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Background: The Ebola epidemic exposed the weak state of health systems in West Africa and their devastating effect on frontline health workers and the health of populations. Fortunately, recent reviews of mobile technology demonstrate that mHealth innovations can help alleviate some health system constraints such as balancing multiple priorities, lack of appropriate tools to provide services and collect data, and limited access to training in health fields such as mother and child health, HIV/AIDS and sexual and reproductive health. However, there is little empirical evidence of mHealth improving health system functions during the Ebola epidemic in West Africa. Methods: We conducted quantitative cross-sectional surveys in 14 health facilities in Ondo State, Nigeria, to assess the effect of using a tablet computer tutorial application for changing the knowledge and attitude of health workers regarding Ebola virus disease. Results: Of 203 participants who completed pre- and post-intervention surveys, 185 people (or 91%) were female, 94 participants (or 46.3%) were community health officers, 26 people (13 %) were nurses/midwives, 8 people (or 4%) were laboratory scientists and 75 people (37%) belonged to a group called others. Regarding knowledge of Ebola: 178 participants (or 87.7%) had foreknowledge of Ebola before the study. Further analysis showed an 11% improvement in average knowledge levels between pre- and post-intervention scores with statistically significant differences (P < 0.05) recorded for questions concerning the transmission of the Ebola virus among humans, common symptoms of Ebola fever and whether Ebola fever was preventable. Additionally, there was reinforcement of positive attitudes of avoiding the following: contact with Ebola patients, eating bush meat and risky burial practices as indicated by increases between pre- and post-intervention scores from 83 to 92%, 57 to 64% and 67 to 79%, respectively. Moreover, more participants (from 95 to 97%) reported a willingness to practice frequent hand washing and disinfecting surfaces and equipment following the intervention, and more health workers were willing (from 94 to 97%) to use personal protective equipment to prevent the transmission of Ebola. Conclusions: The modest improvements in knowledge and reported attitudinal change toward Ebola virus disease suggests mHealth tutorial applications could hold promise for training health workers and building resilient health systems to respond to epidemics in West Africa.
The study consisted of quantitative cross-sectional surveys in selected health facilities, with pre- and post-intervention knowledge, attitude and practice (KAP) measurements of health workers. This research is set in Ondo State, western Nigeria. Ondo State has a population of 3.9 million and is made up of 18 local government areas (LGAs) with Akure as its capital city [23–25]. The state has about 800 primary health facilities, 18 general hospitals and 6 tertiary health facilities [26]. Primary health facilities are managed by LGAs and funded through statutory allocations from the state government. The doctor/patient ratio in the state is 1:14 000 as against 1:5000 recommended by the WHO. A recent study shows that human resources for health (HRH) employed by the state government include the following: 148 medical doctors, 908 nurses, 137 medical laboratory technologists and scientists, 185 Community Health Officers (CHOs) and 1152 community health extension workers (CHEWs) [27, 28]. Evidence also shows an inequitable distribution of qualified HRH, especially doctors and nurses, with higher ratios per population in the urban compared to rural areas [25]. Regarding health indicators, Ondo State has a maternal mortality rate of 371/100 000 live births and an infant mortality rate of 68/1000 live births, considered by the World Bank in June 2009 as the worst health indices in South West Nigeria [28]. This catalysed the ministry of health (MOH) to provide health services free of cost to pregnant women and children aged <5 years as a strategy for improving access to health. Additionally, the government supplied health facilities with tablet computers loaded with an electronic health record system (a proprietary system—CliniPAK application) to improve data collection and ultimately health outcomes. Eligible participants were doctors, nurses, midwives, laboratory technicians, CHOs and CHEWs drawn from 14 health facilities across Ondo State purposively selected because the facilities were already supplied with tablet computers loaded with an electronic health record system. We approached the heads of the 14 facilities, explained the objectives of the study and invited FHWs from the facilities to participate in the study. All 14 facilities are equipped with and use Vecna Cares’ CliniPAK health data capture system for the daily documentation of MCH care delivered in the clinics. The application leverages the CommCare Open Data Kit platform to provide an easy-to-use electronic health record system front-end interface that runs on tablet computers. The evaluation of the front line health worker education and disease management (FLEM) application intervention consisted of (i) pilot testing a tablet computer tutorial application for improving diagnostic and management responses to EVD and (ii) conducting before and after surveys to assess changes in the KAP of FHWs regarding EVD. The electronic tutorial application was designed by a multidisciplinary group of ICT and infectious diseases experts and