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BACKGROUND Zambia is faced with a severe shortage of health workers and challenges in national health financing. This burdens the medical licentiate practitioner (MLP) program for training nonphysician clinical students in Zambia because of the shortage of qualified medical lecturers and learning resources at training sites. To address this shortage and strengthen the MLP program, a self-directed electronic health (eHealth) platform was introduced, comprising technology-supported learning (e-learning) for medical education and support for health care practice. MLP students were provided with tablets that were preloaded with content for offline access. OBJECTIVE This study aimed to explore MLP students’ and medical lecturers’ perceptions of the self-directed eHealth platform with an offline-based tablet as a training and health care practice support tool during the first year of full implementation. METHODS We conducted in-depth qualitative interviews with 8 MLP students and 5 lecturers and 2 focus group discussions with 16 students to gain insights on perceptions of the usefulness, ease of use, and adequacy of self-directed e-learning and health care practice support accessible through the offline-based tablet. Participants were purposively sampled. Verbatim transcripts were analyzed following hypothesis coding. RESULTS The eHealth platform (e-platform), comprising e-learning for medical education and health care practice support, was positively received by students and medical lecturers and was seen as a step toward modernizing the MLP program. Tablets enabled equal access to offline learning contents, thus bridging the gap of slow or no internet connections. The study results indicated that the e-platform appears adequate to strengthen medical education within this low-resource setting. However, student self-reported usage was low, and medical lecturer usage was even lower. One stated reason was the lack of training in tablet usage and another was the quality of the tablets. The mediocre quality and quantity of most e-learning contents were perceived as a primary concern as materials were reported to be outdated, missing multimedia features, and addressing only part of the curriculum. Medical lecturers were noted to have little commitment to updating or creating new learning materials. Suggestions for improving the e-platform were given. CONCLUSIONS To address identified major challenges, we plan to (1) introduce half-day training sessions at the beginning of each study year to better prepare users for tablet usage, (2) further update and expand e-learning content by fostering collaborations with MLP program stakeholders and nominating an e-platform coordinator, (3) set up an e-platform steering committee including medical lecturers, (4) incorporate e-learning and e-based health care practice support across the curriculum, as well as (5) implement processes to promote user-generated content. With these measures, we aim to sustainably strengthen the MLP program by implementing the tablet-based e-platform as a serious learning technology for medical education and health care practice support.

UNSTRUCTURED E-learning has been heralded as a revolutionary force for medical education, especially for low-resource countries still suffering from a dire lack of health care workers. However, despite over two decades of e-learning endeavors and interventions across sub-Saharan Africa and other low- and middle-income countries, e-learning for medical education has not gained momentum and continues to fall short of the anticipated revolution. Many e-learning interventions have been cul-de-sac pilots that have not been scaled up but rather terminated after the pilot phase. This is usually a result of not adopting a system-wide approach, which leads to insufficient scope of training, insufficient technological maintenance and user support, unattainably high expectations, and unrealistic financial planning. Thus, a multitude of e-learning evaluations have failed to provide scientifically sound evidence of the effectiveness of e-learning for medical education in low-resource countries. Instead, it appears that technological development has overwhelmed rather than revolutionized medical education. The question of how to push e-learning into a higher gear in low-resource countries persists. Provision of e-learning as a technology is insufficient. E-learning needs to be vigorously and sustainably integrated into the local educational setting and aligned with national strategies and other national endeavors and interventions. Adhering to a standardized framework for the implementation and evaluation of e-learning endeavors is key, especially to bridge the gap in robust evidence that should also guide e-learning implementations. The primary objective of e-learning for medical education is to strengthen the health system in order to serve the population’s health care needs and expectations. Currently, medical e-learning does not measure up to its potential or do justice to medical students in low-resource countries. Technology may help unfold the potential of e-learning, but an all-encompassing change is needed. This can only be achieved through a joint effort that follows a systematic and standardized framework, especially for implementation and evaluation.

