Using a mHealth tutorial application to change knowledge and attitude of frontline health workers to Ebola virus disease in Nigeria: a before-and-after study

The Ebola virus disease (EVD) outbreak in West Africa commenced in a remote area of southern Guinea in December 2013 while the first cases were reported in March 2014. Unlike previous outbreaks in East and Equatorial Africa [1] that were brought under control fairly swiftly, the West African outbreak is considered the worst in history due to an almost unimpeded spread from Guinea to Sierra Leone, Senegal, Liberia, Mali and Nigeria [2, 3]. The growing concern that followed its spread to other countries and the cumulative number of deaths led to the declaration of EVD as a Public Health Emergency of International Concern by the World Health Organization (WHO) in August 2014 [2]. EVD has a case fatality rate of 60–90%, and there is still no available drug or vaccine [3] for the disease [4].

The initial spread of EVD in West Africa was fuelled by socio-cultural factors and a collective failure to ensure availability of adequate health staff, basic healthcare resources and systems in the most affected countries [5, 6]. Subsequent patterns of spread revealed that health services in affected countries were overstretched by the epidemic [7] and that frontline health workers (FHWs) were at increased risk of contracting EVD by coming in contact with body fluids of infected patients. Many health workers who dealt with the outbreak were neither provided with protective clothing nor equipment to reduce their risk of infection when caring for patients and/or the deceased. In the USA and Spain where personal protective equipment was in abundant supply, FHWs were put at risk by inadequate training on how to safely provide medical care to persons with EVD. This situation led to an unprecedented number of infections and deaths among FHWs, thus depleting a vital asset during the control of the outbreak. By 12 April 2015, about 868 (or 3.4%) cases of Ebola reported globally were among health workers, 503 (or 2%) of who died from the disease [2, 6].

Understandably, the moral, physical and psychological consequences of the epidemic dampened the enthusiasm of FHWs [8] to provide essential services in affected countries. The hesitancy of FHWs to put themselves in harm’s way placed an even greater strain on fragile health systems. To counteract this situation, the presidents of affected countries and the Director-General of the WHO launched a joint $100 million emergency response to control the epidemic, including through providing adequate protective clothing, training and support for anyone who was in contact with Ebola patients [7]. Integral to the emergency plan were collaborations between national governments and mobile network providers to harness the high penetration of mobile phone subscription in Guinea (63/100 people), Liberia (60/100 people) and Sierra Leone (44/100 people) to provide low-cost, high-impact mobile health (mHealth) solutions [9] for mapping outbreaks, providing education interventions to support behaviour change [10] and providing reference and training materials that FHWs can download onto their phones [8, 11]. In many ways, the successful utilization of advanced wireless technologies to fight the Ebola outbreak in Nigeria drove the increased focus on mobile phones elsewhere in the region. These partnerships aimed to tap into phenomenal growths in information and communication technology (ICT) in low- and middle-income countries (LMICs), to improve health and healthcare services in countries affected by Ebola.

The use of mHealth technology refers to the incorporation of wireless devices such as mobile phones, tablets, personal diagnostic assistants (PDAs), patient-monitoring devices and other wireless devices into medical and public health practice to improve health or ensure healthcare [9, 11‐13]. Recent reviews show the explosive innovation in technology has inspired a proliferation of mHealth pilot initiatives, many of which have demonstrated that mHealth can alleviate specific health system barriers such as balancing multiple priorities, lack of appropriate tools to provide services and collect data, and limited access to training and supervision [14, 15].

Despite the utility of mHealth for strengthening health systems in a range of health fields including mother and child health (MCH), management of diabetes and HIV treatment [11], there is little empirical evidence of the effectiveness of mHealth in improving health system functions during the West African Ebola epidemic. This paper therefore aimed to assess the effect of using a tablet computer application to deliver an education intervention to change frontline health workers’ EVD-related knowledge and attitude in Nigeria. We sought to answer the following questions: (a) are tablet computer applications effective for streaming EVD-related tutorial to FHWs, in the context of an epidemic, and (b) what is the effect of the education intervention (tutorial) on FHWs’ knowledge about and attitude toward EVD? The hypotheses were that (i) EVD-related information can be delivered at a distance from tablet computers to FHWs in the context of an epidemic and (ii) tablet-delivered education intervention could positively change FHWs’ biomedical knowledge of EVD.

Only 2 of 14 participating facilities were tertiary-level facilities (see Table 1 for Akure and Ondo MCH hospitals). The remaining 12 facilities consisted of 6 secondary-level comprehensive health centres and 6 primary-level basic health centres, selected to represent the three senatorial districts of Ondo State (Ondo North, Ondo Central and Ondo South). Two hundred and three FHWs (or 72%) of the recruited 282 participants completed the pre-KAA, EAT and post-KAA surveys. Fifty-five of the 203 health workers (or 27%) were from Akure MCH located in the State capital while just two health workers (or 1%) from Odo-aiye health centre (Table 1). The majority of participants were female (185 people; 91%). There were 94 (46.3%) community health officers/primary healthcare workers (PHC), 26 (12.8%) nurses/midwives, 8 (3.9%) laboratory scientists and 75 (37%) in the subgroup of ‘others’ which comprised of auxiliary nurses, pharmacy technicians and health record staff.

