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• Time for a rebalance: psychological and emotional well-being in the healthcare workforce as the foundation for patient safety
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• http://orcid.org/0000-0002-1762-7606 Kate Kirk
• University of Leicester , Leicester , UK
• Correspondence to Dr Kate Kirk, University of Leicester, Leicester, UK; kate.kirk{at}leicester.ac.uk

https://doi.org/10.1136/bmjqs-2024-017236

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• Patient safety
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The COVID-19 pandemic shone a light on the work and needs of the healthcare workforce like never before, resulting in an increased focus of workforce well-being research, policy and within mainstream media. Despite this recent attention, the relevance of workforce well-being for healthcare delivery and efficiency is not a new phenomenon. The National Health Service (NHS) in England employs around 1.4 million people, 1 and as such provides a prominent case study for these issues. A landmark report in 2009 by Dr Steve Boorman (commissioned by the English Department of Health 2 ) reviewed the health and well-being of the NHS workforce in England. The report highlighted issues with poor well-being, sickness and the likely relationship between workforce well-being and patient outcomes. Recommendations were outlined to reduce staff sickness and improve experiences of work, with cost savings predicted at £500 million per year if sickness was reduced by a third. Dr Boorman’s report was one of the first calls for change and many have since followed.

Forward to 2024 and the NHS workforce is experiencing unprecedented demand with systemic stress, burnout and sickness alongside the psychological legacy of the pandemic. 3 Sickness rates in the NHS are higher than in the rest of the economy. 4 In 2023, around 42% of staff felt unwell in the last 12 months as a direct result of workplace stress and just under 55% had come to work in the last 3 months despite not feeling well enough to do their duties, known as ‘presenteeism’. It is important to note that for this most recent round of the NHS Staff Survey, 5 48% of staff completed the survey; some argue this in itself speaks loudly to how staff in the NHS feel, given that 52% did not complete it. 6 Recent analysis by the International Public Policy Observatory, via The University of East Anglia and RAND Europe, estimated the cost of poor mental health and well-being to NHS England might amount to £12.1 billion per year. 7

Workforce well-being issues are fundamental for retention and the delivery of quality healthcare, yet can be labelled as ‘soft’ and easily overlooked compared with more technical aspects of healthcare management. This is regardless of the evidence showing that where staff well-being is prioritised, patients are safer. Despite these observations in the academic literature, the prioritisation and management of workforce well-being in practice are complex. In line with this complexity, in this issue of BMJ Quality and Safety , Taylor et al 8 used a fitting realist lens to synthesise literature on the causes of psychological ill-health and interventions designed to support the workforce. Their study focusses specifically on nurses, midwives and paramedics as these groups make up around 30% of the total NHS workforce and over half of the clinical workforce. The realist analyses drew on initial theory development from 8 key reports and 159 sources. The authors identified 26 context–mechanism–outcome configurations: 16 explaining causes of psychological ill-health and the other 10 helping to explain why well-being interventions have not worked to mitigate psychological ill-health. These were synthesised into five key findings:

A blame culture makes psychological well-being difficult to promote.

System needs frequently over-ride staff psychological well-being.

Implementing and upholding values at work often have unintended personal consequences for staff.

Interventions designed to support well-being are usually focused on the individual and fail to recognise cumulative chronic stressors.

Identifying and implementing interventions is challenging.

Through their analysis, the authors identified several tensions between the realities of healthcare delivery that seem incompatible with and affect the psychological ill-health of the workforce. Therefore, they call for an urgent need to restore the balance in four key areas and prioritise multilevel systems approaches that consider the conflicting demands between meeting service delivery requirements, and protecting the workforce:

Psychological harm to frontline healthcare workers should be anticipated and planned for.

Listening and learning cultures should be balanced with the need for professional accountability.

Interventions that are reactive in nature (usually in response to traumatic events) must be balanced with proactive preventative interventions.

An individual focus where feeling blamed for their own psychological ill-health must be balanced with an organisational focus to address systematic issues—A systems approach to staff psychological well-being is needed, which balances individual responsibility for psychological ill-health with organisational responsibility, interventions and bundles of support.

The unique contribution of the study relates, in part, to the use of a realist methodology, which has facilitated insights into the complexity of healthcare environment context(s). As the authors note, previous studies have failed to explore this sufficiently and have often focused on individual professional groups. Studying across groups and subsequently across contexts stands to gain a deeper exploration of cross-disciplinary challenges.

Emotional ‘cost’ of care and mechanisms ofsupport

Psychological ill-health is a product of cumulative stress as well as exposure to individual traumatic events. The emotional complexity of healthcare delivery is intensely stressful and rarely acknowledged or recognised, 9 even though heightened emotional experiences affect clinical decision-making and play an integral part in care delivery and patient safety. 10

This labour is not without cost to the individual, one of many unintended personal costs of upholding and implementing values as shown by Taylor et al . Certain types of emotional labour (namely ‘deep acting’, where staff try to manipulate true feelings to conform to the ‘expected’ emotional display) are related to burnout, poor well-being and intention to leave. 13 This can result in secondary trauma, ‘moral injury’, suppressing guilt, frustration and grief as staff are unable to deliver care which aligns with their professional values. 14 In a study undertaken during the COVID-19 pandemic, healthcare workers were twice as likely as the general population to experience post-traumatic stress disorder, and one in five met the threshold for conditions such as anxiety and depression. 15

In practice though, strategies to address psychological well-being often focus on strengthening an individual’s resilience and are usually designed to respond to acute trauma (eg, trauma-focused peer support known as ‘TRiM’) rather than considering cumulative stress and moral injury. Many argue that placing the emphasis on individual resilience as an inherent quality is further damaging to staff and ignores organisational responsibility, 16 particularly at a time when the workforce is already showing great resilience. Concurrently, as shown by Taylor et al , the absence of a structured approach to workforce well-being means implementation is challenging. Front-line staff often struggle to access interventions in a meaningful way. Organisational challenges and culture prevent staff, particularly more junior staff, from accessing support. 17 Taylor et al call for whole-system approaches to improving well-being, with organisation-wide interventions and bundles of support, which are preventative as well as reactive; a request echoed in the wider literature. 3

Staff well-being as the foundation to improve patient safety

We know that over time, as staff suppress their true emotion (deep acting), they experience compassion fatigue and can become numb to the suffering of others, described by Taylor et al as a ‘buffer’ against secondary trauma. Ultimately and unsurprisingly, staff with better well-being are more likely to deliver compassionate care. 4 18

Psychological well-being is also intrinsic to clinical safety outcomes. This is evident in two ways. First, staff who are well deliver safer care and are less likely to make clinical errors. 19 20 Second, when staff are well, they are less likely to be absent. Staff who are off sick from work contribute to depleted staffing which is fundamental for patient safety. In nursing, for example, when staffing is reduced and/or skill mix is poor, patients are more likely to die 21 and any resulting care left ‘undone’ results in poor patient experience. Patients in hospitals with highest patient to lowest nurse ratios have 26% higher mortality (95% CI: 12% to 49%) 22 with more recent research echoing the same. In addition, the nurses left behind are twice as likely to be dissatisfied with their jobs, to show high burnout levels, and to report low or deteriorating quality of care in their hospitals, 21 continuing the cycle.

