Blended learning in HSSR: experiences from ARCADE * Young T, * Dudley L, * Khondowe O, * Chola L, ⱡProtsiv M, ⱡ * Zwarenstein M *Faculty of Medicine and Health Sciences, Stellenbosch University; ⱡ Karolinska Institute

About ARCADE HSSR • The African Region Capacity Development for Health Systems and Services Research (ARCADE-HSSR) project, is a European Union (EU) funded project commissioned in 2011. The aim of ARCADE is to strengthen Health Systems and Services Research (HSSR) in Africa. Stellenbosch University (SU) has partnered with other institutions in Africa and Europe to develop post-graduate, doctoral and post-doctoral training. The ARCADE-HSSR partners are developing cutting-edge online courses, blended learning modules and joint programmes that will enable training of researchers in low- and middle-income countries who might not otherwise have access to such material.

• Core content was based on the Trial Protocol Tool (TPT) www.practihc.net/toolindex.htm • The RCT module was adapted in 2012 for blended learning for MSc students and PhD candidates in HSSR within ARCADE HSSR; • The RCT blended learning module was piloted between July and October 2012, with participation of 25 students at SU; 3 at KI and 3 at MU.

• Asynchronous learning through the Moodle platform was complemented by additional e-learning resources such as online video and audio recordings. Software options and tools were tested to create podcasts and vodcasts (e.g. Camtasia, video recording). • Synchronous learning was possible by linking participants at all institutions to the ‘live’ lectures and discussions using Scopia.

An Evaluation Framework of E-learning

Delivery: Lessons learnt

ARCADE Work packages

People: Lessons Learnt WP 4: Delivery of Blended Learning Objectives :

• To facilitate teaching/learning in innovative ways, by using appropriate technology and providing opportunities through decentralised learning; • To develop, and implement, a web platform on which modules can be mounted for download, with capacity for student registration, interactive learning, and progress assessment and testing. • To develop the capacity of participating faculty and students in the use of information and communication technologies (ICT) to support postgraduate studies; • To implement course modules in blended learning approaches- mix of face to face, web based and self learning courses at each hub university.

• The P3 model (Khan 2004) proposed discrete teams to undertake different tasks and phases of e-learning. This was not possible in a resource constrained environment. • Within ARCADE, the same academic staff have to fulfil multiple roles, with limited support from specialised expertise in technology and education; • The appointment of teaching assistants was necessary to develop suitable e-learning tools such as on-line exercises and MCQ quizzes, to refresh materials and information on the learning platform, and to facilitate discussion lists; • Ongoing participation of dedicated ICT support staff at all participating institutions was critical in the planning and design phase, particularly in decision making on appropriate hardware and software, and to support delivery in the different environments.

Evidence on e-learning

Process: Lessons learnt

• A meta-analysis of 201 studies on e-learning interventions in medical education1 found that:-- E-learning has similar outcomes to face to face teaching in acquiring knowledge, skills and behaviours; -- Longer and more interactive e-learning i.e. practise exercises, tutorials, online peer discussions, were associated with better learning outcomes

• Core planning, design and delivery of the module occurred at SU, but depended on participation of all partners; • To ensure appropriateness of course design and delivery, the process required complex coordination within and across at least 4 institutions and countries with numerous teleconferences, Skype meetings, and email correspondence with multiple role players at each; • Teams tended to focus on technology more than pedagogy, with less time on design of teaching and learning; • Clear and knowledgeable leadership on ICT, with a sound understanding of academic and ICT context in Africa, was needed to steer the project through the maze of proposed options and limitations in delivering e-learning in Africa; • Active communication, coordination and project management are needed to ensure that participants within and across institutions are clear on goals, roles, deliverables and time frames.

• The planning of the RCT blended module was informed by this evidence; • Formative and summative evaluations of the blended learning module were planned to inform further e-learning development in ARCADE HSSR. • Models of evaluation of e-learning2,3 were identified 1. Cook D, Levinson A, Garside S et al. Internet-Based Learning in the Health Professions: A meta-analysis. JAMA. 2008;300(10):1181-1196 ; 2. Khan, B.H. (2004). Comprehensive approach to program evaluation in open and distributed learning (CAPEODL) model. Introduced in the Program Evaluation course. George Washington University. 3. Khan, B. H. (2004a, September-October). People, process and product continuum in e-learning: The e-learning P3 model. Educational Technology. Vol.44, No. 5. pp. 33-40. http://bookstoread.com/etp/ elearning-p3model.pdf

Blended module on Randomised Control Trials • The RCT module was designed and delivered as face to face teaching on a MSc in Epidemiology programme at Stellenbosch University since 2009 www.sun.ac.za/clinepi

Product: Lessons Learnt • The availability of on line resources such as the Trial Protocol Tool facilitated the process of development of a blended learning module on RCT’s; • However TPT needed to be adapted, updated and placed on a common learning platform. Moodle was selected as an open source e-learning platform which was accessible, affordable, functional in the different environments and user friendly; • Additional teaching and learning material and activities were successfully built around the TPT to fill gaps and complement content e.g. Ethics and Good Clinical Practise.

• Asynchronous learning: students were able to register on the learning system, and to access reading materials and the TPT to prepare for the module.

-- SU students had used another learning platform (Blackboard), and some were unhappy to change learning systems, but most found the platform easy to adapt to and user friendly. -- ICT staff were able to monitor visits and use of different resources on the site by students, provide feedback to course convenors, and support students who experienced difficulties; -- Most students (>20) accessed the platform frequently (every 3-7 days), and used online self-assessment quizzes (18); -- There was limited participation in on-line discussion lists. Lecturers and tutors will need to engage more with students on the e-learning platform to facilitate this. -- Assignments were submitted on-line, and marks and feedback provided to students on the system; • Synchronous learning: the ‘live’ links between the SU classroom, MU and KI students functioned well with minor technical problems. -- Some SU students had difficulty with ‘interruptions’ as a result of questions from other sites. Students at MU and KI found the access easy, and teaching and interaction useful. Generally students felt that more interaction between the sites and students would have been useful. -- Lecturers were not experienced in manage teaching across multiple sites, and will need further training in facilitating this interaction. -- Trained tutors played an important role in supporting students at the ‘distant’ sites.

Conclusions • It is possible in an African context to increase access to and share scarce resources for teaching and learning in HSSR for postgraduate students using e-learning systems; • Strong communication, coordination and project management across multiple institutions is needed to plan and deliver such programmes; • Additional requirements include ICT support for design and delivery, training of lecturers in use of e-learning, teaching assistants and other support staff; • Formative evaluations have assisted in the adaptation and further improvement of the programme; • Ongoing evaluation will assess learning outcomes, and more in-depth studies are planned on the pedagogy of e-learning systems for postgraduates in HSSR.

ARCADE HSSR Partners • Karolinska Institutet, IHCAR, Sweden • Makerere University, College of Health Sciences, Uganda • Stellenbosch University, Faculty of Health Sciences, South Africa • Institute of Development Studies, University of Sussex, UK • Muhimbili University of Health and Allied Sciences, Tanzania • University of Malawi, College of Medicine, Malawi • Norwegian Knowledge Centre for Health Services, Norway • The ARCADE HSSR project is funded by an EU FP7 grant.