mLearning in Nursing and Midwifery Education: Are Ghana’s Students Ready? Thomas ERKERT1, Karsten GAREIS2, Maximilian GLÄTZNER3, Robert KABA4 Healthare Information Technology for Africa e.V., Institut für IT im Gesundheitswesen, Reichenaustr. 1, 78467 Konstanz, Germany, Tel: +4993540251, Email:
[email protected] 2 Healthcare Information Technology for Africa e.V., Institut für IT im Gesundheitswesen, Reichenaustr. 1, 78467 Konstanz, Germany, Tel: +49 17661712938, Email:
[email protected] 3 Goethe University Frankfurt, Theodor-W.-Adorno-Platz 1, 60323 Frankfurt am Main, Germany. Tel: +49-69-798-0, Email:
[email protected] 4 University of Health and Allied Sciences, Public Health Nursing, PMB 31, Ho, Ghana, Tel: +233 241226409, Email:
[email protected] 1
Abstract:. In preparation of a suggested intervention for the implementation of an mLearning system at a health training institution in semi-rural Ghana, we conducted an interview survey of all students at a nursing & midwifery college in late 2017. The objective was to explore current smartphone take-up and patterns of use among the target group, with a particular focus on use for learning-related purposes. The results support our assumption that use of the mobile phone / smartphone for purposes related to learning and exchange of knowledge among peers is already an established social practice. Students make heavy use of WhatsApp, social networking apps and internet searches. The main constraint to effective online use of smartphones appears to be low available bandwidth. These findings support claims that the mobile telephony infrastructure is a huge potential waiting to be tapped for effective interventions in the education domain. Keywords: mLearning, nursing & midwifery education, health workers, Ghana, interview survey, students, health training institutions, connectivity
1. Introduction There is wide recognition that the recent, rapid extension of mobile information & communication technology (ICT) in sub-Saharan Africa (SSA) offers huge opportunities for achieving sustained improvements in health worker training. The present paper looks at the case of Ghana, a West African country that has seen substantial progress in health system performance in recent years, but continues to face a range of challenges in particular with regard to human resources in health. In preparation of a suggested intervention for the implementation of an mLearning system at a health training institution in a semi-rural part of Ghana, we conducted a paper & pencil survey of all current students at the nursing & midwifery college in Ho, Volta Region in late 2017. The main objective was to explore current smartphone take-up and patterns of use among the target group. Results are being discussed against the background of our our own, earlier research that has consisted of face-to-face interviews with school principals and IT tutors as well as field visits to school campuses, health posts and rural hospitals.
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2. Objectives and background 2.1
Research objectives
The main objective of our paper is to present the findings from a written survey of all current students at the nursing & midwifery college in Ho, Volta Region in late 2017, and place it in the context of the findings of earlier research using e-mail interviews of teaching staff / school principals, stakeholder workshops, non-structured interviews and participatory observation. The research sought to explore current mobile phone / smartphone take-up and patterns of use among the target group. We are interested, in particular, in the ways students use their smartphones for purposes related to their learning. 2.2
Background: The case for novel approaches to nursing & midwifery training
The WHO counts Ghana among the African countries suffering from critical shortage of human resources for health, which is seen as one of the biggest challenges facing the developing world in general, and sub-Saharan Africa (SSA) in particular [1]. It has given rise to the notion of a global health workforce crisis [2]. In rural parts of SSA, the worker shortage relates mainly to nurses and midwives, which are the primary source of healthcare outside of the large cities, as doctors are few and far between and will remain so in the foreseeable future. The capability of nurses and midwives in rural areas to provide high-quality healthcare is therefore one of the main determinants of a country’s health performance in the developing world [3]. Unfortunately, rural and peripheral regions are also the most underserved when it comes to quality health worker training and attractive working conditions. Some SSA governments, including Ghana, have fully accepted the challenge and responded by stepping up enrolment in nursing and midwifery training programmes. The country's health-sector plan, prioritising health workforce development, has been, according to an evaluation by the WHO, "backed by strong political will and is being implemented jointly by the Ministry of Health and the Ghana Health Service. A particular priority is being placed on the scale-up of mid-level health workers (including nurses and midwives), which is based on experience on the ground and evidence from elsewhere in sub-Saharan Africa demonstrating their cost-effectiveness, improved retention and acceptance of rural postings compared with doctors" [4]. The Human Resource Policy and Strategy 2014-2017 [5] has confirmed the policy goal to “increase production of midwives, nurses, and other neglected programmes” with a particular emphasis on the most underserved regions. As a consequence, nursing and midwifery schools outside of the southern agglomerations have radically increased student intake in recent years (by means of establishment of new training schools and enlargement of existing ones), with the result that “equity with regards to nurses has however improved significantly with an equity index of 1:2.26 in 2007 and an index of 1:1.75 as at 2012 (ratio of best staffed over worst staffed region)”. This trend has, however, brought new problems: school infrastructure is stretched to the limit, class sizes are huge and there is a serious lack of teaching materials including textbooks and clinical skills based simulations and practice [6][7]. There are strong indications that the overall performance of the system for education of nurses and midwifes leaves much room for improvement, as indicated by large numbers of drop-outs and students who do not pass the final exams [8][9]. It can hardly be a surprise, then, that – as the World Bank’s most recent Comprehensive Assessment of the Health Sector in Ghana points out – “we find many health workers are not performing up to standard, particularly in rural areas [and] among the poor” [10]. 2