Although the impact of the experience of the workforce, their emotion and psychological well-being on patient safety is evident, these issues are often considered separately in healthcare management. Taylor et al highlight the lack of attention by regulatory bodies and NHS organisations to consider wider workforce issues when managing clinical error with catastrophic outcomes for those staff involved (secondary trauma and suicidal ideation). Similarly, wider ‘solutions’ to patient safety culture in academic literature can also fail to (explicitly) acknowledge, how critical an adequate and well workforce is to their likely success. The same considerations can be applied to many initiatives that stand to improve care. For example, most attempts to improve patient experience, care quality and increase efficiency in healthcare practice all require the workforce at their core but this acknowledgement is not always obvious. Based on growing evidence showing the relevance of psychological well-being for patient safety, it seems unlikely that safety culture and other initiatives that begin without an adequate and psychological well workforce will produce the desired results or ability to sustain them.

Where next?

There is a growing body of literature confirming the relationship between workforce well-being and patient experience and outcomes. Economic evaluations have outlined potential cost savings into the billions. 7 Concurrently, there are a range of interventions shown to improve the well-being of the workforce and staff’s experiences of delivering care. Yet poor well-being, sickness and retention issues persist and are significantly impacting the NHS’s ability to deliver safe care, and similarly in other countries. Psychological ill-health is, as Taylor et al argue, highly prevalent across the workforce. Although their paper draws attention to the challenges faced by nurses, midwives and paramedics due to their dominance in the clinical field, there is likely to be transferability to other staff groups. This opens up future research opportunities which include other allied health professionals alongside ‘non-qualified’/registered staff. Their study shows the causative explanations of tension, created as organisations juggle between healthcare delivery and the needs of the workforce and how some of these tensions are incompatible.

The call for an urgent rebalance in healthcare working environments to enable healthcare staff to recover and, ultimately, thrive is therefore timely and requires action. A shift to the needs of the workforce as a priority is supported widely in the academic literature and is welcome, but needs to be translated into concrete initiatives in practice. This calls for an open conversation that balances the current risk to patient safety posed by a depleted and unwell workforce versus the likely gains of prioritising the needs of the workforce going forward. Practical measures could be the inclusion of workforce well-being metrics from health and professional regulators. However, caution should be taken that mandating elements of well-being does not become a ‘tick box’ exercise when actualised at a local level.

Ultimately, in support of this rebalance, it is of paramount importance that a fully-staffed, psychologically well workforce is seen as ‘the’ foundational patient safety intervention across practice, policy and research going forward. For example, as researchers, we have a responsibility to make these links obvious when planning, undertaking and publishing our work. Until then, other efforts to improve efficiency, patient experience and safety outcomes can be seen as building a house without laying the foundations… or as one clinical leader told me; the ‘cherry’ on a cake without the flour.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

• The Kings Fund
• Edwards N ,
• NHS England
• The International Public Policy Observatory
• Jagosh J , et al
• Harrison R , et al
• Hochschild AR
• Alderson M ,
• Edgley A , et al
• Stevelink SAM ,
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X @KateLKirk

Contributors n/a.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Provenance and peer review Commissioned; internally peer reviewed.

Linked Articles

• Systematic review Care Under Pressure 2: a realist synthesis of causes and interventions to mitigate psychological ill health in nurses, midwives and paramedics Cath Taylor Jill Maben Justin Jagosh Daniele Carrieri Simon Briscoe Naomi Klepacz Karen Mattick BMJ Quality & Safety 2024; - Published Online First: 04 Apr 2024. doi: 10.1136/bmjqs-2023-016468

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Ethical dilemmas faced by health care workers during COVID-19 pandemic: Issues, implications and suggestions

Vikas menon.

a Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantri Nagar P.O, Puducherry, 605006, India

Susanta Kumar Padhy

b Department of Psychiatry, All India Institute of Medical Sciences, Bhubaneswar, 751019, India

The unexpected and unprecedented challenges brought on by the COVID-19 pandemic has inflicted tremendous strain on health care resources, even in developed countries. The sheer magnitude of numbers coupled with high virulence of the infection has triggered country wide lockdowns across vast swathes of the globe. One group expected to work as usual in these trying times are health care workers and, therefore, the impact of COVID-19 pandemic on the mental health of frontline health care workers is gaining legitimate attention ( Ayanian, 2020 ; Lai et al., 2020 ). In this regard, we point out a few moral and ethical dilemmas that can be faced by health care workers (HCW) while attending the call of duty:

• 1. Dilemma 1 – How to balance my ethical duty to care for my patient against genuine concerns of contracting COVID-19 and spreading it to my family? These concerns are likely to be more pronounced among health care workers with aged parents or young children. To some extent, these concerns are also fuelled by limited availability of personal protective equipment (PPE), inequitable distribution of available equipment and limited and constantly changing recommendations on usage of masks and other PPE.
• 2. Dilemma 2 – Should I retain ventilatory support for a critical patient who is unlikely to survive or use the ventilator for a less critical patient with better prognosis? As much as doctors are bound by the Hippocratic oath that entrusts every doctor to treat all sick patients to the best of their abilities, in times such as these, triaging of finite resources is a pragmatic consideration. Consequently, frontline HCW’s may find themselves in an unpleasant situation where they have to make a choice of allocating scant resources for those who need them the most.

Adding a further layer of complexity to this issue are laws governing passive euthanasia in India, which state that a medical board constituted for the purpose by the hospital should first discuss the issue with family members and only after obtaining their written consent, proceed with withdrawal of ventilatory support. Clearly, for an acute illness like COVID 19, it is going to be an onerous task to convince emotionally charged family members about the limited chances of their loved one’s survival and ask them to be ‘altruistic’ enough to spare the ventilator for another sick patient with better chances of survival.

