Setting
This blended learning experience was piloted in Guinea, a West African country with approximately 12 million inhabitants (in 2018), 64% of whom live in rural areas [22, 23]. The Guinean health system has three levels: local (38 health districts), intermediate (eight health regions), and central (MoH) [24]. In 2018, the health personnel working under the authority of the Ministry of Health was 15,889, including 2476 medical doctors, 217 pharmacists, 5249 paramedical staff (nurses, midwives, biologists, laboratory technicians), 4933 administrative and technical staff, and 3014 community health workers [25]. The national education system is organized into pre-university, university, and technical and vocational training levels. Medical training is provided by one governmental university (UGANC) and two private ones (the Kofi Annan University and the La Source University). The training of paramedical personnel, in particular nurses, midwives, and community health workers, is mainly provided by health schools (public and private) under the supervision of the Ministère de l’Enseignement Technique, de la Formation Professionnelle, de l’Emploi et du Travail. The three aforementioned universities also train paramedical personnel. The CNFRSR was created on November 16, 1988, and attached to the MoH with namely the following aims: 1) participating in the continuing education of human resources for health nationwide, 2) undertaking operational socio-health research to make recommendations for improving public health status, 3) providing care to the population of Maferinyah, and 4) delivering practical training for medical students in primary health care (PHC) (Présidence de la république de Guinée: Décret No95/233/PRG/SGG portant attributions et organisation du centre de formation et de recherche en santé rurale de Maferinyah, unpublished).
Blended learning course design and delivery
As part of this blended learning experience, a team from CNFRSR developed two courses whose outlines were designed using the ‘backward design’ model [26,27,28]. Seven modules were developed for the eSSP course (introduction to PHC, local health system, PHC data management, monitoring of a health area, quality and integration of PHC, Community health approaches, and Health promotion). Eight modules were developed for the eSSR course (Introduction to Sexual and Reproductive Health (SRH), Local Health System, SRH data management, monitoring of a health area, quality and integration of care in SRH, Community approaches in SRH, SRH Promotion, and Gender and rights in SRH). A detailed description of the training design and implementation process has been published elsewhere [29]. A team from CNFRSR was first trained in e-learning through a blended learning program at ITM. An ITM team provided technical and scientific support throughout the development process of the training. The courses targeted health professionals, including medical doctors, nurses, midwives, community health workers, public health technicians, and last-year medical school students.
Learners were selected based on the following criteria: profession (health personnel), current occupation, motivation to take the course, exposure to computer and internet, residence, and nationality. Although the courses were specifically designed for the Guinean health workforce, they were also opened to foreigners who met the selection criteria to test the scope of the courses and get some feedback from French-speaking participants residing in other African countries. Thus, the courses were implemented by cohort of 20 to 25 learners, including at most five who were foreigners or resided outside Guinea. One administrator for each course was responsible for developing the contents of the modules and mentoring over the course duration. Each week-long module had an ‘expert’ facilitator who was in charge of responding to learners’ questions in the discussion forum. Learners were given a catch-up week after the first four modules and another catch-up week after the last module. The learning platform (Moodle) was locally managed by information technology (IT) specialist supported by ITM staff. A local course coordinator led the program. A face-to-face capacity-building workshop for learners from the second and third cohorts of both courses was organized.
The Kirkpatrick model (Fig. 1) was used for the training evaluation [30] and the results presented in this paper are based on levels 1 and 2 of this model.
Study design and period
An evaluation of the implementation of the first phase (January 15, 2018, to January 15, 2019) of both courses (eSSP and eSSR) was conducted. It was a cross-sectional study using a mixed-methods approach.
Study population and sampling
The quantitative strand included all enrollees (doctors, nurses, midwives, community health workers, public health technicians, and last-year medical school students) for both courses and all those who completed the courses and filled in the individual course evaluation form. Exhaustive sampling was therefore used for this quantitative component.