We conclude that a key bottleneck today is the low capacity of training institutions to equip health workers with the skills required for service, both pre-registration and inservice (lifelong learning). This is an area where there is an urgent need for major improvements, in spite of the limited leeway of the Ghanaian government to fund larger investments. 2.3
The potential of mLearning
A growing body of research from around the world suggests that eLearning and mLearning can offer an effective way to enhance existing ways to impart knowledge in low-resource settings. A key factor in this regard is the potential of mLearning to create a learner centred environment that is interactive, collaborative, situational, meaningful and relevant [11]. This is in contrast to traditional education ("teacher-centred learning"), which situates the teacher as the primarily "active" role while students take a more "passive", receptive role [12] – by far the most dominant way of learning in Ghana’s nursing and midwifery schools today. Learner-centred education theory and practice, based on the constructivist learning theory that emphasizes the learner's critical role in constructing meaning from new information and prior experience [13], shifts the focus of instruction from the teacher to the student, e.g. by putting some of the responsibility for the learning path in the hands of students. Learner-centred instruction focuses on skills and practices that enable lifelong learning and independent problem-solving [14], which are key to successful performance as a nurse or midwife especially in low-resource environments [15]. eLearning, in particular if delivered in a blended approach in combination with classroom-based learning (blended learning), has been found to be a major enabler of effective, learner-centred education, with a body of research evidence available also for the case of nursing and midwifery education in developing countries [16][17][18]. Another key concept in modern educational theory is collaborative learning, based on the model that knowledge can be created within a population where members actively interact by sharing experiences and take on asymmetrical roles [19]. Advances in ICT have become an important enabler for collaborative learning; online environments based on the internet have allowed for a shared space for groups to interact in ways not known before. eLearning and mLearning systems typically come with a range of features that enable collaborative learning, such as Wikis, blogs and group chat. Again, there is a wealth of evidence suggesting that ICT-enabled collaborative learning can be a highly effective method in nursing and midwifery education in developing countries [20][21]. 2.4
Challenges to successful take-up
While mLearning has an obvious potential for improving education in the nursing & midwifery sector in SSA, pilot research has shown that successful practice depends strongly on the way the intervention is being designed and implemented, in particular on the extent to which the learning system is adapted to the needs and preferences of the various target user groups, embedded in established social practices, and taking account of existing barriers to utilisation of ICT such as the quality and price of online access and other factors influencing acceptance of technology. A number of authors have conceptualised these barriers to access in the context of theory-building on the so-called “digital divide”. Warschauer [22], for example, argued that the ability not only to access but also to apply, adapt and create knowledge using ICTs is critical to social inclusion: “This focus on social inclusion shifts the discussion of the "digital divide" from gaps to be overcome by providing equipment to social development challenges to be addressed through the effective integration of technology into 3
communities, institutions, and societies. What is most important is not so much the physical availability of computers and the Internet but rather people's ability to make use of those technologies to engage in meaningful social practices”. Key of van Dijk’s model is a number of kinds of access in succession, starting from motivation, over physical and material access, digital skills and finally usage [23]. As far as (physical and material) online access is concerned, Ghana (like all SSA countries) has only very limited fixed-line telecommunication networks. eLearning applications depending on good coverage with terrestrial internet are therefore bound to be of limited impact. The recent, rapid diffusion of mobile telephony opens up novel possibilities, however. Access to the mobile network is spreading very fast: In Ghana, the number of mobile subscriptions per 100 inhabitants was 139 in 2016, up from 50 in 2008 [24]. While the high figure reflects the fact that many Ghanaians have multiple subscriptions, a representative population survey in mid-2015 [25] found that the share of mobile phone users in the adult population was 75% already, up from 34% in 2007. 21% used a smartphone in 2015 (27% when only looking at persons aged 25-34). Industry sources suggest that smartphone penetration rates will grow to levels of around 70% across SSA by 2020 [26]. Providing physical access to a piece of technology is insufficient if prospective users lack the skills to use it in a purposeful way. Digital skills can be measured directly (via examinations) or indirectly, by observation of the activities for which the technology is used. The latter is the approach chosen for the research presented below.