• 1. Dilemma 3 – If I have some respiratory symptoms and I think I may have been exposed, should I open up about my symptoms and stay at home, risking social and workplace discrimination, or continue to go about my work as usual, risking my colleague’s health, till my test comes positive? How do I balance my physical and mental health care needs against the call of duty in these testing times? Every health care worker counts during these times and there have been instances where entire hospitals have been forced to shut down because of presumed exposure or suspected status of one health care worker. In such an all hands-on deck scenario, to try and push oneself to the limits of endurance, neglecting physical symptoms and needs, is par for the course.

The above dilemmas, apart from being very personal, may also have larger ramifications for health care delivery. As these thoughts pre-occupy the mind, juxtaposed with other considerations such as looking after the needs of their families, their own physical and mental health care needs, as well as day to day demands of work and caregiving, judgment of HCW’s may become clouded. This, in turn, may affect clinical decision, increase chances of medical errors and eventually increase the risk of burnout.

We offer some suggestions to tackle the above scenarios:

• 1. Institutions need to be upfront about their plans, policies and standard operating procedures to its staff and health care workers. Availability of patient care, safety equipment and risk stratification protocols must be communicated clearly and updated on institutional websites. All health care workers should be briefed periodically about the rational use of PPE so that their safety concerns are addressed and at the same time, resources are utilized rationally. There must not be any attempt to paper over cracks; instead an open admission of possible shortcomings and steps taken to overcome them will allay anxieties and allow HCW’s to mentally prepare themselves for challenges. As COVID-19 duty is admittedly stressful, institutions may consider giving reduced shift hours (for instance, 4−6 h) per work day to prevent burnout.
• 2. Institutions must consider giving accommodation and quarantine facilities for its staff. If there are resource constraints, this facility must be made available at least to the HCW’s during the period of COVID duty as many of them may not feel comfortable going back to their families every day during this period.
• 3. Pre-counselling of HCW before going to the frontline may help to allay concerns and provide opportunities for clarifying safety queries. The above mentioned ethical and moral dilemmas can be discussed beforehand so that HCW’s are mentally prepared to handle such scenarios. Involvement of mental health professionals at this stage would add value to the process by enabling utilization of their specific expertise in crisis counselling and problem-solving skills.
• 4. Setting up of a COVID support cell in every institution would serve as a one stop resource for mental and physical health care needs of HCW’s. It also provides a forum for HCW, who may feel overwhelmed from time to time by the demands of caring, to discuss ongoing concerns and help to prevent burnout. As mentioned earlier, every HCW matters and their mental health often correlates with workplace productivity ( Duffield et al., 2014 ; Kim et al., 2018 ). Health care team leaders should be trained to recognise signs of burnout among junior doctors as early identification and intervention is key ( Greenberg et al., 2020 ).
• 5. Ultimately, personal health is an individual responsibility. If an HCW has respiratory symptoms and does not wish to endanger others, the onus is on them to stay back and give a proper explanation for their decision. When in doubt, it is desirable to apply the ethical self-test as follows; “If my colleague at work had these symptoms, would I prefer him to come for duty?” Setting out standard operating procedures for HCW’s in this regard would remove ambiguity, facilitate individual decisions and lessen discrimination.

Extraordinary times call for extraordinary measures. We hope that the measures outlined above would assist institutions and team leaders in providing the best possible working conditions for their staff and health care workers. This will enable and motivate frontline health care workers to give their best while simultaneously preserving themselves for another day.

Financial disclosures

There are no financial disclosures or sources of support for the present work.

Declaration of Competing Interest

The authors declare no conflicts of interest relevant to the contents of the manuscript.

Acknowledgments

• Ayanian J.Z. Mental health needs of health care workers providing frontline COVID-19 care. JAMA Health Forum. 2020; 1 doi: 10.1001/jamahealthforum.2020.0397. e200397–e200397. [ PubMed ] [ CrossRef ] [ Google Scholar ]
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• Open access
• Published: 23 April 2024

A mixed methods evaluation of the impact of ECHO ® telementoring model for capacity building of community health workers in India

• Rajmohan Panda 1 ,
• Supriya Lahoti   ORCID: orcid.org/0000-0001-6826-5273 2 ,
• Nivedita Mishra 2 ,
• Rajath R. Prabhu 3 ,
• Kalpana Singh 4 ,
• Apoorva Karan Rai 2 &
• Kumud Rai 2  

Human Resources for Health volume  22 , Article number:  26 ( 2024 ) Cite this article

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Introduction

India has the largest cohort of community health workers with one million Accredited Social Health Activists (ASHAs). ASHAs play vital role in providing health education and promoting accessible health care services in the community. Despite their potential to improve the health status of people, they remain largely underutilized because of their limited knowledge and skills. Considering this gap, Extension for Community Healthcare Outcomes (ECHO) ® India, in collaboration with the National Health System Resource Centre (NHSRC), implemented a 15-h (over 6 months) refresher training for ASHAs using a telementoring interface. The present study intends to assess the impact of the training program for improving the knowledge and skills of ASHA workers.

We conducted a pre–post quasi-experimental study using a convergent parallel mixed-method approach. The quantitative survey ( n  = 490) assessed learning competence, performance, and satisfaction of the ASHAs. In addition to the above, in-depth interviews with ASHAs ( n  = 12) and key informant interviews with other stakeholders ( n  = 9) examined the experience and practical applications of the training. Inferences from the quantitative and qualitative approaches were integrated during the reporting stage and presented using an adapted Moore’s Expanded Outcomes Framework.

There was a statistically significant improvement in learning ( p =  0.038) and competence ( p =  0.01) after attending the training. Participants were satisfied with the opportunity provided by the teleECHO™ sessions to upgrade their knowledge. However, internet connectivity, duration and number of participants in the sessions were identified as areas that needed improvement for future training programs. An improvement in confidence to communicate more effectively with the community was reported. Positive changes in the attitudes of ASHAs towards patient and community members were also reported after attending the training. The peer-to-peer learning through case-based discussion approach helped ensure that the training was relevant to the needs and work of the ASHAs.

Conclusions

The ECHO Model ™ was found effective in improving and updating the knowledge and skills of ASHAs across different geographies in India. Efforts directed towards knowledge upgradation of ASHAs are crucial for strengthening the health system at the community level. The findings of this study can be used to guide future training programs.

Trial registration The study has been registered at the Clinical Trials Registry, India (CTRI/2021/10/037189) dated 08/10/2021.

Peer Review reports

The Alma Ata Declaration of 1978 has recognized primary health care as an essential element for improving community health. Community health workers (CHWs) have the potential to complement an overstrained health workforce and enhance primary healthcare access and quality [ 1 ]. Low- and middle-income countries (LMICs) face a triple burden of low density of doctors and nurse-midwives, low government expenditure on health, and disproportionately larger poor health outcomes [ 2 ]. The roles and responsibilities of CHWs vary across LMICs [ 3 ]. A systematic review has documented that the socio-cultural, economic, health system, and political context in which CHW interventions operate in LMICs influence the implementation and success of interventions [ 4 ].

