluation was systematically integrated into the DWD intervention design for in-depth evaluation of intervention reach (proportion of the target audience received the intervention), dose (the amount of intervention delivered), fidelity (intervention delivered as intended), acceptability, and sustainability.[14] The process measures included attendance records for training and intervention activities, post training satisfaction survey, records for diabetes patients who attended baseline and end-line clinical evaluation, and semi-structured in-depth interviews. The process data were collected from key stakeholders, including the community (ASHA) and frontline health workers (ANM, MPWs), medical officers, village head (sarpanch and deputy sarpanch), and project implementation team. The use of a mixed-methods approach allowed the process of triangulation.[15]

Training attendance records

The attendance records for each training were collected by the project implementation team to keep records on the date, venue, number, and participation in the training conducted.

Post training satisfaction survey

A comprehensive survey comprised of both subjective and descriptive variables to assess the level of participant's satisfaction with the content, relevance, duration, structure, strategies, and methodology adopted, completed by all the training participants at the end of the training.

Attendance records for each intervention activity

The attendance records for each intervention activity were collected by the project implementation team to keep records on the activities conducted and participation rate.

Baseline and end-line evaluation forms

The information on the clinical examinations, high-risk screening, referral, and a home visit by ASHA was collected using baseline and end-line evaluation forms.

In-depth interviews at the end line

Twelve key informant semi-structured in-depth interviews were conducted at end line with participants including ASHAs (n = 6), village leaders, i.e., Sarpanch and Deputy Sarpanch (n = 4), ANM (n = 1), and Medical Officer (n = 1) from PHC of intervention area. The interviews covered all aspects of DWD intervention, including perceptions about the training, process related to intervention implementation, strategies used, perceived effectiveness of an intervention, impeding and enabling factors for implementation, opportunities, and challenges for upscaling the intervention.

Each in-depth interview was conducted by a moderator and facilitator, trained in study protocol using in-depth interview guides. These interviews were mostly conducted in Marathi (local language). The discussions lasted between 45–60 min, conducted at a scheduled time and place, either PHC or a venue within the community as per the convenience of the participants. All in-depth interviews were audio-recorded (after due consent), transcribed, and translated (into English).

Ethics statement

The ethical approval for the study was obtained from the Public Health Foundation of India's Institutional Ethics Committee (TRC-IEC-286/16) and the Research Ethics Committee at Chellaram Diabetes Institute (CDIEC/2016/051) before the commencement of the study. Written informed consent was obtained from all the study participants before their recruitment for the study.

Data preparation and analysis

All training attendance records, intervention activities, and information on clinical examinations were maintained and analyzed in Microsoft Excel 2019. All interview recordings were transcribed and analyzed using NVIVO version 12 (QSR International, Melbourne, Australia), qualitative data analysis software.[16]

  Results Top


In total, 22 ASHAs were enrolled and trained (n = 10 from control and n = 12 from intervention) for screening of subjects at-risk of diabetes using IDRS and glucometer (both from control and intervention), self-care and management of diabetes patients, and their engagement in diabetes awareness activities in the community (only from intervention area).

Overall, the project reached 431 adults (newly diagnosed = 73 and known diabetes = 358) with Type 2 diabetes in the age group between 30 and 70 years. In total, 3725 high-risk diabetes out of 27,923 population (13.3%) in intervention and conventional care areas were identified and referred by ASHA for screening to MDC. At the MDC, 431 participants with diabetes (out of 3725) were identified through blood tests (glycated hemoglobin [HbA1c] and RBG) and enrolled for the study. Of 431 subjects with diabetes enrolled at baseline, a total of 416 participants (96.5%) were followed up at the end line. Fifteen subjects were lost to follow-up at end-line evaluation. The demographic characteristics of patients have been published elsewhere.[12]

The number of community members reached through support groups and committees included: Diabetes support group (n = 26), Women's Self-Help Groups (n = 108), Village Health Sanitation and Nutrition Committee (n = 141), and Gram Sabhas (n = 181).