3. Methodology We conducted the survey in mid-2017 [27]. Between 24 July and 8 August 2017, 300 paper questionnaires were distributed to students present on the campus of Ho Nurses’ Training College, subsequently collected by class representatives and returned to the Head of Department. The questionnaire was administered in the form of a paper-and-pencil survey consisting of two closed context questions and ten closed questions on ICT take-up and patterns of use. For developing the survey instrument, we made use of the findings from earlier research consisting of face-to-face interviews with school principals and IT tutors as well as field visits to school campuses, health posts and rural hospitals across all regions of the country [6]. This research was carried out during field trips in 2011, 2016 and 2017. In addition, an e-mail survey of 24 health training institutions across six Ghanaian regions had been conducted by the authors in early 2016 [28]. Respondents were school principals and IT tutors, who were asked to estimate the share of their current students who own a mobile phone, smartphone and laptop computer. Estimates ranged between 50% and 98% of all their students owning a smartphone, and practically all owning at least a mobile phone. A similar survey had also targeted at a nursing & midwifery school in Zambia (data from late 2016) and found an estimate of 40% smartphone ownership, which suggests that while Ghana may be among the leaders in smartphone penetration in SSA, similar developments can be observed across the continent. Additional information and contextual data was gathered using non-structured and semi-structured methods, in particular in-depth discussions with UHAS School of Nursing and Midwifery teaching staff and oral interviews with students and other Ghanaians in the same age group (25-35 years). The survey was pilot-tested in the Ho region in the context of semi-structured interviews with a small number of Ghanaians in the same age group as the target. The pilot showed that all questions are understood as intended by the interviewer. Paper questionnaires were collected and later processed, taking full account of all applicable EU 4
data privacy regulations. The survey response was analysed using Excel and SPSS, and results visualised using off-the-shelf graphic tools.
4. Findings 233 complete questionnaires were returned, which translates into a response rate of 78% [27]. About one in two respondents is enrolled in a nursing course (2-year, 3-year of 4year), 42% in a midwifery course, and 9% in public health nursing. Three in four are women. Ages at the time of the interview range from 20 to 45, the average age is slightly above 30, which is significantly higher than in comparable education programmes in Europe. All 233 respondents stated that they do own a smartphone (Q3); the most frequent brands in use are Samsung, Techno, Infinix, and ITEL. Asked for how long they use the smartphone per day (Q4), only 18% of respondents state that they use their smartphone for 20 minutes or less per day, whereas 11% do so for 21-30 minutes, 35% for 31-60 minutes, and more than one in three (36%) for more than one hour. This shows the large extend to which smartphone use has become embedded in the daily activities of students on the campus. Which features of your phone do you use, and how often? WhatsApp Internet Voice calls Social networks Text messaging Camera Digital school content Entertainment Video messaging Radio 0%
20%
several times a day
daily
40%
2-3 times a week
60%
once a week
once a month
80%
100%
once in a while
Figure 1: Applications used on the phone (n=233)
The figure above shows what applications respondents use (Q5), and how frequent they do so. WhatsApp’s popularity among students is striking, with 88% of respondents stating they use it daily, and 39% do so even several times per day. Internet access is almost as widespread (86% daily use), as are voice calls, with 81% of respondents reporting they go online on a daily basis. Social networks such as Facebook are also in wide use (76%). The remaining applications listed are being used less often. 60% of respondents state that they do use “digital school content”, which shows that some teaching staff have started to experiment with integrating online content in their courses.