The National Rural Health Mission (NRHM), India introduced Accredited Social Health Activists (ASHAs) as female CHWs in 2005. The ASHAs are women volunteers selected from the local village and were initially conceptualized with a vision to improve maternal and child health in the country; however, over time, they are now involved in different national health programmes [ 5 , 6 ]. Despite their potential to contribute to preventive and promotive healthcare, they remain largely underutilized because of their limited knowledge and skills [ 1 ]. The World Health Organisation (WHO) has suggested ‘regular training and supervision’ for CHWs to fulfil their role successfully [ 7 ]. In India, the health system lacks methods for continuous education and routine upgradation of the ASHA’s skills [ 8 , 9 , 10 ].

In LMICs, digital training programs can help expand the reach of training to large numbers of healthcare workers at a low cost without interfering with the delivery of routine healthcare services [ 11 , 12 ]. An evidence-mapping study of 88 studies that used technology for training CHWs in LMICs found that the focus of trainings was maternal and child health and other high-burden diseases were neglected [ 13 ]. In India, studies evaluating digital trainings for CHWs have focussed on specific diseases or have been limited to specific states in the last decade [ 10 , 14 ]. This study was conducted across multiple states. More such studies with larger sample size are needed on the evaluation of such training initiatives in India [ 13 , 15 , 16 ].

Project Extension for Community Healthcare Outcomes (ECHO) presents an educational opportunity for capacity-building through a telementoring platform that uses video conferencing to create a continuous loop of learning and peer support. The sessions are facilitated by didactic presentation and case-based learning that allows problem-solving through shared best practices [ 17 ]. ECHO India, in collaboration with National Health System Resource Centre (NHSRC), provided refresher training for ASHAs [ 18 ]. There is increasing evidence of the positive effect of ECHO training on medical provider’s learning and self-efficacy. However, its value as a training platform to CHWs in LMICs is limited. Previous studies that evaluated the use of the ECHO Model ™ for CHWs focussed on specific diseases and were conducted in high-income countries (HICs) [ 19 , 20 , 21 ]. For the adoption of digital technology, CHWs in LMICs encounter challenges such as poor proficiency levels in accessing and using digital platforms, limited access to troubleshooting, poor internet connectivity, and in-house support for resolving issues [ 22 ]. The present study was designed to assess the impact of the ECHO telementoring model for improving the knowledge and skills of ASHA workers in delivering comprehensive health services. This will provide new insights for measuring outcomes of digital training programs for CHWs (ASHA workers).

Study design

A pre–post quasi-experimental design using a convergent parallel mixed-method approach [ 23 ] was employed. The quantitative and qualitative data were collected concurrently. Inferences from both approaches were integrated during the reporting stage. This allowed for a comprehensive understanding of the effect of training on the knowledge and skills of ASHAs.

The ECHO training intervention and curriculum

Project ECHO ® designed a 15-h (over 6 months from October 2021 to March 2022), virtual, refresher training program to enhance the capacity of ASHAs to deliver counselling services for comprehensive healthcare in four states ( n  = 2293). Each session lasted for 90 min. The ECHO NHSRC training used a “hub and spoke” structure in which a multidisciplinary team of experts (trainers) based at a regional academic medical centre (the “hub”) engaged with the ASHAs (the “spokes”) [ 24 ] who attended the sessions from dedicated learning sites (PHCs). Each site also had a coordinator who would help facilitate the discussions and questions. The training curriculum was developed based on the NHSRC ‘ASHA training modules’ [ 18 ] in the regional languages in consultation with partners (hub-leaders and trainers). It comprised 10 sessions covering a range of topics, such as maternal health, new-born care, child health, nutrition, reproductive health, violence against women, tuberculosis, vector-borne diseases, non-communicable diseases, COVID-19, palliative care, and mental health. The training presentations included text with visual learning methods, such as images, videos, and links to training resources.

Study settings

The evaluation study was conducted in four states of India, where training sessions were held. These states represented the four geographical regions—northern (Himachal Pradesh) ( n =  499), southern (Tamil Nadu) ( n =  500), eastern (West Bengal) ( n =  618), and north-eastern (Sikkim) ( n =  676). The intervention (training sessions) was completed in March 2022. The end-point data were collected from March 2022 to May 2022.

Study participants and recruitment

Simple random sampling was used to select the ASHAs from each state for the quantitative survey. The participants were recruited from a list of ASHAs who would be receiving the ECHO NHSRC training. To be included, ASHAs had to be enrolled in the refresher training, planning to continue working for the next 10 months, with available contact details and consenting voluntarily. The ASHAs were contacted through mobile phones in each state. Key informant interviews (KIIs) were conducted with hub leaders who were involved in implementing the training, trainers (faculty) who delivered the lectures, and in-depth interviews (IDIs) with ASHAs.

Sample size

The sample size for the quantitative study was estimated by assuming a 25% improvement in knowledge and skills, 80% power, and a design effect factor of 1.7%. An adjustment of 30% loss to follow up and 20% non-response (from previous experience) led to a sample of 591 participants across four states, i.e., 148 participants from each state. For the qualitative study, purposive sampling with maximum variation across age, education, practice sites, and years of work experience was used for the selection of the participants. A total of 12 IDIs were conducted with ASHAs and nine KIIs with stakeholders (Additional file 2 : Appendix S2).

Study tools and data collection

For quantitative data collection, a structured questionnaire was designed through a collaborative approach with the research and program implementation team. The knowledge of ASHAs was assessed by a combination of 18 technical questions and case vignettes. Learning and competence, performance, and satisfaction were assessed with a 5-point Likert scale, using 1 = Strongly Disagree; 2 = Disagree; 3 = Neither Agree nor Disagree; 4 = Agree; and 5 = Strongly Agree. The face validity of the questionnaire was tested with ten ASHAs, separate from those recruited in the study and five primary care experts. The changes related to language, clarity, and relevance were made in the questionnaire based on the feedback from experts and participants. Separate discussion guides were developed for KIIs with trainers (Additional file 3 : Appendix S3) and hub-leaders (Additional file 4 : Appendix S4) and IDIs with ASHAs (Additional file 5 : Appendix S5). The guide focussed on examining the experience and practical applications of the training and was field tested before being administered in the main study. All study tools were translated into the local languages of the states and back-translated to check discrepancies.

