Discussion

While the developing infrastructure to support E-learning and mobile technology within the health sphere holds profound promise, it also raises equally significant questions. The myriad ways that these technologies can be harnessed, and the seemingly endless possibilities that they produce, prompt us to wonder: are all mHealth solutions created equal? Indeed, as investment in mHealth continues to surge, rigorous evaluations of the efficacy and functionality of these platforms must be demanded. mHealth approaches for medical education are no exception. The stakes in this realm are particularly high from both an economic and health outcomes perspective, because they are primarily being created for and utilised in developing countries. Thus, reviewing the literature on employing mobile health technologies to train healthcare professionals in resource-limited settings can help to inform future policy and intervention design.

There was significant variation between the studies reviewed, both in terms of intended audience, intervention design, assessment method and outcome. The first theme to emerge from the analysis concerned who the targeted participants were in each of the articles. Three studies assessed the integration of mHealth solutions into the training of allied healthcare professionals,10–12 three assessed resident doctors,13–15 and another assessed undergraduate medical students.16 Therefore, depending on the users, some interventions aimed to deliver supplementary information for purposes of professional development while others were intended for point of care or workflow support.

One study introduced the low-cost Android tablet, connecTAB, to deliver video tutorials and remote online peer-tutoring for clinical skills training to Malaysian students.16 The connecTAB was specifically developed for areas with low bandwidth and videos were preloaded in order to circumvent the issue of streaming in areas with slow internet speeds, which was indicated as a barrier in several of the other studies reviewed, particularly Zolfo et al.11 The connecTAB, which is significantly less expensive than internet-enabled smartphones, could be one potential solution that might be useful for developing countries. The remaining studies used mobile phones as the medium through which to facilitate learning, with two studies requiring internet-enabled smartphones.11 ,14 Interventions using mobile phones included short message service (SMS), smartphones with internet access and preloaded relevant applications, an electronic dosing tool and a module-based clinical training programme. The final study assessed the incorporation of educational technology in a formal medical curriculum more broadly rather than focusing on the impact of a particular intervention.15 Indeed, this study gathered focus groups of students from two Nepalese teaching hospitals to explore the use and impact of educational technology in medical education, enabling the participants to drive the conversation rather than the interviewer. This methodology allowed several salient themes to be revealed, including the central role that social network sites play in educational attainment, among others. One of the most important things that Pimmer et al15 touch on is the concern among leaders in medical education that information and communication technology sacrifices quality of instruction and instead promotes a ‘copy and paste mentality’ whereby students search the internet for immediate answers to their questions rather than learning the content in its entirety. Some of the technologies reviewed, particularly the web-based applications, may be susceptible to similar criticism. This will be one of the pivotal obstacles that mHealth will be forced to grapple with.

Six of the studies utilised questionnaires to evaluate the knowledge acquired by participants, with five recruiting pre–post knowledge tests. Within these monitoring and evaluation schemes, though, there was much variance. The study that employed the connecTAB for clinical skills training,16 for example, utilised standardised Observed Structured Clinical Examination (OSCE) scores to assess outcomes. However, there was no control group with which to compare the changes in scores because all of the study's participants were given the technology. By contrast, one of the studies conducted in Tehran, Iran, “Comparison of Teaching about Breast Cancer via Mobile or Traditional Learning Methods in Gynecology Residents,” opted to use a pretest and a post-test to examine the efficacy of their SMS method compared to the traditional method by having a single cohort rather than distinct intervention and control groups.13 Not only did the mobile method have a better effect on learning compared to the traditional training, but participants also indicated that the former generated more interest in the subject. Surely the latter data, which are equally valuable, could not have been yielded without this single cohort methodology. Perhaps this study design merits further investigation, particularly because of its potential to capture things like functionality and user-friendliness, which are critical to gaining local buy-in for and the success of mHealth interventions. Also, since many of the technologies were intended to be pedagogical adjuncts to more traditional curriculums, it is often difficult to determine the extent to which the intervention is contributing to the results that we observe. This is also true of multipronged interventions. That being the case, it may prove useful to adopt more quantitative methods to determine the educational benefit of mHealth tools.

The studies were also quite diverse in terms of geography, ranging in location from Iran to Peru. Only one study, however, was carried out in Africa.14 This is striking for several reasons. First, the poor health outcomes that plague much of the continent, coupled with pervasive poverty and budget restraints, make Africa a seemingly perfect candidate for mHealth utilisation. Further, the number of cellphone subscribers and cellphone coverage in sub-Saharan Africa, more than that in the USA or Europe, suggests that these approaches would most likely be embraced and integrated into existing medical education with relative ease.9 Third, it is important to recognise that innovations in mHealth need to be developed with end-user stakeholders in mind and a one-size-fits-all approach is not appropriate. Technology and education developments need to be made so that they are targeted towards and relevant for the intended audience. To be sure, while the iPhone may prove a powerful tool in places like Peru, as Zolfo et al11 examine, the high investment cost for the Smartphones’ purchase could present a limitation and may not be a viable option in the context of countries with very low income per capita.

It would also be interesting to observe in greater detail the effect mHealth has on the training of allied healthcare professionals, including nurses and community healthcare workers. Health workers are inequitably distributed throughout the world, with severe imbalances between developed and developing countries. Sub-Saharan Africa faces the greatest challenge; with 11% of the world's population and 24% of the global burden of disease, it has only 3% of the world's health workers.17 To solve this healthcare worker shortage, community-based interventions have been proposed. It has been shown that a well-implemented community health programme can (1) reduce infant and child mortality and morbidity; (2) improve healthcare seeking behaviour and (3) provide low-cost interventions for common maternal and paediatric health problems. These community-based healthcare programmes are delivered through Community Healthcare Workers (CHWs), laypeople who live in the community and serve as a critical link between these communities and the primary healthcare system.18 CHWs perform a variety of roles including home visits, first aid, health education, family planning activities and referrals. Despite their importance, CHWs still have an ambiguous role within the healthcare system. More specifically, in a review, Delacollette et al observed that CHWs wanted to be more than symbolically remunerated for their services; they were eager to receive further training to expand their scope of practice.2 It is important to consider the training of these allied healthcare professionals, with the mHealth model being one potential way to ensure standardised, high-quality training. This is one critical direction that future studies should take as there is currently a lack of them.