HealthLearn’s First Pilot: Promising Results

Summary

With the support of Nigeria’s Federal Ministry of Health, HealthLearn worked with local nonprofits to pilot a course for health workers based in primary health centers (PHCs). 342 participants learned essential practices in newborn care, with a focus on the first day after birth. Over the six-week pilot:

• 87% of health workers who were asked to take the course completed it,

• >98% of participants agreed that they enjoyed the course,

• >99% of participants agreed that the course was relevant to their work,

• course completers had large and statistically significant gains in their knowledge of newborn care, and

• participants reported improvements in adherence to evidence-based birth care practices.

Our experience in the pilot suggests we have the capacity to offer this training for free to every PHC-based health worker who attends births in Nigeria.

A health worker in Gombe state tries out the course. Image credit: The Taimaka Project.

Background on the pilot

There is strong evidence that in-person health worker training prevents newborn deaths, but it can be difficult to scale up while maintaining quality and controlling costs. HealthLearn has created an approach for simple, case-based, smartphone-optimized training that has high levels of health worker engagement and learning. We hypothesize that this can improve adherence to guidelines- and evidence-based best practices, thereby saving lives. We are starting our work in Nigeria because we have a track record in the country and there are high rates of newborn mortality. This small-scale pilot assessed the feasibility of providing a course on newborn care for PHC-based health workers in Nigeria.

Implementing partners worked closely with state and local governments and health facility leadership to:

• secure approval for the pilot,

• identify health workers who attend births and have WhatsApp to participate in the pilot,

• promote the course to health workers, and

• provide mobile data bundles to participants (who used their own phones to take the course).

Implementing partners led and managed all communications with health workers and local governments, with HealthLearn only playing a consultative role.

HealthLearn developed the course, basing it off of Nigeria’s national guidelines. Experts appointed by the Newborn Care Unit of Nigeria’s Federal Ministry of Health (FMOH) reviewed the course and validated its contents. HealthLearn hosted the course on its custom learning platform and provided grant support and technical support to the implementing partners. 

The objectives of the pilot were to:

• assess uptake of the course (the percentage of health workers asked to take the course who did complete it),

• measure knowledge gains within the course using a matched pre- and post-test,

• collect feedback from health worker participants,

• identify areas for improvement, to enhance both the technology and the training itself, and

• assess feasibility of scaling up the project to entire states or regions.

For more information, check out our previous posts on the pilot and the evidence base behind HealthLearn’s intervention.

Pilot outcomes

Participant information
373 participants completed a pre-course survey with basic demographic questions. Among these respondents:

• 97% accessed the course on a smartphone,

• 94% had completed clinical training, with an almost equal split between nurse/midwives (47%) and community health extension workers / officers (47%),

• 69% said they were asked to take the course by a supervisor,

• 97% reported some maternal and child health-related clinical responsibilities, and

• More than two-thirds of participants had not trained in newborn care for more than 12 months (or ever).

Clinical responsibilities reported by participants.

Time since last training reported by participants.

The training reached staff who provide birth care in PHCs (nurse/midwives and community health workers). We were also able to engage many supervisors in the training, which may help to ensure the learning is put into practice.

Course uptake and completion
In each of three subnational regions, ~100 health workers who work in PHCs and attend births were asked to take the course. Of this target group (299 individuals in total), 261 completed the course, an uptake of 87%. Partners encouraged health workers to take the course but they did not require participation. An additional 81 people who were not in the target group chose to take the course. 
  
The high percentage uptake of the course among health workers suggests that this course is accessible to a majority of PHC workers who attend births in Nigeria. This seems to be the case even though the course was only available in English and required a (low bandwidth) internet connection. We were able to invest more effort per learner during the pilot phase than will be possible at scale, so we suspect that 87% uptake approximates a “ceiling” that we can benchmark against in the future.

Learning gains
The course included a pre-test and matched post-test assessing participants’ knowledge of Nigeria’s guidelines on newborn care. Among course completers, the average pre-test score was 64.8%; this increased to 82.4% on the post-test, a substantial and statistically significant improvement. Scores improved in the groups of learners from each subnational region and also among the 81 learners who were not asked to take the course.

Relatively low pre-test scores and robust learning gains suggest that many health workers in Nigeria could benefit from this type of refresher training in newborn care.

Box-and-whisker plot of pre-/post-test scores among health workers who completed the Newborn Care course.

Course feedback
Participants were overwhelmingly positive about the course. In responses to a post-course survey, over 98% agreed that they enjoyed the course, and over 99% agreed that the course was relevant to their work. The net promoter score of the course was +85, which is in the “world-class” category.

This positive feedback indicates that this course was enjoyable for most participants, pointing to a pathway to scale up the course in Nigeria.

Indications of improved clinical practice
We also asked participants about their intention to implement three different evidence-based best practices in newborn care (delayed cord clamping, keeping the newborn in skin-to-skin contact with the mother for the first hour after birth, and gently coaching the mother to initiate breastfeeding early). Over 99% of participants agreed that they intended to implement these practices. In post-course discussions among participants, run over WhatsApp by partner organizations, many health workers said they were implementing these practices as a result of the course. Some of the implementing partners are also interviewing participants to hear how the course has affected their work.

These testimonials and survey results suggest that the course may help health workers improve their use of evidence-backed birth care practices. This behavior change is necessary for us to achieve our mission of helping health workers save lives by providing high-quality care.

A participant reflects on the course. Video credit: Thriving Up Initiative.

Areas for improvement

Participant feedback and support requests helped us to identify three areas for improvement:

1. Navigation: We encountered some cases in which learners were confused about where to go next in the course. We can lessen these challenges by improving the interface, making navigation as consistent as possible, and testing out the improved interface before we scale up.

2. Connectivity challenges: In rare cases, spotty internet access caused a learner to get “stuck” until our technical support intervened. We are working to improve the speed and performance of the platform to eliminate these situations.

3. Backwards compatibility: The platform that we used in the pilot did not work quite right on devices that run old browsers. We adapted by providing learners with simple instructions on how to update their browsers. In the future, we aim to have a platform that is compatible with all but the oldest browsers.

We were able to support learners through these challenges. However, we’re committed to making our training as broadly accessible as possible and we’re actively working on new technical solutions.

Future directions

This feasibility pilot was not designed as a systematic investigation, so we cannot draw conclusions about the impact of the training on clinical practice or public health outcomes. We hope to address those uncertainties in our future work, but our top priority at the moment is to discuss the pilot with government stakeholders in Nigeria and collaborate with them to plan the next steps we will take.  

Acknowledgements

This pilot would not have been possible without the leadership and support of:

• The Family Health Department at FMOH and its director, Dr. Stella Nwosu,

• The Newborn Care Unit at FMOH and its head, Dr. Abdullahi Jatau,

• The National Emergency Maternal and Child Health Intervention Center at NPHCDA and its head, Dr. Laila Umar,

• Our implementing partners: The Taimaka Project, Thriving Up Initiative, and iDevPro, as well as the subnational governments involved in the pilot,

• The Global Health Media Project, who created the videos used in the course and gave us permission to use them,

• Our advisors, especially Dr. Obinna Orjingene, who served as editor-in-chief for all of the course content,

• Colleagues at Resolve to Save Lives, who played a catalytic role in developing this approach to training and have been supportive of our work from the start,

• Our volunteer software engineers, who built a new WhatsApp-based login to make the course more accessible to health workers, and

• All of the health workers who participated in the course.

This post was updated on October 31, 2023 and November 14, 2023.

Questions, feedback? E-mail us at contact@healthlearn.org