The data were collected on the cell phone by experienced and trained researchers from social sciences backgrounds. Due to telephonic data collection, we were unable to capture non-verbal interview data such as emotions or gestures, particularly important in qualitative data. This may affect the richness of data and interpretation of responses. The quantitative tool was designed in the CS Pro software (version 7.5) and data were collected using its smartphone application. The qualitative interviews lasted around 40–50 min and were audio recorded. All interviews were translated and transcribed verbatim.

Data analysis

We summarized the quantitative data using descriptive statistics. Continuous variables were summarized using mean ± SD, and categorical variables were summarized using percentages and frequencies. The responses recorded using the 5-point Likert scale were recategorized during the analysis into three categories, i.e., ‘agree’ (combining strongly agree and agree), ‘disagree’ (combining strongly disagree and disagree), and ‘neutral [ 25 ]. Paired t test was used to find the difference between the pre- and post-scores of learning and competence and the attitude of participants toward ECHO training. McNemar’s test was used to assess changes in pre- and post-test scores for the technical domain. A p value of less than 0.05 was considered significant. STATA 16.0 statistical software was used for the analysis.

Qualitative data were analyzed according to the principles of the Framework approach [ 26 ], which combines inductive and deductive approaches. As a first step, two authors (SL and NM) familiarized themselves with four randomly selected transcripts and independently coded them using initial codes that were developed based on Moore’s framework levels of participation, satisfaction, learning, competence, and performance [ 27 ]. New codes that emerged while undertaking the analysis were included. The discussion and comparison of the double-coded transcripts enabled the development of an agreed set of codes. Any disagreements were discussed and resolved with the help of the third author (RP) to achieve inter-coder agreement. A final codebook was developed and applied to all the transcripts. The codes were combined and categorized into key emerging themes., The themes, including quotes (respondents’ exact words), were included to represent the main findings. Atlas.ti (version 8) software was used for data analysis.

Moore’s level 1—participation

Table 1 represents the baseline demographics of the recruited participants. From 610 participants who completed the pre-training survey, 490 participants completed the post-training survey, resulting in a follow-up rate of 80% (95% CI 76.6, 83.1). A total of 120 (20%, 95% CI 16.8, 23.3) participants were lost to follow up. This was due to a) contact numbers not being operational ( n =  96) and b) refusal due to time considerations ( n =  24). The field investigators attempted three additional phone calls, coordinated with hubs for participants’ alternate contact information, and offered flexible phone appointments to ensure maximum participation in the post-training survey. The majority (68%) of ASHAs were posted at sub-centres. A sub-centre is the most peripheral unit of contact of the health system with the community [ 28 ]. The majority of the participants (75%) had completed their high school (10th) education.

A hub leader described the efforts made by the ECHO to facilitate the participation of the ASHAs in the training.

“ECHO provided a facility where everyone can gather at the nearest block for the training. Physical and online modes [are] both available” (Hub-leader, Himachal Pradesh).

Moore’s level 2—satisfaction

The end-point survey assessed participants’ satisfaction with the ECHO training. The survey included eight items that measured overall training satisfaction and five items that measured satisfaction with factors specific to the telementoring model using close-ended questions. Satisfaction with the training content and environment was measured with four items. Except for one topic area (sharing of additional resources and training material), over 90% of participants were satisfied with almost all of the different components of the ECHO telementoring intervention (Additional file 1 : Appendix S1, Tables S1.1, S1.2, S1.3). While participants found the overall intervention favourable, 54.5% of all participants were dissatisfied with internet connectivity in the training sessions. Around one fourth of the participants faced challenges with the duration (31.2%), frequency (31.2%), and number of participants (28.4%) in the sessions (Additional file 1 : Appendix S1: Table S1.3).

The qualitative findings also show that most of the trainees were satisfied with the learning opportunity provided by the ECHO training.

“After attending these ECHO sessions, I felt we are constantly learning new techniques and it’s a deep sense of satisfaction” (ASHA, Tamil Nadu).

The ASHAs also shared areas or features of the ECHO model that did not meet their requirements and need improvement. They felt that the duration allotted for a session was not sufficient and some topics were covered very fast.

“They rush a lot while teaching over phone. It will be more helpful if they take more time and explain the things in a more detailed manner” (ASHA, WB)

Another ASHA suggested increasing the duration of training to improve their understanding of some topics.

"Increase the time of the training. Topics can be made deeper, and richer for better explanations" (ASHA, Tamil Nadu)

ASHAs described challenges related to connectivity while attending the training.

“The network connection was a problem and video used to lag” (ASHA, Sikkim)

Trainers shared their opinion about aspects of online trainings that did not meet their expectations.

“The problem is that they only join the meeting [online training] and do their own work, they actually do not listen properly.” (Trainer, WB)

A trainer mentioned that the large number of participants in some sessions affected the interaction among participant ASHAs.

“Sometimes a session has too many participants causing coordination efforts to be a challenge in these sessions” (Trainer, TN)

Difficulties in reaching the PHCs were recorded from the state of Sikkim. The geographical location and lack of transport facilities were mentioned by a trainer.

“We have transportation problem, our ASHA comes from rural area and it’s difficult to get taxi, which makes [it] harder to attend classes” (Trainer, Sikkim)

Many participants regarded organizational support as a facilitator for attending the training program. An ASHA from Tamil Nadu described how the issue of distance was resolved through management interventions from the organization.

“Our Block is 30 km away. There is another Block nearby that is 1 km only from here, they sent us there… so there was no problem” (ASHA, TN)

Moore’s level 3—learning

McNemar’s Chi-square statistic showed a significant difference between pre-ECHO and post-ECHO proportions in various aspects of health-related technical knowledge. Before the training, 1% of participants were aware of the correct schedule to be followed in the first week after the delivery of a child, which increased to 40% of participants post-training (p < 0.001). Overall, a statistically significant increase of 6% (95% CI 0.0003, 0.12; p =  0.038) in participants’ technical knowledge after ECHO training was found. After the training, a 7% increase in knowledge of malaria ( p =  0.002) and its symptoms and a 9% increase in knowledge of the right action to be undertaken (p < 0.001) was reported. Knowledge related to some areas such as recommended duration of physical activity or exercise (p < 0.001), immunisation after child birth ( p =  0.001), family planning in women after child birth ( p =  0.002) showed a decrease after attending the training (Additional file 1 : Appendix S1, Table S2). Post ECHO training, ASHAs reported an improvement in their knowledge of using a smartphone (switch on and off, and navigate) ( p =  0.0005) and navigating a mobile application ( p =  0.59). The ASHAs reported a 2% decrease in their knowledge of downloading content in the mobile ( p =  0.07) (Fig.  1 ).

