iDEA: Interactive Distance Education Application

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Providing health workers with mobile-based video instruction and reference materials

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CONTACT

Kemi Oluwagbohun
Service Delivery Consultant
Johns Hopkins Center for Communication Programs
Email

CASE STUDY SOURCE

UPDATE: March, 2021

mHealth Compendium, Volume 5
Published by:
Management Sciences for Health
Originally published:
June, 2015

PROJECT STATUS

Active


The information below appeared in the original case study.

IMPLEMENTATION PARTNERS

Johns Hopkins Bloomberg School of Public Health Center for Communication Programs
Digital Campus

FUNDER

Bill and Melinda Gates Foundation

CONTACT (as Listed in Original Case Study)

Mike Bailey
Systems Development Manager
Johns Hopkins Center for Communication Programs

GEOGRAPHIC SCOPE

Nigeria

Target Users

Health Care Provider, Health System Manager

Enabling Environment Building Blocks

Services and Applications

Family Planning Program Classification

Service Delivery

This case study was originally published in the mHealth Compendium Volume 5, developed by the African Strategies for Health project, implemented by Management Sciences for Health with support from the U.S. Agency for International Development (USAID). Updates to the original case study, submitted by the implementing organization in March 2021, appear in the final section of this case study.

Introduction

Nigeria has one of the highest population growth rates in the world. The United Nations projects that the current population estimates of roughly 160 million will increase to almost one billion by the end of the century. Despite the pressing need, Nigeria has had a stagnant contraceptive prevalence rate (percent of currently married women who use contraceptives) of only around 15 percent and a fertility rate of 5.5 births per woman for nearly 10 years.1 The Nigerian Urban Reproductive Health Initiative (NURHI) managed by the Johns Hopkins Bloomberg School of Public Health Center for Communication Programs (CCP) discovered that the service providers in the cities of Abuja, Ibadan, Ilorin, and Kaduna were restricting the use of many family planning methods based on internal biases and reasons that included the client’s age, parity (number of births), their marital status, and whether their spouse had granted consent.

About iDEA

NURHI staff found that provider bias is difficult to change, and often remains even after refresher training. Due to the midwives’ work schedule, the desire to use videos as the medium for information sharing, and the need to track progress, a mobile-based solution was proposed. As a result, NURHI launched the Interactive Distance Education Application (iDEA) system for midwives in order to provide a platform for providers to access relevant educational content and resources from Android-based smartphones or tablets.

iDEA is adapted from the Digital Campus open source application OppiaMobile. Educational content is integrated into the application to reinforce skills after training to increase a provider’s ability and willingness to deliver family planning methods that are appropriate and based on clients’ desires and medical eligibility. NURHI, in conjunction with a local production company, developed instructional videos with an entertainment-education approach. Each video scenario features examples to help providers recognize their biases and then address them by suggesting alternative approaches towards counseling. Each scenario has a pretest and a posttest to gauge learning.

iDEA is integrated with Moodle, a popular open-source learning management system, which provides users with the ability to create educational modules complete with videos, images, text, or audio in minutes. OppiaMobile automatically converts the modules for use with Android, which users can install from Google Play. With a one-time connection to the Internet, users can download the app, install the educational content, and register, and then can run the application and content offline. (See image in Evaluation and Results.)

Evaluation and Results

In Nigeria, pretests determined midwives’ knowledge of counseling techniques prior to exposure to educational content. The average pretest score was 70 percent while the ensuing post-test showed an average improvement of about 5 percent. One likely explanation for the relatively minor improvement in scores was that the midwives already knew the material; what they did not recognize, until a video role play was provided, was their own tendency to display a negative bias towards their clients. Qualitative interviews demonstrated that the midwives recognized themselves in the “bad” example of client counseling and they then felt uncomfortable with their own behavior. Focus group discussions were held; some midwives expressed guilt at having prevented clients from making their own decisions.

The self-assessments were typical in that the videos reflected and helped them recognize some of their biases. This was confirmed during the pilot test and during follow-up focus group discussions several months after initial deployment.

Usage statistics are routinely collected by the application and are uploaded to the administration server whenever there is a connection. The graph below reflects the typical usage rates where, for example, over the course of one week, 59 different users accessed 242 pages in the family planning module, attempted 129 quizzes, and viewed 587 media sources. (See Figure 1 above.)

An evaluation is planned for early 2015 using a two-arm quasi-experimental design with client exit interviews to compare providers with and without phones. Interviews will be conducted with providers to document perceptions about iDEA and assess diffusion. The provider interviews will help supply an explanation of the findings of the client exit interviews.

