Understanding the use of health information technology for maternal and child health practitioner training in low and middle income countries
Authors: Rogers Michelle , Masud-Paul Janice , Desoki Rania El 
Published: November 2019

Objectives: To assess the evidence of information communication technology (ICT) use in the training of maternal and child health (MCH) workers, discuss methodological issues present in the identified studies, and identify future work areas. Introduction: The explosive growth of cellphone usage in low and middle-income countries (LMIC) has made mobile technology an increasingly attractive form of information communication technology (ICT) to be used to meet healthcare needs that go unmet, rising due to the paucity of trained clinical workers (O’Donovan, Bersin, & O’Donovan, 2015). The portability and relative low cost of cellphones have made them ubiquitous and efficient to use. For example, subscriptions in Africa have risen from 12.4 per hundred inhabitants in 2005 to per hundred inhabitants in 2015 (ITU, 2017). ICT is an umbrella term that encompasses the hardware, software and networks that provide its users with data and information resources. As far as healthcare is concerned, these resources include access to varied tools and services such as electronic health records, point-of-care databases, decision support systems, clinical guidelines or training modules for continuing education (Machingura et al., 2014). This technology has made healthcare more efficient in affluent countries where funding and infrastructure to build, support and maintain ICT is readily available. However, ICT development is critical to LMIC’s which have the greatest barriers to effective and efficient healthcare systems and fewer resources to overcome challenges. The aims of this paper are to (1) summarize the literature on ICT use in the training of MCH workers, (2) discuss methodological issues present in the identified studies, and (3) identify future work areas. Our specific research questions are: Which ICT tools have been used in developing countries for training the MCH workforce? How successful are the tools for instructing health care workers? A major impediment to health care improvements in underdeveloped countries is the low ratio of health professionals to patients. A developed workforce is critical for sustaining healthcare infrastructure. Because there is an insufficient number of professional practitioners, many MCH health needs are met by community workers with limited or no formal training (Chipps et al., 2015). Since the level of services range from general check-ups to life-saving interventions, training must address a variety of educational requirements. (Agarwal et al., 2015). In addition to primary professional education, health workers require training for re-licensure and continuous professional development (CPD). Training, particularly in remote areas, requires travel, time away from work as well as funding for food and lodging (Chipps et al., 2015). This exacerbates uneven healthcare coverage with the majority of MCH health care workers concentrated in urban centers, leaving rural residents with inadequate services (Middleberg et al., 2013; Modi et al., 2015). ICT reduces costs by enabling personnel to remain in their communities while providing digital access to educational content, mentors, guidelines and decision support systems (Saronga et al., 2015). It is commonly recognized that underdeveloped countries have occasional brown-outs in their urban centers and the power grid may not reach rural or remote areas. Even if seed money is acquired for start-up costs, funding for technology maintenance and technical manpower beyond the pilot stage can be tentative (Achampong, 2012). Secondly, while cell phone use across LMICs has exploded in recent years, its use for advancing training has not grown in comparison. A limited number of reports have been published, reporting the use of ICT for communication (Andreatta et al., 2011), tracking health worker behavior (Awoonor-Williams et al., 2013), attitudes towards using ICT (Sukums et al., 2014; Zakane et al., 2014), and the impact of the design of ICT (Valez et. al., 2014). This paucity of studies understanding the impact of ICT on measurable training outcomes leaves a troubling gap in the literature if progress is to be made in addressing the training needs. Finally, government entities, educators and administrators may be reluctant to adopt ICT into health training for practical, fiscal and political reasons. Because health personnel may not have exposure to technology in their daily lives, staff may require basic computer training on operating systems, file management, word processing and databases in conjunction with ICT projects (Sukums, 2014). In addition to a lack of knowledge about computers in general, use of ICT also comes with associated monetary costs. Both of these issues are also exacerbated by resulting government policy changes. We endeavored to fill this gap by completing a literature review to bring the disparate work together, but to our surprise, it did not really exist. This paper reports on (1) what studies have been conducted on the use of ICT in training; (2) what common methods are used and how they are evaluated and (3) what outcomes have been reported. Methods: Medline (OVID), CINAHL and Web of Science were searched for relevant articles published between January 1, 2007 and February 28, 2017. Studies were included if they included training and education in low and middle-income countries using ICT for maternal child health workers. Results: 111 unique articles from electronic searches with seven additional articles discovered through hand-searching reference lists were identified. After review, 15 articles aligned with the necessities to analyze the current environment of the ICT tools. The study designs in the reviewed articles were usually pre- and post-evaluations (n=7). There were also a small number of single cross-sectional studies (n=3) measuring the use of the tool. Two studies also evaluated the use of electronic clinical decision support systems (CDSS) applications or algorithms. The remainder of the studies (n=3) used ICT to provide resources for meeting information needs, as well as repositories of protocols and best practice documents. The outcomes reported ranged from access to medical resources (n=3), accuracy in clinical documentation (n=2), need for remedial computer training (n=2) and an increase in clinical knowledge and proper use of protocols (n=4) Discussion and conclusion: The current evidence-base does not show a clear indication that there were particular initiatives using ICT for the training of health workers. While the majority of projects identified were shown to improve outcomes, there were limited results reported. This lack of documented evidence hinders decisions about the content and methods that should be used to support training. We are missing an opportunity for advancement. The World Health Organization identified community health worker training as a lever to move the improvement of health care in low and middle-income countries (LMICs). An understanding of barriers and facilitators to using ICTs to meet this need, provides key directions for policy makers and non-governmental organizations as they apply limited resources to these issues.