Self-rated ICT knowledge of ASHAs

The qualitative data show that ASHAs who did not have a smartphone found it difficult to download and save content. One of the participants reported receiving additional training content in the form of a pdf file. She also mentioned that those who do not use a smartphone find it challenging to access this additional resource.

“We get the study material in a pdf so that simplifies our work further. But those who do not have a smartphone, find it difficult to get this opportunity” (ASHA, WB)

3A—Declarative learning

Declarative learning assesses how participants articulate the knowledge that the educational activity intended them to know (knowing what). The qualitative findings show that the training had increased the ASHA’s knowledge in specific domains such as breastfeeding during COVID-19.

“The doubt was whether a mother can breastfeed the baby when suffering from COVID-19. I got clarity about that… many such topics were cleared” (ASHA, Himachal Pradesh)

3B—Procedural learning

Procedural learning assesses the participants' articulation of how to do what the educational activity intended them to know (knowing how).

Participants reported that they had gained new skills related to the approach and identification of healthcare issues after attending the ECHO training.

“Earlier we wouldn’t know if ear related issues had a resolution – But following the ear related training we are aware that such issues can be cured or have treatments” (ASHA, Tamil Nadu).

The qualitative interviews revealed additional themes that described the value of the ECHO training program in improving the learning experience of ASHAs.

ASHA workers felt that the case presentations from their peers enhanced their learning experience.

“One ASHA shared a case of an anaemic mother. Based on this case we learned that this could have been prevented if iron tablets are provided from the adolescent stage” (ASHA, Tamil Nadu).

The interactive nature of the sessions and the discussions benefitted the learning experience of the ASHAs.

“Open discussion helped us so much. We can discuss any topics if we haven’t understood and sir used to explain again” (ASHA, Sikkim)

Moore’s level 4—competence

The participants reported significant improvement in their confidence to identify and manage several health conditions like birth asphyxia (for home deliveries) and management with a mucus extractor ( p =  0.01), screen and refer pregnant women ( p =  0.01), disseminate information on domestic violence and sexual harassment ( p =  0.001). Overall, a statistically significant increase of 6% (95% CI 0.01, 0.10; p =  0.01) in participants’ competence after attending the ECHO training was found. Participants reported a decrease in their confidence to track child immunisation ( p  < 0.001), monitor symptoms of COVID (p < 0.001), and clarify concerns of the community ( p  < 0.001) after attending the training (Additional file 1 : Appendix S1, Table S3).

Participants mentioned an improvement in their confidence while communicating with patients and their families.

“Initially we could not talk to people so comfortably, we hesitated at times but after being trained we can talk to people and their families properly and easily now” (ASHA, West Bengal)

An ASHA described a gap in their ability to talk to mothers in the field and suggested including more training content on efficient communication skills.

“We go on field and talk to mothers. There was no training for these, but I feel it will be good if we can have training on how to talk to mothers comfortably” (ASHA, WB)

Moore’s level 5—performance

The study identified a significant improvement in ASHAs’ positive attitude toward maternal and child health issues. Overall, a 5% improvement (95% CI − 0.009, 0.10; p value = 0.09) in participants’ attitudes post-ECHO training was found. Almost all the participants (99%) reported applying the skills learnt during the training at their workplaces. More than 90% of the participants felt that the ECHO training expanded access to healthcare in their community (Fig.  2 ). The ASHAs reported an improvement in their attitude towards inclusion of HIV patients in the community ( p =  0.01) and home visits for new born babies (p < 0.001) (Additional file 1 : Appendix S1, Table S4).

Self-reported performance of ASHAs

The ASHAs shared specific examples where they made changes in their practice or treatment strategies after attending the training.

“[Earlier] the implementation was not proper [correct]. As an example, if a child’s life has to be saved on the spot, we would take the medicines and syringes separately. Now we take the necessary items section wise including the AFI kit. So that’s the change” (ASHA, Tamil Nadu).

The results of this evaluation suggest that Project ECHO provides a suitable and efficacious platform for training for ASHAs. The participants reported an improvement in their knowledge, skills, and practices. They also described improved confidence to communicate more effectively. Some areas in which the ASHAs reported a lack of knowledge and confidence include newborn immunisation and family planning after pregnancy.

The NRHM guidelines for the recruitment of ASHAs require candidates to have at least eight or 10 completed years of formal education. Low literacy and inadequate training of ASHAs have been observed in different states in India [ 30 , 31 ]. However, with the proper training and support, ASHAs can provide comprehensive preventive and promotive healthcare services [ 29 ]. In this study, the majority (75%) of ASHAs across all states had ten or more years of schooling. The ECHO training will bolster their knowledge, skills, and confidence in providing effective services.

The ASHAs receive 23 days of training in the first year, followed by 12 days of training in every subsequent year to keep them updated with the knowledge and skills needed to effectively perform their roles and responsibilities. Previous studies have identified many challenges in the training of ASHAs, such as lack of regular refresher training [ 32 ], shortage of competent trainers, insufficient funds, and use of obsolete health information [ 33 ]. The training programs have mostly been didactic-based and had limitations in the engagement of participants [ 34 ]. The ECHO NHSRC refresher training addresses these limitations by promoting peer-to-peer learning and through a case-based discussion approach [ 35 ].

Our findings report a significant increase in the knowledge of ASHA workers with respect to specific domains like maternal and child health. A randomized controlled trial in Karnataka, India, found a significant improvement in mental health knowledge, attitude, and practice (KAP) scores amongst ASHAs trained by a hybrid training (traditional 1-day in-person classroom training and seven online sessions using the ECHO Model) against conventional classroom training [ 14 ]. This study findings highlight the improvement in knowledge of ASHAs related to oral health and palliative care post-ECHO training. An improvement in knowledge has also been observed in other studies that have evaluated ECHO telementoring interventions in cancer screening [ 36 ], palliative care [ 37 , 38 ], HIV [ 39 ], and chronic pain [ 40 ] In this study, ASHAs reported poor knowledge of the immunisation schedule for a newborn as well as the confidence to record and track immunisation in the community even after the ECHO training. A critical function of ASHAs is to assist ANMs or nurses with all immunisation activities [ 41 ]. A previous study in Karnataka in 2020 found inadequate knowledge among ASHAs about child immunisation. The above study also documented that by increasing the number of days and focusing on child care the ASHAs had a better understanding of interventions related to child healthcare [ 42 ]. As a part of the course structure, ECHO provides one session on new born and post-partum care. An assessment of the number of sessions needed to cover the topics was beyond the scope of our research but would be beneficial.