health system researchers to extend and enhance existing CliniPAK electronic health information systems to disseminate critical information to FHWs in real time via tablet computers. The application is unique in that it requires minimal instruction for use after download and installation. Following the development of the FLEM application, an orientation programme was organized for FHWs of the facilities during which potential participants were trained to use tablet computers and the CliniPAK electronic application. As part of the orientation, the objectives of the study were explained to FHWs after which they were invited to participate in the study. Participants were subsequently provided with instructions on completing a pre-tutorial survey, reviewing the electronic Ebola tutorial and completing a post-tutorial survey. Participants were assured of absolute confidentiality and the right to either accept or refuse to participate without consequences. However, due to delays in receiving ethical clearance for the study and the time required for pre-testing the tutorial application, the baseline data collection commenced on 3rd October 2014 during the epidemic while the post-intervention data collection was completed on 25th February 2015 after Nigeria was declared Ebola-free. Ethical clearance for the study (number G.8061/99) was obtained from Ondo State Ethical Review Committee. The study was implemented via the following steps: Step 1: All participants completed a consent form electronically. Step 2: Participants inputted demographic information into the FLEM application. Step 3: Participants were invited to complete a pre-tutorial knowledge and attitude assessment (pre-KAA), to establish a baseline of health workers’ knowledge of and attitudes toward EVD. The assessments contained objective knowledge questions as well as subjective attitudes and perception questions. Step 4: Ebola awareness tutorial (EAT) was launched on all tablet computers deployed in 14 healthcare facilities in Ondo State. This educational intervention/course comprised essential information on EVD namely the source, incubation period, clinical features and route of spread. Other areas covered included transmission, diagnosis of EVD, clinical management and prevention of Ebola transmission in healthcare settings. Health workers that completed the pre-KAA were required to view the EAT at their convenience over a 2-week period. The 2-week period was chosen to keep the duration of the education intervention short in the context of the FLEM project objective of improving emergency preparedness of the health system to contain the Ebola outbreak. Participants were allowed multiple views of the EAT. Step 5: A post-tutorial knowledge and attitude assessment (post-KAA) was launched to establish the effectiveness of the training on the health workers. The questions asked on the post-KAA were exactly the same as those asked during the pre-KAA to facilitate comparison of performance. All participants who completed the post-KAA were expected to have done the pre-KAA and viewed the EAT on at least one occasion. Tablet computers had prepaid annual subscriptions to mobile networks to circumvent the issue of accessing mobile phone networks while health workers were using the tablets. The responses for the pre- and post-KAA were stored electronically for each participant and subsequently analysed. The pre- and post-KAA data and the logs on all frontline workers who viewed the EAT were downloaded from the CommCare survey data repository database to a Microsoft Excel Package (version 14.0.7145.5000 (32-bit). Two hundred and eighty-two frontline workers completed the pre-KAA survey, while 214 workers completed the post-tutorial survey. We excluded data for 11 workers who did not view the tutorial but completed the post-KAA survey. The study analysis was thus conducted on data for 203 workers who completed the pre- and post-tutorial surveys and viewed the tutorial. The knowledge part of the study contained nine objective questions. We assigned scores of 1 for each correct answer and 0 for wrong answers that frontline workers provided. We counted the number of respective responses to arrive at the number of FHWs that selected each outcome and computed a percentage of aggregate counts for each outcome relative to the total and compared the pre- and post-tutorial scores to arrive at the difference in health worker knowledge of the Ebola virus disease. A paired sample Z test was done on the means of the pre- and post-tutorial scores for knowledge questions, and the significance level was set at P < 0.05. The behavioural and attitudinal part of the study contained seven questions with five possible choices: Strongly Agree, Agree, Not Sure, Disagree, and Strongly Disagree. To streamline interpretations of health worker responses, we combined ‘Strongly Agree and Agree’ to derive ‘Agree’ and ‘Strongly Disagree’ and ‘Disagree’ to derive ‘Disagree’. We thus had three possible outcomes: Agree, Not Sure or Disagree. We counted the number of respective responses to arrive at the number of FHWs that selected each outcome from each health facility. We then took simple averages of the response counts across all the facilities to arrive at the average score for each of the seven questions. Finally, we computed the percentage of aggregate counts for each outcome relative to the total and compared the pre- and post-tutorial scores to arrive at the difference in health worker behaviours and attitudes toward the Ebola virus disease.
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