This case study was originally published by the Ministry of Health, Ethiopia in the Special Bulletin for the 23rd Annual Review Meeting of the Health Sector. Written by Melaku Yilma, Wondesen Nigatu, and Israel Ataro of the Directorate of Health Extension Program and Primary Health Care, Ministry of Health and Abraham Zerihun of Last Mile Health.
The Health Extension Program (HEP) was designed as a community health program delivered by a team of two Health Extension Workers (HEWs) to serve in community health posts with a catchment area population of 5,000 people. The goal of the program is to increase geographic access to primary health care services and address the high burden of preventable diseases. HEWs provide preventive, promotive, and curative health services at their health post, house to house, and outreach (1).
To improve the knowledge, skills, and attitude of HEWs, 15-30 days of in-service Integrated Refresher Training (IRT) is provided to HEWs once every two years at the district level for each of the following six modules: 1) reproductive, maternal, newborn, and child health; 2) hygiene and sanitation; 3) non- communicable diseases; 4) communicable diseases; 5) social behavior change communication; and 6) first aid/emergency (2).
The reproductive, maternal, newborn, and child health (RMNCH) in-service training module is one of the IRT modules which has a seven-day schedule. The Ethiopia Ministry of Health (MoH) and partners have prioritized updating this module. However, the current IRT, which is dependent on only face- to-face sessions, faces many challenges including length of time required to complete the training, cost of the training, limited innovative tools for learning, dependency on only face-to-face training, a limited competency framework, and ineffective measurement and evaluation processes (3).
The MoH has partnered with Last Mile Health, an organization that has worked for 15 years to build exemplary community health systems in partnership with governments, to overcome these challenges by developing a blended learning design for the RMNCH module of the in-service training for HEWs.
The report aims to show the experience of developing blended with a combination of face-to-face and digital sessions, high-quality, learning content for the RMNCH module of the in-service training for HEWs accessible on mobile devices anywhere, anytime.
The development of the RMNCH blended learning content included three components:
- Instructional Design: The competencies of the RMNCH module were mapped against the HEWs scope of practice and occupational standards. Based on that, a blended-model instructional design plan was developed. Accordingly, content for face-to-face training and content for digital self-learning were identified. The instructional design was reviewed and endorsed through an instructional design workshop involving participants from the MoH, Regional Health Bureaus, District and Zonal Health Offices, Partners, and HEWs.
- Multimedia: Locally relevant and culturally appropriate multimedia content was developed in three local languages, including illustrations, animated videos, and animated character stories.
- Digital platform: The training app called Extension Essentials was developed using OppiaMobile, an open-source learning app for health workers, to deliver content on mobile devices. The app has been tested and found to be interoperable with the national electronic community health information system (e-CHIS).
User testing of the app was conducted to ensure the design was user-centered using the following method:
- Five users were selected from three regions with purposive sampling and matched HEW representativeness by age, experience, and sex.
- Using the cumulative binomial probability formula claim that a sample size of five users is sufficient to detect 85% of problems in an interface. The given probability a user would encounter a problem is 31% (as determined by an average problem frequency from several studies).
- The participants were selected based on their familiarity with technology, using eCHIS to get better feedback on the application.
- Data collection tools used were screen recording, question and answer, observation checklist, dashboard monitoring, and focused group discussion.
- User testing was conducted on June 29 and 30, 2021 at Adama, Oromia region.
- User testing was facilitated by female staff to integrate gender consideration and create a friendly environment where participants can speak up.
A blended learning training was designed, which includes an initial 2-days of training in person, followed by 5 days for digital self-learning, and concludes with a 2-day closing in-person session. The Extension Essentials app contains all training content and a daily schedule for digital and facilitated learning.
Once downloaded onto the user’s device, all the contents and activities of the module can be accessed offline by the learner anytime, anywhere. The approach integrates effective learning activities such as role-plays, case studies, group discussions, case-based pre-and -post-knowledge questions, pre-and post-self-efficacy questions, quizzes, and skills assessments. Multimedia resources including illustrations, animated videos, and character stories were effectively integrated with the blended design. The learning methods used in the approach are interactive and engaging to keep the learner focused and interested in the content.
By understanding user experiences and preferences, we were able to amend the training content, format, and resources to better meet learner expectations and needs.
The user testing showed that HEWs were very receptive to the blended design, and they provided vital feedback on the functionality of the app, as well as content and multimedia resources, which were used to further enhance the design. Quizzes and multimedia resources were chosen by HEWs as the best features of the training.
One user said that “The videos and quizzes are good in adding the practical knowledge. As a refresher course, knowing the basics knowledge in our previous training, I say the contents are good.” They were determined to be effective for retraining, interactive, easy to understand as they use local languages, related to real-life community challenges, and easy to navigate as mentioned by one user who said “The application orientation has made us to be familiar with the app and know how to use it. I say I am confident to complete the training at home using this knowledge.”
Conclusion and way forward
The blended learning design can address challenges related to long duration of training, limited interactive content and ineffective learner engagement by enhancing the training content through content review and competency mapping, development of multimedia-aided blended design, and integration with a digital platform that can deliver content on mobile devices. Moreover, the digital platform provides real-time data to evaluate the training, including participation and time spent in activities and course completion, learner’s reaction to the course, pre and post-training knowledge and self- efficacy assessments, quizzes, and engagement with digital components after the training. The RMNCH blended learning approach will be piloted in 20 districts between August 2021 and January 2022, and the lessons learned will inform the scale-up of this module and the future IRT modality nationwide.
- Ministry of Health of Ethiopia. A roadmap for optimizing the Health Extension Program of Ethiopia (2020-2035). 2020.
- Ministry of Health of Ethiopia. Reproductive, Maternal, Newborn, Child, Adolescent, Youth Health and Nutrition (RMNCAYH-N) Integrated Refresher Training Module. 2020.
- Teklu AM, Alemayehu YK, Medhin G. The National Assessment of The Ethiopian Health Extension Program Abridged Report Recommended Citation [Internet]. 2020. Available from: www. merqconsutlancy.org