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Number of applications used daily on smartphone
8 appl. 10%
9-10 appl. 6% 1 appl. 2 appl. 3% 6% 3 appl. 11%
7 appl. 11% 4 appl. 19% 6 appl. 16% 5 appl. 18%
Figure 2: Duration of mobile phone / smartphone use per day (n=233)
The extent to which students have embedded smartphone use in their daily life can be gauged by looking at the number of applications reportedly used by respondents on a daily basis. The result (see figure above) shows that a significant share of all students use a large number of applications on their smartphone – 61% use five applications or more each day, and more than one in four (27%) uses 7 of the 10 applications listed in the survey instrument. This result confirms the findings from other available research [29][30] which suggest that a large share of Ghanaians make heavy use of a range of smartphone applications for staying in touch with friends and getting things done is almost all spheres of life. Quite obviously, the smartphone has been successful in meeting a range of needs of the population of Ghana, as it has across the developing world. The next question (Q6) referred specifically to use of the smartphone in the context of education at the nursing & midwifery school.
Figure 3: Education related uses of the phone (n=233)
Results indicate that “searching for information on the internet” is the most widely and frequently used purpose, followed by “reading” Our complimentary face-to-face interviews 6
revealed that lecturers often ask students to obtain complimentary information including YouTube videos from the internet, for which purpose no specific websites are given – students are on their own in finding adequate sources of information. The shortcoming of this practice, as reported by students as well as teaching staff, is that the quality of the online material is not assessed beforehand by the school, and learning results are not assessed. Other very widespread learning-related uses of the smartphone include “WhatsApp chatting” and “social networking, e.g. learning groups”. About 4 in 5 students use each on a daily basis. This result confirms our own anecdotal evidence according to which Ghanaian health workers make heavy use of a range of smartphone applications for work or education-related purposes such as sharing of photos taken from textbook pages and whiteboard pictures. Field visits by the authors to community health posts (CHPS compounds) in the Volta Region of Ghana in early 2017 showed evidence of Community Health Nurses (both young and experienced) using WhatsApp groups for exchanging work related information such as snapshots of photos and pages from textbooks, see figure below.
Figure 4: Community Health Nurse in Volta Region demonstrating how she uses WhatsApp group chats for exchange of work-related information (March 2017). Photos: Karsten Gareis
Students in Ho reported during face-to-face interviews that they make heavy use of WhatsApp and social networks for various learning-related purposes, but all of these are informal; so far there has been no attempt by the school or individual lecturers to integrate such tools in their teaching practices. Use of the smartphone for recording lectures or for documentation purposes are less widespread. About one in three students report doing so at least once a week; more than one in two do so at least sometimes. One reason for the lower share of respondents reporting using their device for recording and documentation appears to be the cheap quality of the smartphone types being used: their camera does often not allow taking pictures and making recordings of a sufficient quality to be of any use for learning purposes. With regard to the satisfaction with the possibilities to use the phone for specific purposes (Q7), satisfaction was most widespread for “communication with parents, relatives or friends” (78% say the smartphone is “very good” or “good” for this purpose), “common learning” (74%) and “cooperation with other students” (65%). Less than one in two respondents, however, consider the smartphone very good or good for “cooperation with teachers / lecturers” (46%) and “working offline, i.e. making notes with a writing programme” (42%). 7
There is wide variation in average monthly spending on mobile charges (Q8). 21% of all respondents spend GH₵10 (roughly €1.80) or less per month; 25% spend between GH₵11 and GH₵20 (€3.60), 21% between GH₵21 and GH₵30 (€5.40), 13% between GH₵31 and GH₵40 (€7.20), 9% between GH₵41 and GH₵50 (€9) and 11% even more. There can be little doubt that these amounts represent substantial shares of students’ disposable income. According to data from the latest Ghana Living Standards Report [31], the mean annual per capita expenditure in the Volta Region was GH₵2,508 in 2014. Assuming that respondents spend on average GH₵25 per month on mobile charges (i.e. GH₵300 per year) and that their spending budget is equal to the regional average, students would spend more than 10% of their total expenditure on mobile charges1. By comparison, in Europe the average household expenditure on communications was 2.5% of total final consumption expenditure [32]. The survey instrument also included questions dealing with internet access in general (Q9-12). One in two respondents state that they access the internet several times per day, and an additional 42% say they do so at least once per day. Only three respondents state they do not access the internet at all. The by far most common means to access the internet is by their own smartphone or tablet (89% of respondents). Nearly a third (also) use their own PC or laptop. In spite of the fact that the school is equipped with a computer lab, only 9% of respondents use school-owned computers for going online.