Lessons Learned

  • Convenience: As an offline application, connectivity costs are minimal so there is no requirement to enter into negotiations with mobile network operators.
  • Sustainability: By registering the application through Google Play, the odds for project sustainability are great- ly enhanced because midwives are able to update the application themselves. However, connectivity in remote areas is still so problematic that this registration process is not always achievable.
  • Dissemination of messaging: It is important to assume that the smartphone itself will be shared, and in some cases personal media will be loaded onto the phones. There are a variety of measures that can be employed to reduce file tampering, such as password protection, which should be explored.

Conclusion

The public health community is in the midst of exploring whether wide-scale deployment of mobile technology will improve frontline health worker and health system performance. There are several parts to this question, including: (1) technical feasibility; (2) usability; (3) acceptability among users; (4) improvement in health outcomes; and (5) sustainability. The deployment of iDEA has satisfactorily addressed the first three issues, while a planned evaluation in 2015 will begin to address the fourth. The design of the program will, with time, prove to be sustainable given the low cost and accessibility of the open source components of the application and learning management system that form the core of the technology. With a planned integration of the mPowering Initiative’s media sharing platform, these components could provide a complete architectural design of an end-to-end educational media distribution system that any national or regional initiative could adopt in the future. Further plans for an open collaboration in the refinement of the tools and the overall distribution system will further enhance functionality and reduce the cost of future deployments.

PROJECT UPDATES

Phase 1 and phase 2 of the NURHI project, implemented from 2010 to 2020 in three Nigerian states (Kaduna, Lagos, and Oyo) were closed out in December 2020, but a sustainability platform continues through The Challenge Initiative (TCI), which is replicating NURHI’s proven-to-work models in 13 Nigerian states (Niger, Ogun, Rivers, Gombe, Nasarawa, Kano, Bauchi, Anambra, Delta, Taraba, Plateau, Abia, and Lagos).

The scope of the digital health intervention remains the same: to provide FP service providers an opportunity for self-learning and self-evaluation, by emphasizing the key FP knowledge and skills learned during their traditional training and supportive supervision. It also allows FP service providers to self-assess and make the necessary corrections based on appropriate lessons designed to address common challenges encountered in FP service delivery.

The geographic coverage has increased and further expanded through TCI.

The functionality has also been improved to ensure increased speed and user-friendliness. For example, the revised app has an improved user interface, an added chat system, and improved authentication, especially for user registration, password recovery, and login.

The old app, which launched in October 2013, had a section on job aids that was removed from the revised app as recommended by end users, FP service providers.

The revised app was developed from scratch as a standalone app that no longer leverages Oppiamobile and contains the following new components:

  • An additional 18 videos (six demonstrative videos and 12 counseling videos) were added to the initial collection of videos. The themes for the counseling videos are: Balanced Counseling Strategy, Management of Bleeding as a Side Effect, Unmarried Youth as a Client, Integration and Referral for FP, Post Pregnancy Family Planning (PPFP), Contraceptive Logistics Management System (CLMS), and Client’s Confidentiality and Support. The demonstrative videos address adherence to clinical protocols, infection prevention practices, and routine clinic procedures.
  • An interactive chat room, which is a community of practice for FP service providers designed to encourage experience sharing and communication among providers.
  • An FP digest, which serves as a hub for family planning–related publications, newsletters, contraceptive updates, and current trends in family planning programming.
  • A quiz section, deployed in modular format, containing story-like questions with true or false responses.
  • A calendar section, which provides a personal diary for user to schedule events, meetings, and so forth. The calendar also has prompts for important events related to family planning, maternal and child health, and reproductive health.

Lessons Learned

  •  Employing a human-centered design (HCD) training approach to review and update the app provided providers the opportunity to reflect and understand the effect of their own/providers’ biases from the clients’ perspective. All feedback was incorporated into the development of revised counselling videos.
  • NURHI 2 used an interactive teaching approach, relying on the use of examples within the local context, using drawings and illustrations on flip charts, holding multiple group discussions (encouraging constant changes in the composition of groups to enhance interaction among participants), and engaging in role play. These activities helped increase participant understanding of the HCD approach.
  • As of February 2021, there were over 1,000 end users in Nigeria.

References/Resources

Original Case Study

1. Demographic Health Survey Nigeria. 2003 and 2013.

Project Updates

NURHI, My Family Planning Guide: A Post-Training Tool for Family Planning Service Providers, https://nurhi.org/en/wp-content/uploads/2021/03/My-Family-Planning-Guide-Final_For-NURHI-2-Website.pdf.