Previous studies have identified several shortcomings in ASHAs' communication and counselling abilities [ 43 , 44 , 45 ]. The findings of this study revealed that the ASHAs faced communication issues while discussing health matters related to family planning and COVID-19 with the community. Previous research has found that interpersonal communication of ASHAs are influenced by factors such as health system support and community context [ 46 ]. A study exploring the perspectives of ASHAs on a mobile training course in India also found that they encountered barriers in their interactions with beneficiaries such as resistance from family members, fear of poor quality of care, and financial costs of care [ 44 ]. Training programs must therefore, also incorporate how ASHAs can navigate social behaviours and norms to improve the impact of counselling [ 47 , 48 ]. The extent to which the ECHO training can identify and incorporate community hierarchies to improve communication of the ASHAs needs further exploration. In this study, large batch size ( n =  40) and limited use of video by participants during the training hampered the engagement between ASHAs as well as with the trainers. A previous study in the USA suggested that limiting batch size and ensuring face-to-face interactions on the virtual platform ensured a higher level of accountability and made it easier to engage with others in the ECHO training sessions [ 49 ].

CHWs face significant barriers when using digital technology in LMICs, making it challenging for them to access training on digital platforms [ 50 ]. The ASHAs in this study reported an improvement in their ability to use smartphones and navigate mobile applications. Our findings also suggest that ASHAs should be better oriented for accessing content on hand held devices.

The mentorship by trainers added value to participants’ knowledge and helped improve their skills. In this study, participants’ attitudes towards their work changed after attending the ECHO training suggesting that the learning and confidence developed during the training would be transferable to their work in healthcare settings and communities. The ECHO participants of previous studies have also demonstrated similar changes in their practices [ 35 , 40 ]. Our study findings indicate that the ECHO Model is an effective platform that can help foster a virtual community of practice through case-based learning, shared best practices, and online mentorship by experts.

Future directions

There should be more sessions on topics related to post-natal and newborn care as the ASHAs showed poor knowledge and competence in these areas.

There should be more training on counselling and development of communication skills for ASHAs, specially for maternal and child health and COVID-19.

An orientation for ASHAs should be conducted to facilitate the use of technology and the platform for learning. This may also help overcome some of the challenges described by the ASHAs in this study.

Strengths and limitations

The study used a rigorous quasi-experimental design across four different states of India. Our follow-up rate in the study was 80%, indicating a high response from participants completing the pre–post assessment. The presented study has certain limitations. It was not possible to use randomisation and a pure experimental design in this study, and this affects the internal validity of the study. The inclusion of a control group would have strengthened study validity. The self-reported outcomes can be subject to social desirability bias. We did not document the information on attendance and drop outs from the training program. The qualitative results have to be carefully interpreted because of the small sample size of the qualitative study relative to the study sample.

There is increasing recognition of the importance of CHWs globally for promoting a continuum of care and expanding access to health services. ASHA workers constitute critical human resources in the Indian health system and efforts to empower them are crucial for strengthening the health system at the community level. The encouraging results of this study indicate the effectiveness of Project ECHO in building the capacity of ASHA workers across different geographies in the country.

Availability of data and materials

All data generated or analyzed during this study are included in this published article (as Additional files).

Abbreviations

Community health workers

Sustainable development goals

National Rural Health Mission

Accredited social health activists

Digital infrastructure knowledge sharing

Ministry of Human Resource Development

Coronavirus Disease 2019

National Health System Resource Centre

World Health Organization

High-Income Countries

LMICs: Low- and Middle-Income Countries

Extension for Community Healthcare Outcomes

In-depth interviews

Key informant interviews

Continuing medical education

Institutional Ethics Committee

Participant Information Sheet

Jodhpur School of Public Health

Public Health Foundation of India

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Acknowledgements

The authors wish to thank all the healthcare workers who kindly participated in this study giving their time, experience, and insights. We also thank Dr. Sourabh Chakraborty (Professor, JSPH), Mr. Swapnil Gupta, and the JSPH data collection team for their contribution to the collection of good quality data in a short time.

The study was funded by Extension for Community Healthcare Outcomes (ECHO) India.

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Extension for Community Healthcare Outcomes (ECHO) India, Okhla Phase III, New Delhi, India

Supriya Lahoti, Nivedita Mishra, Apoorva Karan Rai & Kumud Rai

HexaHealth, Gurugram, Haryana, India

Rajath R. Prabhu

Hamad Medical Corporation, Doha, Qatar

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Contributions

R.M. contributed to the conception and design of the study and significant inputs for data analysis and made a significant contribution to the drafting of the discussion and conclusion of the paper. S.L. wrote the first draft of the manuscript. N.M. and S.L. contributed to the implementation of the study and development of interview guides, analysis, and validation of qualitative data. R.P. and K.S. contributed to the analysis and validation of quantitative data. R.M., N.M., R.P., K.S, A.K.R. and K.R. reviewed the manuscript and gave significant inputs for improving the paper. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Supriya Lahoti .

Ethics declarations

Ethics approval and consent to participate.

Ethical clearance was received from the Institutional Ethical Committee (IEC) of the Public Health Foundation of India (PHFI) (ref: TRC-IEC 472/21, dated 26 August 2021). The study has also been registered at the Clinical Trials Registry, India (CTRI/2021/10/037189). All methods were performed in accordance with the relevant guidelines and regulations. A written Participant Information Sheet (PIS) and informed consent form was provided to the participants before conducting the interviews. Verbal informed consent was taken from all participants, and the process of verbal informed consent was approved by the ethics committee (Institutional Ethics Committee (IEC) of the PHFI). Data confidentiality was maintained by coding with the unique identification (ID) of all the participants. The interviews were audio-recorded, and audio files and transcripts were kept in a password-protected folder.

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Not applicable.

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The authors declare that they have no competing interests.

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Supplementary Information

Additional file 1.

: Appendix S1. Table S1.1. Satisfaction with different factors of the training. Table S1.2. Satisfaction with content and environment of the training. Table S1.3. Challenges faced with respect to ECHO tele-mentoring model. Table S2. Technical knowledge and skills. Table S3. Statements assessing competence. Table S4. Statements assessing attitude and performance.

Additional file 2

: Appendix S2. Participants in qualitative interviews.

Additional file 3

: Appendix S3. Key informant Interview Guide for Trainers End line Evaluation.

Additional file 4

: Appendix S4. Key informant interview guide for Hub leaders End line Evaluation.

Additional file 5

: Appendix S5. In-depth Interview Guide for ASHAs End line Evaluation.