The qualitative strand focused on the learners who attended the face-to-face capacity-building workshop (after passing the online stage of the training). Only learners residing in Guinea were purposively selected to attend the workshop, and among these attendees, we interviewed those who consented.
Data sources and collection procedures
The quantitative data was collected directly from learners’ selection databases and the results of the different cohorts. Additionally, the individual course evaluation form administered online at the end of each cohort was used for quantitative data collection. This course evaluation form included closed questions whose response options were framed following the Likert scale [31]. Finally, qualitative data was collected through learners’ interviews on the last day of the capacity-building workshop using an individual interview guide and authors’ personal reflection from the course design and implementation process.
Quantitative data
Sociodemographic characteristics (age, sex, profession, residence, nationality, working time, course taken, and cohort) were collected. Course results (completion, success, dropout, and abstention) and learners’ perceptions of the courses and support from the instructors were compiled. Learners’ perceptions were collected of the following aspects: the relevance or adaptation of the courses for the targeted health professionals, the adaptation of the courses to the local health system, the structure and usefulness of pdf course materials, the relevance of the content of modules, comprehensibility of video presentations, helpfulness of discussion forum, helpfulness of additional learning materials, helpfulness of self-assessment quizzes, the relevance of summative assessment quizzes, the relevance of summative assessment assignments, the occurrence of technical problems for accessing learning materials, navigation on the online learning platform, course delivery accordance with the timetable, facilitators’ backgrounds and relevance of their responses to learners’ questions, the regular monitoring of learners by the administrators and their responsiveness to learners’ concerns, and the willingness of learners to recommend the courses to their colleagues and friends.
Qualitative data
We collected learners’ feedback on their blended learning experience. The personal reflection focused on the lessons learned throughout the training and the challenges faced.
Operational definitions
Completion rate
Is the number of learners who completed the course by performing all learning activities over the total number of enrollees.
Dropout rate
Is the number of learners who dropped out from the course after completing some activities over the total number of enrollees.
Abstention rate
Is the number of enrollees who ultimately did not log into the online learning platform although they had received all necessary information to get access over the total number of enrollees.
Success rate
Is the number of learners who passed the course (with an overall mean of marks greater than or equal to 5 out of 10) over the number of learners who completed the course (success rate for learners who completed the course), and over the total number of enrollees (success rate for enrollees). Successful completion was used as the operational measure of success.
Data analysis
Quantitative analysis
The data of the applicants and enrollees and the quantitative information retrieved from the course evaluation form were analyzed using the STATA software version 15 (Stata Corporation, College Station, TX, USA). Descriptive statistics were performed as proportions for categorical variables and as mean with standard deviation for continuous variables. We used Pearson’s chi-squared test and Fisher’s exact test to compare categorical variables and the Student’s t-test to compare continuous variables in the univariate analysis. A binary logistic regression was performed, and the odds ratios (OR; crude and adjusted) were calculated by considering the learners’ success as a dichotomous variable coded to 1 when the learner succeeded the course and 0 when he/she failed. All study variables with a p-value < 0.20 in the univariate analysis were included in the multivariate logistic regression. The significance level was set at 5%, with 95% confidence intervals.
Qualitative analysis
The qualitative data was analyzed using the content analysis approach.
The interviews conducted in French were recorded, then fully transcribed and translated into English manually. Then, we coded information into two categories (strengths and weaknesses) using inductive coding, which based on syntactic (keywords) and semantic (main ideas) analysis units. We processed data manually (semantic analysis) following interviewees’ main ideas and keywords and the resulting meaning [32, 33].
Ethical considerations
The research protocol was approved by the National Ethics Committee for Health Research in Guinea (No: 022/CNERS/2020) and the ITM Institutional Review Board in Belgium (IRB Reference Code: 1363/20). Regarding the qualitative component of the study, free, informed, and oral consent was obtained from each selected participant before carrying out the interviews, and the data collected were coded. Both quantitative and qualitative data were only accessible to the research team. The database is stored on a computer protected by a password at the CNFRSR.