Caroline Francis conducted a systematic review of 37 studies from 2010-2015 examining the extent to which mobile learning (mLearning) can transform community health workforce development in Asia and Africa. The review found that while mLearning shows potential in increasing access to education and improving skills, more research is needed. Specifically, more evidence is required to demonstrate the impact of mLearning on productivity, performance, and health outcomes at scale. Additionally, challenges remain regarding human and financial resources as well as developing policies to support the integration of mLearning into national health systems.

1. October 7, 2015
mLearning for community health workforce development
Caroline Francis
EDDE 801, Athabasca University
in Asia and Africa

2. Caroline Francis
Cohort 8, EDDE 801
arises from my work with the non-formal health workforce in Asia – particularly lay
personnel such as community health workers and peer health educators. These
individuals typically lack access to ongoing learning and skills accreditation, yet it is they
who serve as the backbone of the health system in low resource countries across Asia
and Africa. How can we best support their work? Develop their competencies? Advance
their careers? Improve the lives of their compatriots?
This seminar presents a systematic review of 37 studies written between 2010-2015 that
examine the extent to which mLearning can be utilized to transform community health
workforce development in Asia and Africa. I look forward to our discussions on the
content.
My interest in mobile learning
Hi, everyone!
athabasca8@gmail.com; CFrancis@fhi360.org
www.carolineafrancis.com
@CFrancisHanoi – facebook.com/Caroline.Francis

3. Seminar agenda
Rationale for mLearning
Sustainable development, human resources for health (HRH), mobile technologies
mLearning theory, technology acceptance model, FRAME model
Transformative HRH Agenda
Reframing dimensions for examination of mLearning feasibility
Availability, accessibility, acceptability, quality
Systematic review of the literature
Is mLearning feasible for CHW workforce development?
Research implications and way forward discussion
Research questions, theoretical frameworks, methodology

4. 4EDDE 801, Seminar 6
Seminar development & presentation aims
Stephen Downes (2011) maintains that online educators construct, manage, and impart knowledge in a variety of ways. I assumed – and
will play - a number of roles over the course of the research paper/seminar preparation, although my ultimate goal is to learn from you in
our discussions today and tomorrow(s) . . .
Searching for mLearning
& mHealth resources that
focus on CHW workforce
development in Asia and
Africa
Collector
Acquiring, organizing,
reviewing and
synthesizing information
(research paper, resource
guide, seminar
presentation)
Curator
Through a combination
of formal presentation,
resource documentation
and interactive discussion
Sharer
Expanding my knowledge
base and thinking about
new questions through
cohort-based dialogue(s)
Learner

5. Rationale mLearning Section 1

6. 6EDDE 801, Seminar 6
Sustainable development goals
17 global goals and 169 targets for international development over the next 15 years
Sustainable development theory proposes that policies and practices must meet the needs of the current populace
without compromising the ability of future generations to meet their own needs (United Nations World Commission on
Environment and Development, 1987). Encapsulated within sustainable development theory are concepts of equity,
empowerment, and human wellbeing, which demand inclusive solutions to achieve long-standing change (Sustainable
Development Solutions Network, 2014).
Health in all policies approach emphasizes the importance of health as both a precondition for, and an outcome of,
policies that promote sustainable development (World Health Organization et al., 2013).
Countries around the world are increasingly emphasizing health investment as a prime driver of broader socioeconomic
development, prompting the articulation of ambitious national health targets that aspire towards a goal of universal
health coverage and the right to health (Braun, Catalini, Wimbush, & Israelski, 2013).

7. A universal truth
• Human resources are the most important of the health
system’s inputs (World Health Report, 2000).
• Correlation between human resources for health (HRH) and
population-level outcomes is well-established (Sousa et al.,
2013).
• 83 nations – most of them in Africa and Asia – fall below the
threshold of 22.8 skilled health professionals per 10,000
people. Access to basic health equipment, drugs chronically
lacking; shortage of instructors that can provide quality
training and continuing education (Campbell et al., 2013).
• Community health workers (CHWs) called upon to address
essential service delivery needs, including maternal and child
health, family planning, HIV/AIDS, malaria, and environment
health.
• Multi country study noted “an evolution over time, whereby
CHWs take on additional responsibilities and skills, which are
learned on-site” (Jaskiewiez & Tulenko, 2012, p.2).
“No health without a workforce”
Campbell et al. (2013). A Universal Truth: No Health Without a Workforce. Forum Report,
Third Global Forum on Human Resources for Health, Recife, Brazil. Geneva: Global Health
Workforce Alliance and World Health Organization