Across the intervention period, five out of five comprehensive structured trainings were conducted for ASHAs. The clinical measurements as planned were conducted with enrolled diabetes patients. All high-risk participants screened at MDC (n = 431), underwent a detailed clinical examination, and were referred to PHC (n = 431) for diabetes-related complications. These included anthropometry, blood pressure, biochemical evaluation (RBG, HbA1c, lipid profile, urine microalbumin, biothesiometer testing, monofilament testing, and retinal examination). These clinical assessments were repeated at the end of 6 months in both intervention and conventional care areas.


Overall the intervention was delivered and implemented as planned. The reporting of false-positive cases using the IDRS questionnaire recognized the need for RBS testing using a glucometer to identify at-risk cases. Clinical examinations including ankle-brachial index test, serum creatinine, ECG were practically not feasible to implement at the MDC [Table 3], hence omitted from the final protocol.
Table 3: Data sources used to assess implementation of Diabetes with Dignity intervention

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Overall, the DWD intervention was viewed positively, and participants felt the need for such kinds of interventions in their community. They reported that this was the first diabetes-focused comprehensive intervention conducted in their area. The project concept, activities, and strategies were appreciated by all participants. ASHAs reported that intervention helped them to gain a lot of new information about diabetes, risk factors, investigation of at-risk/undetected patients with diabetes, prevention, and management. The project received full support and cooperation from the community members.

“Through this project, every patient came into surveillance. ASHA learned how to investigate at-risk cases of diabetes.” (Medical Officer)

“Now people are serious and they started doing exercise, taking proper diet, became aware of diabetes and its management. People are now asking to enroll them in the study and getting their test done” (ASHA).

All ASHAs (n = 22) were satisfied with the training delivered, its content, trainers. The majority (n = 21) were satisfied with the language, strategies used, and training duration. A majority of them mentioned the need for such kind of training on regular basis. All of them reported that it enhanced their screening skills (n = 22), use of glucometer (n = 12), diabetes management (n = 12), confidence to communicate about diabetes and related issues with the community (n = 12), and referrals (n = 12). The majority of them (n = 20) reported being comfortable administering the IDRS questionnaire.

“During training, they (study staff) sensitize us about diabetes, the importance of consuming a balanced diet and regular exercise, how to fill IDRS questionnaire, use of a glucometer, interact with people. We have never used glucometer before”. (ASHA)

It was reported that at the initial stages of the project, it seemed difficult for ASHA to communicate with community members, convince them, get their IDRS questionnaire filled and testing done as most of their experience was in maternal and child health. The training built the confidence to interact with the community members and allowed community members to trust them more.

“Initially, it was difficult to convince people as before this project, we only did vaccination of children and pregnant women. But after some time, we managed”. (ASHA)

The footfall of patients with diabetes enormously increased at the PHC after the DWD project implementation. This led to the allocation of a special diabetic clinic for twice a week at PHC and increased procurement of Metformin and Metformin-Glibenclamide combination tablets with the support of the state government and implementing partner.

“Before this [project], they didn't know about the availability of medicines and investigations done at PHC. Now, around 100–125 patients visit PHC in a week which was only 1-2 patients with diabetes per week earlier” (Medical Officer).

The community leaders emphasized the importance of creating self-help groups and organizing gram sabhas (forum to discuss local governance and development and make need-based plans for the village) to raise awareness on diabetes prevention. During these meetings, people interacted and shared their views about symptoms and treatment effects.

“Discussions in the self-help groups were very useful for spreading awareness about diabetes” (Deputy Sarpanch).


All the participants were satisfied with the project components strategies used recognized the need to scale it up further. Almost all the participants emphasized the engagement of ASHAs as a protagonist in the successful implementation of project activities.