One hundred and seventy-eight participants (or 87.7% of FHWs) had heard about EVD prior to the study while 25 (12.3%) had not. Most health workers (116; 57.1%) learnt about Ebola mainly from the radio and television (see Table 2).

Following the Ebola epidemic in West Africa, a number of KAP studies were conducted among the general population and/or health workers in Nigeria [29, 30], Sierra Leone [31], Liberia [32] and Cameroon [33], with a view to using the findings to design strategies for preventing transmission and caring for people affected by Ebola. Similarly, new mHealth learning courses were developed to equip FHWs in affected countries with targeted, high-quality, up-to-date information as a pathway to building resilient health systems that can respond to the epidemic [8, 34]. However, the new mobile learning courses (e.g. mHero associated courses) implemented in Guinea, Liberia and Sierra Leone [8] are yet to be empirically evaluated to establish their effectiveness as health system-strengthening tools. To our knowledge, this study conducted in Nigeria is the first pre- and post-evaluation of a mHealth-enabled education intervention in West Africa that aimed to change the knowledge and attitude of FHWs to EVD.

Our findings mirror those of other studies in two ways. First, the revelation that most FHWs had heard of EVD before our evaluation is consistent with findings of KAP surveys conducted among the general population which showed that the majority of respondents in Lagos [29, 35] and all respondents in Sierra Leone [32] had foreknowledge of EVD before participating in respective surveys. Our finding that most FHWs were aware of EVD prior to the survey is unsurprising considering that the present pre- and post-intervention survey was conducted after Nigeria successfully quarantined all known cases of Ebola. Second, the finding from Ondo State that radio and TV were the dominant sources of EVD information is corroborated by studies in Lagos that identified television as the commonest source of information followed by radio [29], whereas radio was the dominant source of EVD information in Sierra Leone followed by television [32]. These findings together underline the importance of electronic media for disseminating information during such outbreaks.

The effectiveness of the FLEM application in changing FHWs’ knowledge of EVD may be ascribed to disseminating educational materials in real time combined with the convenience of unfettered access to online learning materials by FHWs over a stipulated time period. This underlines the potential benefits of electronic dissemination of educational information to enhance FHWs’ learning. It is noteworthy that improvements in average knowledge of EVD occurred across all cadres rather than in a given category of FHWs. It is, however, unclear whether the reduction in post-EAT scores relating to questions about the natural host of Ebola virus reflects existing uncertainty in the scientific community on this issue.

Besides modest improvements in knowledge, the post-EAT reinforcement of positive attitudes of avoiding handshakes, avoiding bush meat and avoiding risky burial practices during the Ebola epidemic is reassuring. Nevertheless, our findings should be interpreted with caution. Despite a growing recognition in the academic community that it is difficult to obtain reliable information on people’s knowledge and attitudes from KAP surveys [36, 37], we speculate that the modest positive changes in knowledge and attitudes reported by FHWs in Ondo State may be indirectly driven by a desire to use their learning to minimize the risk of contracting EVD in the context of a high case fatality rate and absence of treatment [4]. We, however, acknowledge that getting the general population to change age-long traditions of eating local delicacies or changing norms of social greeting can be a daunting endeavour. Also, maintaining close contact with the remains of deceased family members is commonplace in Nigeria, a practice that was implicated in the propagation of the EVD outbreak in West Africa [31]. During the EVD outbreak in Nigeria, a lot of misinformation was spread via social media about how drinking and/or bathing with salty water or eating bitter kola can prevent EVD [38]. Some faith healers even proclaimed their ability to cure EVD. Reports of surveys conducted in Lagos 2014 showed that 5% of health workers thought EVD was a spiritual problem while 25% of them believed that traditional medicine could cure EVD [35]. We believe delivering correct health information/educational materials quickly and efficiently to FHWs would have been invaluable in countering such false claims in Lagos [34]. Similarly, equipping FHWs with appropriate information is critical in countering misconceptions, e.g. about the role of traditional healers and funeral practices in relation to EVD.

In clinical settings, hand washing and disinfection of clinical areas and equipment remain the cornerstone of infection control. These practices are applicable to EVD prevention as the Ebola virus can be easily denatured by most standard disinfectants used in healthcare [39, 40]. In ideal conditions, the Ebola virus may remain infective on surfaces for up to 6 days [41, 42]. Getting health workers to appreciate the importance of hand washing and disinfection is vital especially when dealing with EVD outbreaks. However, in addition to education interventions discussed in the above paragraphs, we acknowledge that changing age-long practices requires addressing multiple factors ranging from socio-cultural to environmental, economic and structural factors that influence the logic behind people’s behaviour [37, 43].

In conclusion, the FLEM mHealth tablet application appears to be effective for educating FHWs in the context of an epidemic. The modest changes in knowledge and attitudes recorded from the evaluation of this education intervention suggest that mHealth tutorial applications have potential for information dissemination and training of FHWs during EVD outbreaks. The user-friendly nature of this application and regular access to a limitless amount of educational materials, streamed in real time to FHWs, is a strong selling point of this application. Using mHealth tutorial applications as a means of bolstering the capability of health systems to manage disease conditions and improving health in LMICs should be explored further, especially given the increased global utilization of mobile technology and corresponding reduction in cost of mobile phone subscription.

Health Research and Ethics Committee Number: G.8061/99