8. 8EDDE 801, Seminar 6
Mobile learning benefits
Ally (2014) documents the benefits of mobile learning for the informal or non-formal (health) workforce:
Just-in-time learning
Learning at the “moment of need”
Learning in context
The situation (e.g. “on the job”) in
which something is learned or
understood
Learning from anywhere
Learning in, at or to any place; move
towards more ubiquitous learning
Learner-centered focus
Shifting the focus of instruction
to the learner
Location-based learning
Exploiting knowledge about
where a learner is located for
greater personalization
Independent & connected learning
Enabling learner control and learner
interactions

9. Research questions, theory, methodology Section 2

10. 10EDDE 801, Seminar 6
Research questions
To what extent can mLearning be utilized in Asia and Africa to transform community health workforce development?
What are the critical community health workforce development needs in Asia and Africa?
What are the attributes of mLearning or mobile technologies that can be applied to meet community
health workforce development needs?
In what ways does mLearning currently meet community health workforce development needs?

11. 11EDDE 801, Seminar 6
Theoretical frameworks
Three theories or models can be applied to examine the feasibility of mLearning for CHW workforce development
Mobile learning theory
• Learner – rather than
technology – is mobile
• Learning is entwined with
other everyday activities
• Learning can generate as well
as satisfy goals
• Context is constructed by
learners
• Sharples, Taylor & Vavoula
(2005)
Technology Acceptance Model
• Describes how users are
motivated to use a technology
(e.g. usefulness, perceived ease
of use)
• Extension of theory of reasoned
action
• Davis & Bagozzi (1989)
FRAME model
• mLearning is a convergence of
personal, social and technology
domains
• Mobile device on equal footing to
learning and social processes
• Emphasizes constructivism and
builds on the work of Vygotsky
• Koole (2009)

12. 12EDDE 801, Seminar 6
Research methodology
Systematic review of 37 resources written between 2010 - 2015
Literature search
Google Scholar, PubMed,
grey literature
Assessment
Scanning and culling
Coding
Priori topic and emergent
coding
Analysis
nVivo node classifications
Synthesis
Data interpretation
186 sources 37 key docs coding triangulation documenting

13. Transformative HRH agenda Section 3

14. 14EDDE 801, Seminar 6
HRH conceptual framework
Adapted from Campbell et al. (2013)
A “fit for purpose and fit to practice” health workforce must be
examined, strengthened and monitored within the context of 4
critical HRH dimensions:
Availability
Sufficient supply of health workers1
Accessibility
Equitable access of all people to health workers,
health infrastructure, and health services
2
Acceptability
Ability of workforce to promote and provide
health services that are perceived as valuable or
worthwhile
3
Global HRH Agenda
Quality
Competencies, skills, knowledge and behavior of
health workers as measured by professional
norms and perceived by users
4

15. 15EDDE 801, Seminar 6
CHW mLearning conceptual framework
Adapted from Campbell et al. (2013)
Reframing of 4 HRH dimensions as a means for examining the
feasibility of mLearning for CHW workforce development
Availability
Sufficient supply of mobile technologies, and requisite
financial, human and technological resources
1
Accessibility
Access of CHWs to mLearning and performance
support
2
Acceptability
Suitability, usability and adoption of work-based
mLearning educational offerings.
3
Quality
CHW productivity and performance as a result of
mLearning; scalability and sustainability of CHW
mLearning initiatives
4

16. Systematic review of the literature Section 4

17. 17EDDE 801, Seminar 6
Availability dimensions
Global penetration of mobile phones is over 79% in the developing world (GSMA Intelligence, 2013; ITU, 2014; We are Social, 2015) and are the most
common technological vehicle for delivering CHW professional education.
7.5%
Social media use
5% (Africa) and 10%
(Asia)
10%
Internet use
10% in Africa and Asia
10%
Broadband penetration
0.5% (Africa) and 44%
(Asia)
79%
Mobile subscription
69% (Africa) and 89%
(Asia)

18. 18EDDE 801, Seminar 6
Availability dimensions
Technology Resources
• “Law of distance education research” (Misra, 2012, p.112) states that it is not
technologies with inherent pedagogical qualities that are successful in DE, but
technologies that are generally available to citizens.
• Experts are divided about whether devices should be procured by
projects/governments or whether mLearning offerings should capitalize on
technologies CHWs already own or make use of (Bollinger et al., 2013; Hall et al., 2014).
• Network coverage is both a driver and barrier for mobile access and learning. 2G
capability (which mostly services voice and text) has over 85-90% coverage; 3G is
more limited.
• Only passing reference to technology platforms, e.g. Linux, iOS, Android; emphasis
on open source technologies that can handle increases in user volume, geographic
expansion, and technological change.
• SMS and voice capabilities are key mLearning mediums; use of mobile web, cloud-
based hosting, diagnostic tools, and native applications on the rise.