“People in our area have a good opinion about this project and are very happy. ASHA herself visits home every time, tests blood sugar, and patients are getting free medicines”. (ANM)

  Discussion Top

The process evaluation of DWD intervention revealed that intervention was well appreciated and received by the community members, frontline health workers, and village leaders. This study adds to the limited scientific evidence base in India on involving ASHAs for diabetes care, improving diabetes outcomes, and providing culturally appropriate services to communities that are medically underserved in rural settings. Our study is consistent with a community-based, participatory diabetes prevention and management intervention in rural India using CHWs, which reported significant changes in all clinical, biochemical and physiologic indicators.[8] A review found that CHWs have the potential to improve knowledge, health behavior, and health outcomes related to the prevention and management of T2DM in low- and middle-income countries.[17] Several trials focusing on enhanced CHW interventions have been conducted across populations, revealing evidence of improved glycemic control compared to usual diabetes care.[6]

The intervention was implemented with high fidelity, and the dose delivered was as intended. ASHAs received comprehensive training allowing them to have the foundation and knowledge base to deliver the intervention. The satisfaction with training and reported confidence in dealing with diabetes patients after the training was very high among ASHAs. The program was able to successfully improve ASHA knowledge about diabetes, skills related to diabetes screening, glucometer use, and effective communication with the community members about diabetes and related issues. The findings are consistent with the revised guidelines of the National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS), which stipulate the role of ASHAs in screening the community members for diabetes, referring and following-up with patients, providing lifestyle-related behavioral intervention through house-to-house visits.[9] This upskilling of ASHAs is further going to help the achievement of the objectives of the Government of India's flagship comprehensive primary healthcare program, i.e., Ayushman Bharat.[18]

Globally, the role of CHWs has been recognized as vital in raising awareness about diabetes management and has proven to be successful in enhancing self-care among patients with diabetes.[19] The evaluation of the ASHA program highlighted that ASHAs are more identified as facilitators for appropriate care, and there is less acceptance for their preventive or curative role in the community.[20] Consistently, the DWD findings demonstrated building ASHAs capacity intensively on prevention, management, and referrals for health conditions (like diabetes) is feasible and effective.

The several-fold increase in the footfall of diabetes patients visiting the PHC led to special diabetes clinics twice a week. This development was consistent with the NPCDCS guidelines for establishing regular NCD clinics at sub-center, primary and community health center, district, and referral hospital levels.[21]

Community buy-in and support from village leaders and committees were recognized as a crucial part of DWD intervention raising diabetes awareness. Such platforms can convene local resources to support successful public health interventions[22] and are in line with the NPCDCS guidelines for engaging community and civil society.[9]

Despite being offered suitable incentives, some ASHAs found it difficult to commit sufficient time dedicated to DWD activities. Research in India has shown that the existing CHWs, including ASHA are overburdened with their engagement in an increasing number of vertical national health programs.[23] Suitable incentives as per NPCDCS guidelines with the recruitment of dedicated ASHAs for NCD prevention and control under NPCDCS may help overcome some of these barriers as well as to retain their interest and enthusiasm for continuing the community-based activities for prevention and management of diabetes. Ensuring the availability of glucometer to ASHA along with adequate training for its use is vital for the implementation of the DWD model.

Strengths and limitations

Under the National Health Mission, a model has been introduced to build the skills of the ASHA for health promotion, screening, early detection, and referral for noncommunicable diseases, but it has not been tested.[24] The DWD intervention involved extensive training and capacity building of ASHAs for the prevention and management of diabetes. Our study tested the feasibility and effectiveness of a model of enhanced diabetes care for adults, empowering ASHAs, and thus provides initial evidence of the efficacy of that model. The study is limited to selected villages of one block of one district, hence, limiting the generalizability of findings. The acceptability of the intervention across different populations may differ, which needs to be investigated further.

  Conclusions Top

The findings of DWD intervention satisfaction, reach, and participation favored the capacity-building of ASHAs for screening of those at risk of diabetes, referrals of high-risk subjects, and community-based health promotion activities in rural Indian settings. A large-scale evaluation of this model across different states of India is recommended.


The authors would like to thank members of Scientific Advisory Committee formulated for this study for providing the overall guidance and supervision for the study, team of researchers from Chellaram Diabetes Institute (CDI), Pune (as Implementing agency), Public Health Foundation of India (PHFI), New Delhi (as Evaluating agency) and Health Related Information Dissemination Amongst Youth (HRIDAY), New Delhi (as data collection agency).

Financial support and sponsorship

This work was supported by Sanofi India Limited as part of its public health initiatives for prevention and management of diabetes

Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3]


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