Perspectives of Auxiliary Nurse Midwives [ANMs] on Using Digital learning in Bihar: A Qualitative Study

Introduction

Frontline health workers, including ANMs, form the backbone of India’s rural health system, delivering critical maternal and child healthcare services[1]. Despite their importance, access to high-quality, continuous training remains limited due to logistical barriers such as geographic isolation, staff shortages, and outdated curricula[2]. In this context, digital learning has emerged as a promising tool to enhance workforce competency and bridge training gaps[3] [4].

In Bihar—one of India’s most resource-constrained states—strengthening the capacity of ANMs is particularly important given the high burden of maternal and neonatal health challenges[5]. The e-Kshamata digital learning platform was introduced to support both pre-service and in-service ANMs through interactive modules, videos, quizzes, and structured mentorship. While quantitative components of the broader intervention demonstrated improvements in knowledge and skills, qualitative exploration is essential to understand how ANMs experience digital learning, perceive its usefulness, and navigate contextual barriers to engagement[6].

This paper presents the qualitative findings from the larger mixed-methods study “Empowering Auxiliary Nurse Midwives in Bihar Through Digital Learning”, focusing on the experiences, attitudes, and perceived barriers among ANMs using the e-Kshamata like platform[7].The aim of this qualitative study was to Evaluate the effectiveness of the digital learning app, e-Kshamata in empowering ANMs in Bihar, focusing on knowledge and skill enhancement among both pre-service and in-service ANMs. The primary research questions were: Does digital learning improves the competency of ANMs? And what challenges do ANMs face while accessing or using digital learning platform.

Methods

Findings

Discussion

This qualitative analysis highlights how digital learning fosters psychological empowerment, professional identity, and learning autonomy among ANMs in Bihar. The findings reinforce that knowledge acquisition through technology is not merely a cognitive process but also an affective experience that builds confidence and motivation.

The results echo prior research demonstrating that e-learning enhances self-efficacy, engagement, and satisfaction among nursing students and healthcare professionals[2][3]. Importantly, the integration of mentorship played a decisive role—ensuring that theoretical learning translated into tangible clinical competence. This supports global frameworks such as the WHO’s Digital Health for Education strategy, which advocates blended, mentorship-supported learning for sustainable workforce development .[11]

However, persistent infrastructural and socio-digital barriers must be addressed for scalability. Poor connectivity and low digital literacy are consistent with challenges noted across low and middle-income countries[12] [8]. Addressing these issues through offline-compatible platforms, localized language content, and trainer capacity-building will be essential to ensure equity and sustainability.

From a theoretical perspective, these findings can be understood through the lens of Self-Determination Theory[13], which emphasizes autonomy, competence, and relatedness as key drivers of intrinsic motivation. The digital platform satisfied these needs by allowing self-paced learning [autonomy], providing structured feedback [competence], and fostering peer-mentor interactions [relatedness]. Consequently, ANMs not only improved their knowledge but also developed a stronger sense of professional empowerment.

Limitations

This study has few limitations. The qualitative sample was limited to 15 participants from a single district, which may restrict generalizability. Translation of FGDs from Hindi to English may have resulted in subtle loss of meaning despite careful cross-checking. Social desirability bias may also have influenced participant responses during group discussions.

Conclusion

This qualitative study provides in-depth insights into how a blended digital learning intervention shaped the learning experiences, confidence, and professional self-perception of ANMs in Bihar. The findings reveal that digital learning, when combined with structured mentorship, can move beyond knowledge transmission to foster psychological empowerment, motivation, and greater autonomy in clinical practice. ANMs reported improved confidence in performing maternal and child health procedures, increased willingness to engage with technology, and appreciation for the flexibility and accessibility offered by the digital platform.

At the same time, the study highlights that the effectiveness of digital learning is strongly influenced by contextual factors. Persistent infrastructural challenges such as poor internet connectivity, limited access to personal devices, and varying levels of digital literacy constrained optimal engagement. Social context—including gendered domestic responsibilities—and workplace dynamics further shaped how ANMs accessed and benefited from the intervention. These findings underscore that digital learning initiatives for frontline health workers must be designed with sensitivity to social, gender, and institutional realities, rather than assuming uniform access or readiness.

Several areas remain unclear and warrant further investigation. The long-term retention of knowledge and skills gained through digital learning, its sustained impact on service delivery outcomes, and the scalability of such interventions across diverse districts and health system settings were beyond the scope of this study. Additionally, perspectives of supervisors, mentors, and health system administrators were not explored and may provide valuable insights into institutional facilitators and barriers to implementation.

Future research should adopt longitudinal designs to assess sustained learning outcomes and clinical practice changes over time. Mixed-methods studies incorporating supervisory and policy-level perspectives could help identify system-level enablers for successful integration of digital learning into routine ANM training. Investing in infrastructure, digital literacy support, and mentorship capacity will be essential to ensure that digital learning platforms contribute meaningfully to strengthening the frontline health workforce and improving maternal and child health outcomes in resource-constrained settings.

References

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