19. 19EDDE 801, Seminar 6
Availability dimensions
Several studies suggest that mobile technologies reduce the human resources needed to deliver, manage, support and
monitor CHW workforce development initiatives in low resource settings (Aranda et al., 2014; Bollinger et al., 2013).
Research similarly stresses the need for ICT experts that can maintain software and hardware platforms, provide
technology training and ongoing support; and act as an interface between technology and health programming
components (Jaskiewiez & Tulenko, 2012).
Decreased training and opportunity unit costs associated with situated capacity building at point of care; however,
mLearning design and support expenditures can be higher than for traditional training, particularly if participants employ
a variety of devices (eLearning Guild, 2013).
Human and financial resources
Government budgets often inadequate to support CHW workforce development – particularly capital investments for
technology, equipment, connectivity and infrastructure – and external donors currently subsume many of the expenses
associated with mLearning and other continuing education (Aranda-Jan et al., 2015; Frenk et al., 2010)

20. 20EDDE 801, Seminar 6
Accessibility dimensions
Accessibility is examined through reference to learner and learning contexts; knowledge dimensions and learning paradigms; and the
broader policy and governance environment (Braun et al., 2013; Hall et al., 2014; Kallander et al., 2013).
Context sensitivity
Tailoring for specific language,
literacy, cultural and work needs
Sensitivity to the personal being
and preferences of learners
through integration into
workflow (little research on
distracted learning; deep versus
surface learning; and device
interaction)
Policy and governance
HRH policy and governance
poorly formulated and
implemented
Few national mLearning or
mHealth policies, strategies or
guidelines
Limited knowledge of what
works, how it works, and how
much it costs
Knowledge access & use
Increases access to knowledge
by “pushing out” or “pulling in”
Behaviorist learning paradigms
common in literature; active
utilization and constructivist
learning largely anecdotal
Adherence to guidelines, policies &
procedures enhanced; collection
of data improved

21. Acceptability dimensions
• High acceptance of and familiarity with mobile phones have
been identified as primary reasons for positive perceptions of
mLearning (Agarwal et al, 2015; Labrique et al., 2013).
• Age; digital literacy; education levels; privacy, security and
confidentiality; ease of use; and health work experience affect
adoption and sustained utilization of mLearning. Ongoing
support and performance feedback is critical.
• Feelings of empowerment associated with device and
knowledge acquisition; more efficient use of time; novelty
effects?
• Institutional tolerance for mLearning technology system
instability or failure can be low.
• User-centered design and delivery will require higher levels
of commitment to HRH than what is currently observed in
literature.

22. 22EDDE 801, Seminar 6
Quality dimensions
Research increasingly assessing mLearning quality, sustainability and scalability (Arawal et al., 2015; Bollinger et al., 2013; Braun et al., 2013).
Productivity & performance
Enhanced data collection and
reporting competencies;
improved supervision of and
communication between CHWs
and health system
Few countries have standards
for CHW performance; almost
none have criteria for CHW
accreditation
Scalability & sustainability
Large scale implementation of
mLearning limited by shortage
of empirical evidence
supporting value in terms of
cost, performance and health
outcomes
Limited knowledge of what
works, how it works, and how
much it costs
Health systems strengthening
Pilot projects demonstrate
conceptually how mobile
technologies alleviate specific
health systems constraints
Significant gap in evidence on
behavioral, social, economic and
health outcomes of using
mLearning for improving health

23. mLearning feasibility Section 5

24. 24EDDE 801, Seminar 6
Is mLearning feasible for CHW development?
Availability
• Ubiquitous mobile technologies can
deliver education without dependence
on extensive communications
infrastructure
• Mobile technologies are a part of
people’s daily lives
• Requires requisite technical, human and
financial resources which may be
lacking
Accessibility
• Fostered by tailored content, immersive
and embedded learning
• Responsive to issues that CHWs face in
the field
• More research needed on how
mLearning promotes and personalizes
social and self-directed learning in
constructivist, non-constant
environments

25. 25EDDE 801, Seminar 6
Acceptability
• May improve motivation, self-efficacy
and enthusiasm for (unpaid) work
• Familiarity = key criterion for adoption;
processes for technology adoption not
evident (technology determinism?)
• May improve remote supervisory
mechanisms and enhance reporting
systems
• Little evidence on country
institutional/organizational culture(s)
and support mechanisms that facilitate
or impede workplace learning utilizing
mobile technologies
Quality
• Much of the data focused on pilot
interventions, process evaluations, and
qualitative evidence
• Governments require more evidence
about what works, how it works and
how much it costs to operate at scale

26. 26EDDE 801, Seminar 6
Way forward
Questions, comments, suggestions, discussion . . .

27. Thanks for participating!