mPossible! Health Workers Can Get Training Anytime, Anywhere with Interactive Voice Response

This post originally appeared on the K4Health blog.

Advances in mobile health—or mHealth—have expanded the realm of possibility for remote education, diagnostic and treatment support, communication and training, disease tracking, monitoring, and data collection. Every day, mHealth grows to include more sophisticated applications for high-tech smartphones and tablets. But what about health workers—specifically those in rural areas who don’t have access to the latest technology?

To learn more about mLearning (or mobile learning) for health workers, IntraHealth International, through the CapacityPlus project, piloted an innovative program to provide refresher training to family planning service providers in Senegal using interactive voice response (IVR) technologies on basic mobile phones.

© 2013 Chelsea Hedquist, Courtesy of PhotoshareI’ve been very excited to follow this unique initiative. Because while many in global health want to capitalize on the newest apps or fast and fancy ways to use tablets, not everyone has access to these resources.

Health workers who provide family planning and other services need in-service training to learn new skills and best practices in counseling and service provision. They also need ongoing refresher training to retain skills they already have. IntraHealth’s IVR mLearning platform is designed to provide distance training to health workers using a simple cell phone with text and talk capabilities. The IVR mLearning platform delivers more content than a standard text message but does not require an expensive smartphone or tablet.

How IntraHealth’s IVR mLearning platform works

CapacityPlus developed the IVR platform using Moodle and FreeSwitch open-source software. The first content was a refresher course on managing contraceptive side effects, rumors, and misconceptions for 20 nurses and midwives in two districts in Senegal. The course delivered 20 audio questions with accompanying explanations using the spaced education methodology, a question-and-answer learning approach that has been scientifically proven to help students retain information.

Participants indicated via text messages when they were ready for the course. They then received a phone call, listened to audio recordings of the questions, typed a number corresponding with their answers, and received feedback on their responses right away. Once they correctly answered all the questions twice, participants completed the course. The course ran for nine weeks, and all content was delivered in French.

An enthusiastic reception

“This approach quickly helped make a difference,” said Youssou Diop, ISSU project coordinator in the Dakar region. “Not only did health providers have the opportunity to strengthen their skills, they were able to do so while remaining available at their facility. Although this approach is particularly useful in rural settings, it would be good to roll it out in urban areas as well.”

The system made 619 IVR calls, 80 percent of which delivered family planning course content. The average IVR call was just under 13 minutes. And most calls took place outside of normal working hours, which indicates that this method of delivering refresher training poses few disruptions to service delivery.

“The approach was also cost-effective, since we did not have to leave our health facility in order to attend the training,” noted Bounama Thiam, head nurse at Ngaye Diagne Health Post in Mékhé District, Thiès Region. “In the past, we sometimes had to leave our health facility during two or three days in order to be trained, and it would prevent us from adequately meeting the needs of our patients.”

An evaluation of the course found that 100 percent of the participants had a “very good” or “good” experience using a mobile phone to complete a training course, and 90 percent said following instructions for refresher training on the mobile phone was “very easy” or “easy.” Poor cellular reception was cited as the biggest challenge.

CapacityPlus hosted two events to share the results of the pilot and the evaluation, one at the regional level and another at the national level, with stakeholders from the Ministry of Health, mHealth and telecommunications implementers, some course participants, and Senegalese government and global health representatives.

“We were worried that the training would prevent us from carrying out our regular duties at the facility level, but our concerns were short-lived,” said Dr. Pape Ibrahima Camara, district medical officer in Tivaouane District, Thiès Region, at the national dissemination event in Dakar in March 2014.

“This training was timely and helped us solve recurring problems in the area of family planning, especially in the management of myths and rumors. This program should be scaled up in order to reach more health workers. We must uphold the right of clients to be informed. After the training, we noticed an uptick in the enrollment of new patients. We were lacking some sort of capacity which prevented us from fully meeting the needs of our clients. The training helped us better address these issues.” — Dr. Camara

Dr. Camara felt the course content should be expanded. “The course only focused on one aspect of family planning: the management of rumors and undesirable side effects,” he said. “Nine weeks might be too much time to only focus on this one particular area. Sharing knowledge through this approach is pretty innovative.”

Knowledge gains inspire vision for scale-up

© 2013 Mike Bailey/JHUCCP, Courtesy of PhotoshareCapacityPlus was eager to learn not only how effective the course delivery was, but also how well the participants retained their new knowledge. The project found that participants’ knowledge gains were modest but significant and sustained. Participants scored an average of 12.6 out of 20 points on a pre-test related to knowledge of contraceptive side effects and misconceptions, and the average score improved to 16 out of 20 after the course. Ten months after the IVR refresher training and in the absence of any additional reinforcement, the average score was 14.8 out of 20 points.

Innovative mHealth and mLearning approaches such as the IVR technology will help ensure more of Senegal’s health workers get the training and information they need. “We are about to reach a critical milestone in the development of eHealth and mHealth in Senegal,” stated Professor Mbayang Ndiaye Niang, technical advisor for eHealth in Senegal’s Ministry of Health. “We feel that the timing is right and that something is happening. The conditions in Senegal are perfect for this type of innovative approach, given the extended cell phone coverage across the country.”

Reflecting on the IVR experience, Gorgui Diallo, senior program officer at AFRICARE Senegal, remarked, “From a technological standpoint, this experience will be easy to scale up. The resources are concentrated on a server, and there is no need to develop an additional platform. This initiative is needed as part of the broader evolution of eHealth and mHealth in Senegal.”

Stay tuned:
Kate E. Gilroy, Abdoulaye Diedhiou, Carie Muntifering Cox, Luke Duncan, Djim Koumtingue, Sara Pacqué-Margolis, Alfredo Fort, Dykki Settle, and Rebecca Bailey. Use of an Interactive Voice Response system to deliver refresher training in Senegal: Findings from pilot implementation and assessment. CapacityPlus, Washington, DC. Forthcoming.

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Photo 1 © 2013 Chelsea Hedquist, Courtesy of Photoshare. A community nutrition educator in Barwani, India, enters data on her mobile phone during a home visit in one of the villages she serves. Photo 2 © 2013 Mike Bailey/JHUCCP, Courtesy of Photoshare. A midwife uses a smartphone for training in Kaduna, Nigeria.