Figure 5: Applications used on the phone (n=233)
Additional insight can be derived from the data gathering using semi-structured and non-structured interviews. Some key findings include the following: Most nursing & midwifery students in the area (Volta region) apparently stem from what in Ghana counts as middle-income households, although there is substantial variation in this respect. The personal budget students have available per month was reported as around GH₵200. In some cases, interviewees were deriving extra income from side jobs during the education programme, in which cases they reported a personal budget of up to GH₵700. Smartphones of the most popular types (Techno, Infinix) cost between GH₵300 and GH₵600. Mobile charges are low if compared to Europe: A data volume of 1GB/month costs around GH₵10, for GH₵30 consumers can get as much as 35GB/month. Use of mobile data transfer is hampered by low available bandwidth, however. Because of differences in network coverage and quality, most Ghanaian mobile users have 1
The average annual per capita expenditure on communication was GH₵166 in 2014 according to GLSS6.
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subscriptions to two networks (all phones available in Ghana have two or more SIM card slots). Most students are strongly religious, which also plays a strong role in the decision to choose a career in the health sector. The nursing profession generally seems to enjoy a high social status in the country, and the pay – although modest – is considered sufficient to (help) sustain a family. For European observers, the apparent high ambition of students and their eagerness to learn are striking. The motivation appears to be both intrinsic (see above) and extrinsic (the substantial financial investment required from a family who sends a daughter or son to nursing school means that students experience a strong pressure to succeed).
We conclude that education-related smartphone use is indeed very widespread among nursing and midwifery students in Ghana. There is strong evidence that a large majority of Ghanaian students in this sector have the motivation as well as the physical access required to use smartphones, and that they already use a range of applications for purposes related to their learning activities. The amount of money students spend on phone charges makes up a substantial part of their total expenses, which points to the perceived utility of smartphone, but also indicates a bottleneck to using the device for extensive mLearning purposes, namely the cost of connectivity. The problem is exacerbated by the low available bandwidth for data connections. In our own field research in six regions of Ghana, we observed a general consensus among interviewees that network coverage (including 3G for mobile data services) is satisfactory and improving even in remote and rural areas, while the quality of access in terms of speed of data transfer is considered insufficient for many purposes, and there has be no improvements in this regard in recent years [33]. Our research does, however, have some limitations due to the methodology used and the choice of reference unit. With regard to sampling error, we do not have sufficient data on non-respondents to rule out the possibility of systematic differences between response and non-response groups. It is possible that some interviewees who do not own a smartphone decided not to return the questionnaire as they felt that most questions were not applicable to them. With regard to non-sampling error, our observations during the fieldwork indicates the possibility of the response being subject to social desirability bias. This is most likely to affect validity of response for our questions about satisfaction with current learning opportunities (Q12) and entertainment related smartphone uses as opposed to learning related purposes. Results should therefore be treated with care.
5. Conclusions Our survey provides further evidence indicating that in Ghana, the majority of persons at working age already own a smartphone and a mobile subscription including a data plan. Because of the low charges for mobile data transfer, the latter does typically allow for regular use of WhatsApp, Facebook and other social networking, and internet searches. The main constraint to effective online use of smartphones appears to be the low available bandwidth. Use of the mobile phone / smartphone for purposes related to learning and exchange of knowledge among peers is already an established social practice. Taken together, these findings give credit to claims that the mobile telephony infrastructure is a huge potential waiting to be tapped for effective interventions in the education domain. The findings support key initial assumptions that underlay our plans for setting up mLearning systems at nursing and midwifery training institutions in peripheral 9
and semi-rural parts of Ghana. Due to our methodology’s limitations in terms of the lack of data on non-respondents, however, full account should be taken to prepare for the possibility that not all students own a fully operable smartphone, and therefore may need to be equipped with a device for the duration of their training.
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