BACKGROUND E-learning in medical education can contribute to alleviating the severe shortages of health workers in many low- and middle-income countries. In the past few decades, the rapid development of technologies resulted in an abundance of new resources, including personal computers, smartphones, handheld devices, software and the Internet – at constantly decreasing costs. Consequently, educational interventions increasingly integrate e-learning to tackle the challenges of health workforce development and training. However, evaluations of e-learning interventions still lack clear methodology to assess the effectiveness and the success of e-learning for medical education, especially in those countries where they are most needed. OBJECTIVE Our specific research aim was to systematically describe currently used evaluation methods and definitions for the success of medical e-learning interventions for medical doctors and medical students in low- and middle-income countries. Our long-term objective is to contribute to generating effective and robust e-learning interventions to address critical health worker shortages in low- and middle-income countries. METHODS Seven databases were searched for e-learning interventions for medical education in low- and middle-income countries, covering publications ranging from January 2007 to June 2017. We derived search terms following a preliminary review of relevant literature and included studies published in English which implemented e-learning asynchronously for medical doctors and/or medical students in a low- or middle-income country. Three reviewers screened the references, assessed their study quality, and synthesized extracted information from the literature. RESULTS We included 52 studies representing a total of 12294 participants. Most of the e-learning evaluations were assessed summatively (83%) and within pilot studies (73%), relying mainly on quantitative evaluation methods using questionnaire (45%) and/or knowledge testing (36%). We identified a lack of evaluation standards for medical e-learning interventions, as methods varied considerably in the evaluation of their medical e-learning interventions with a high variation in study quality (general low study quality, based on study quality scales MERSQI, NOS and NOS-E), study period (ranging from 5 days up to 6 years), assessment methods (6 different main methods) and outcome measures (a total of 52 different outcomes), as well as in the interpretation of intervention success. The majority of studies relied on subjective measures and self-made evaluation frameworks, resulting in low comparability and validity of evidence. Most of the included studies reported success in their e-learning intervention. CONCLUSIONS The evaluation of e-learning interventions needs to produce meaningful and comparable results. Currently, a majority of evaluations of e-learning approaches to educate medical doctors and medical students is based on self-reported measures that lack adherence to a standard evaluation framework. While the majority of studies report success of e-learning interventions – suggesting the potential benefits of the e-learning – the overall low quality of the evidence makes it difficult to draw firm conclusions. Methods development, study design guidance, and standardization of evaluation outcomes and approaches for e-learning interventions will be important for this field of education research to prosper. Methodological strength and standardization are particularly important, because the majority of the existing studies evaluate pilot interventions. Rigorous evidence on pilot success can improve the chances of scaling and sustaining e-learning approaches for health workers.

BACKGROUND Zambia faces a severe shortage of health workers, particularly in rural areas. To tackle this shortage, the Medical Licentiate program was initiated at Chainama College of Health Sciences in the capital, Lusaka, in 2002. The objective of the program was to alleviate the shortage of human resources in curative care. On-the-job training is conducted in decentralized teaching hospitals throughout Zambia. However, the program faces significant challenges such as shortages of senior medical instructors and learning materials. OBJECTIVE Our aim was to address these challenges by introducing a self-directed, e-learning platform with an offline tablet as part of a collaborative blended-learning intervention to supplement local teaching and training. METHODS The pilot phase of the e-learning platform was evaluated using a mixed-methods approach with a convergent parallel design. Various methods were employed to test the data’s adequacy and potential for generating valid results. Methods included questionnaires according to the technology acceptance model and information system success model by DeLone and McLean, semistructured interviews, learner diaries, pretesting, the collection of usage data, exam results, demographics, and informal feedback. Outcome measures included usage, adoption, efficiency, acceptance, user-friendliness, and gained knowledge and skills. RESULTS In total, 52 students and 17 medical instructors participated in the pilot evaluation. The questionnaire results showed a high acceptance of the technology (>80%) and high agreement (>75%) with the e-learning platform. Semistructured interview results showed an overall appreciation of the e-learning intervention, but the need for more e-learning materials. Respondents identified a need for multimedia materials that transfer skills such as medical procedure visualization and interactive exercises to practice procedural knowledge. The learning diaries identified the lack of specific learning materials and potential shortcomings of existing learning materials. However, students were satisfied with the current e-learning content. The majority of students used the e-learning platform offline on their tablets; online e-learning was underutilized. CONCLUSIONS The pilot phase of the tablet-based e-learning platform to support the self-directed learning intervention was well received and appreciated by students and medical instructors of Chainama College of Health Sciences. E-learning for knowledge acquisition appears to be adequate and feasible for this low-resource educational environment. Our evaluation results guide the further development of the full implementation of the e-learning platform in this educational setting. E-learning materials should reflect curriculum requirements, and additional multimedia and interactive content is needed, as well as improved integration and active participation from medical instructors in the e-learning processes.

E-learning has been heralded as a revolutionary force for medical education, especially for low-resource countries still suffering from a dire lack of health care workers. However, despite over two decades of e-learning endeavors and interventions across sub-Saharan Africa and other low- and middle-income countries, e-learning for medical education has not gained momentum and continues to fall short of the anticipated revolution. Many e-learning interventions have been cul-de-sac pilots that have not been scaled up but rather terminated after the pilot phase. This is usually a result of not adopting a system-wide approach, which leads to insufficient scope of training, insufficient technological maintenance and user support, unattainably high expectations, and unrealistic financial planning. Thus, a multitude of e-learning evaluations have failed to provide scientifically sound evidence of the effectiveness of e-learning for medical education in low-resource countries. Instead, it appears that technological development has overwhelmed rather than revolutionized medical education. The question of how to push e-learning into a higher gear in low-resource countries persists. Provision of e-learning as a technology is insufficient. E-learning needs to be vigorously and sustainably integrated into the local educational setting and aligned with national strategies and other national endeavors and interventions. Adhering to a standardized framework for the implementation and evaluation of e-learning endeavors is key, especially to bridge the gap in robust evidence that should also guide e-learning implementations. The primary objective of e-learning for medical education is to strengthen the health system in order to serve the population’s health care needs and expectations. Currently, medical e-learning does not measure up to its potential or do justice to medical students in low-resource countries. Technology may help unfold the potential of e-learning, but an all-encompassing change is needed. This can only be achieved through a joint effort that follows a systematic and standardized framework, especially for implementation and evaluation.