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Panda, R., Lahoti, S., Mishra, N. et al. A mixed methods evaluation of the impact of ECHO ® telementoring model for capacity building of community health workers in India. Hum Resour Health 22 , 26 (2024). https://doi.org/10.1186/s12960-024-00907-y

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Received : 14 March 2023

Accepted : 10 April 2024

Published : 23 April 2024

DOI : https://doi.org/10.1186/s12960-024-00907-y

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John Goldsmith on scientific misconduct and the Lilienfeld study (An oldie but still relevant today)

Background to the Lilienfeld study and the “Moscow signal”:

In the early 1960s it was discovered that from 1953 the Soviets had been beaming highly focused microwaves directly into the US Embassy in Moscow at an estimated power density that ranged from .005 mW/cm2 to .018 mW/cm2.112 Averaged measurements determined that although the intensity reaching the Embassy was approximately 500 times less than the US standard for occupational exposure, it was twice the highest limit allowed in the Soviet standard.This created a quandary for the US, for if they truly believed their thermally-based 10 mW/cm2 standard was safe they could hardly conclude that the level of microwaves at their Embassy was undermining the health of the Embassy staff. Concerns were raised about the purpose of irradiation of the Embassy. Was it eavesdropping or a more sinister attack on the health of the employees? An initial study was done on the Moscow personnel in 1967 that examined a group of 43 workers, (37 exposed and 7 not exposed). They were tested for abnormalities in chromosomes and 20 out of the 37 were above the normal range among the exposed, compared to 2/7 among the non-exposed. In the final report the scientists urged a repeat and follow-up study which was clinically indicated for 18 persons, but was not undertaken by the end of the contract period, June 30, 1969. The evidence of chromosome changes was strong enough to have triggered clinical guidelines that would have recommended ceasing reproductive activity until the condition had improved. At a Superpower summit in June 1967 the irradiation of the Moscow Embassy was the subject of a confidential exchange between US President Lyndon Johnson and Soviet Prime Minister Alexi Kosygin. Johnson asked that the Soviet Union stop irradiating its Moscow Embassy with microwaves and harming the health of American citizens. In 1966 a covert study, called Project Pandora, was commenced to study the possible effects on health from the microwave irradiation of the Moscow Embassy staff, who were not told the true reason for the investigation. In a related study, Project Bizarre, a primate was exposed to microwaves at half that permitted by the US standard. The findings of this study concluded, “[t]here is no question that penetration of the central nervous system has been achieved, either directly or indirectly into that portion of the brain concerned with the changes in work functions”�.

A haematologic study by J & S Tonascia in 1976 found highly significant differences between Moscow Embassy employees and other foreign service staff (control group). White blood cell counts were much higher in the Moscow staff as well as several other significant changes noted over time. These results were never published, but obtained under the Freedom of Information Act. At this time there was a US Congressional radiation inquiry underway and the Department of Defense (DoD) was arguing that the US RF/MW Standard was already strict enough. They argued that there was no scientific evidence for the Soviet Standard being set at a level one thousand times lower than the US standard. The Moscow Embassy employees and dependants were studied for possible health effects of microwave irradiation by a team from John Hopkins University, under the direction of epidemiologist Professor Abraham Lilienfeld. Dr Lilienfeld noted that the study group was quite small and that the follow-up time too short to generally identify significant health effects such as cancer. He recommended that continued health status surveillance should be carried out, but this was not done. The incidence of sickness and death were compared with employees & dependents in other Eastern European embassies, and with the average US rates. The incidence of multiple-site cancers was far more frequent in the Moscow Embassy group than in any other population studied. It was noted that while multiple-site cancers are characteristic of older populations, the Moscow Embassy group was relatively young. According to Goldsmith, concerns of the John Hopkins team were “downgraded”� by the state department and the wording of the team report altered to lessen its impact. Lilienfeld strongly recommended that additional follow up studies be undertaken since the latency periods for some types of cancer had been insufficient for cancer to occur, if indeed it were to result from microwave exposure. Nevertheless, according to Goldsmith, the overall findings were consistent with excess cancer incidence both in the Moscow Embassy cohort and in the other Eastern European embassy personnel.Data on exposure and occurrence of some cases of cancer were withheld from Professor Lilienfeld until after his report was completed and it was too late to include in the results. Reviews of the work done by contract investigators were interpreted as inconclusive because the State Department had failed to complete the necessary follow-up work which was recommended by the Lilienfeld team.

From The Procrustean Approach , pp. 105 – 107

*******************************************************

From Iris Atzmon, June 1, 2012:

Where the trail leads… Ethical problems arising when the trail of professional work lead to evidence of cover-up of serious risk and mis-representation of scientific judgement concerning human exposures to radar

– Prof. John R. Goldsmith, M.D., M.P.H.

Epidemiology and Health Services Evaluation Unit, Faculty of Health Sciences, Ben Gurion University of the Negev, P.O.B. 653, 84105 Beer-Sheva, Israel Eubios Journal of Asian and International Bioethics 5 (1995), 92-4. Introduction

Professional interaction over fifteen years between myself, an epidemiologist, and a lawyer started in 1974, when we were both in Washington, evaluating environmental health problems. The lawyer, recently disappointed with the outcome of a case which hinged on the testimony of an epidemiologist, began a dialogue about the criteria for use of probabilities in the scientific and judicial system. We agreed on the importance of making clear these differences, and he documented them in an article.

These differences can be misused in both legal and scientific procedures, under circumstances in which the failure to demonstrate conventional statistical significance (scientifically) is erroneously interpreted as meaning that preventing exposure would not be a reasonable public health measure.

When the lawyer started his private practice he sought expert epidemiological advice in the case of foreign service workers with cancer who had been exposed to microwave radiation in the US Embassy in Moscow.

The trail then led to a major investigation of health risks of Embassy staff by a leading U.S. epidemiologist. The report of this study was said to be negative but actually had some disturbing findings. The trail took a sharp turn when the lawyer provided me copies of documents, obtained under the Freedom of Information Act, which indicated persistent cover-up and deliberate distortions of views of highly regarded scientists with respect to risks from these exposures. A published report on personnel risks from radar exposure in the U.S. Navy diluted the experience of increased leukemia in an exposed group with the low rates in a less exposed group, bringing down likelihood of a significant result and concluding that no effect occurred.

The ethical issues concern whether a scientist who inadvertently finds this evidence should disclose it, in light of security considerations among other matters. The trail, in this presentation, ends with an application of the legal use of probability in interpreting epidemiological evidence on the central scientific issue, the possible health risks from microwave radiation.

For the full paper: http://www.eubios.info/EJ54/EJ54H.htm

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