Infection prevention and control
There is increasing recognition of the importance of infection prevention and control (IPC) as a key component of epidemic preparedness and response and as a critical tool for keeping health workers (HWs) safe [
1‐
3]. HWs have higher rates of infection than the general population, particularly during epidemics, and weak IPC programs as well as gaps in emergency preparedness contribute to this risk [
1]. The COVID-19 pandemic has further highlighted the association between IPC and HW safety [
4,
5]. In the early months of the pandemic, HWs were three times more likely than members of the general population to have COVID-19 [
6]. While effective strategies for improving IPC programs and practices are an active area of research, an emerging consensus indicates that multiple synergizing approaches, including training, are required to bring about improvements in IPC [
7‐
9]. Notably, HWs who received IPC training were at lower risk of developing COVID-19 [
6]. Effective and continuous training is particularly important to keep HWs updated on rapidly evolving IPC guidance in the context of COVID-19 [
10]. Ongoing training will also be needed to address new epidemics of other infectious agents.
The World Health Organization (WHO) defines HWs broadly to encompass health service providers as well as managers and support personnel [
11]. A wide array of different HWs (including doctors, nurses, administrators, laboratory staff and community health workers) play a role in IPC implementation and require some foundational IPC knowledge to do their jobs safely and effectively [
7]. In addition, officials and HWs at all levels of the health system (national, subnational, district and local) play a role in IPC. However, IPC training is far from universal. A recent assessment of 88 countries’ national IPC programs found that just over half provide in-service IPC training, while fewer than half provide pre-service IPC training [
12]. In a recent survey comparing HWs’ access to personnel trained in IPC across the six different WHO regions, fewer than 40% of respondents in the African region reported that they had access to trained personnel “always” or “often,” the lowest of any WHO region [
13]. Although such surveys indicate that many HWs do not currently receive IPC training, less is known about the IPC knowledge of individual HWs across different countries and in different positions in the health system. Integrating assessments into training may be helpful to better define gaps in IPC knowledge and skills and develop targeted interventions to address those gaps.
Online learning: limitations and solutions
Many organizations replaced in-person training with online learning in response to restrictions on gathering and travel imposed during the COVID-19 pandemic. This shift required an expansion of online learning opportunities for HWs, which currently include massive open online courses (MOOCs) [
14], webinars [
15] and synchronous virtual communities of practice [
16]. However, accessing, engaging with and learning in online environments can be challenging even under optimal circumstances. Though MOOCs and other online courses are lauded for their potential to deliver learning at scale, their completion rates are low [
17,
18]. Moreover, high rates of learner multitasking online can impede focused learning [
19]. While these findings hint at the impediments to achieving depth of impact and scale through online learning [
17], a growing body of research points to best practices in online course design that improve engagement and learning. Simple and organized online learning experiences lead to less frustration and sustain learners’ sense of self-efficacy [
20], while focusing on only essential content improves knowledge retention [
21]. Assessment that is designed to provide feedback and promote learning rather than to evaluate learners (formative assessment) is a powerful way to activate learning offline and online [
22,
23]. The addition of short explanations after assessment questions improves learners’ perceptions of the learning experience [
24]. Course design factors also influence learner engagement and retention. For example, shorter online courses and those with deadlines have higher completion rates [
25,
26].
Online learning for HWs in Africa
In both online and face-to-face learning, content- and learner-specific factors influence course completion and learning outcomes. When learners believe content has career utility or relevance to their daily professional lives, they are more likely to persist [
27] and HWs report higher interest in online learning that is relevant to their work [
28]. The efficacy of different online learning approaches is context-dependent: working adults who prioritize flexibility prefer self-paced learning, but this modality might disadvantage learners who are less motivated or need more structure. Moreover, online learning is not equally suited to all of the knowledge, skills and abilities that HWs need to develop [
29]. It can be challenging to teach and assess complex clinical skills in a virtual setting [
28]. Online learning may be a useful tool to address existing gaps in IPC training, but more work needs to be done to delineate what IPC knowledge, skills and behaviors can be effectively taught online.
Residents of low- and middle-income countries face some additional barriers to learning online. In Africa, most internet users connect using mobile broadband (rather than fixed connections), and mobile network coverage is still rapidly growing. As of 2020, an estimated 77% of the African population is within range of a 3G wireless signal [
30], though it is likely that access to internet and mobile devices is higher among HWs [
13]. Factors other than the reach and quality of internet connections (including reliability of electrical service, wireless data and device costs and digital literacy skills gaps) represent additional barriers to access and use of internet resources [
30,
31]. This environment favors the adoption of simple, mobile-compatible and user-friendly web applications that do not consume much data.
Although the objective of most training is to develop learners’ knowledge and skills, more accessible metrics, such as participation, completion and learner satisfaction are more frequently evaluated [
32]. Only a fraction of studies evaluating online medical education in low- and middle-income countries report learning gains [
33]. There are comparatively few studies that assess fully online training of in-service HWs in Africa, perhaps in part because the continent is under-represented in the medical education research literature [
34]. In the case of one app-based training for nurses and midwives in Rwanda, learners received a half-day in-person introduction to the app and were coached on its use during frequent site visits [
35]. In a training on Ebola Virus Disease in Nigeria, HWs accessed the training via tablets placed in health facilities [
36]. There were significant short-term learning gains in both studies, though long-term knowledge gains were not assessed. It may be logistically complex and costly to scale up interventions that involve providing learners with devices and in-person support, challenges that are heightened by COVID-19-related travel restrictions and safety measures. These cases highlight the need for more research on the efficacy and limitations of fully online training for learners in Africa.
In this work, we hypothesized that online learning for HWs in Africa could be improved by designing learning experiences that play to the strengths of online learning and proactively address the barriers faced by this population of learners.