Mobile Learning as an Integral Part of Samrakshan IRIA national program

Authors: Ramesh Shenoy, Rijo M Choorakuttil, Rajalingam Bavaharan, Palanisamy Devarajan, Praveen K Nirmalan for the Samrakshan Team 

Running Title: Mobile Learning 

Author Affiliations

1. Ramesh S Shenoy,  Consultant Radiologist, Lisie Hospital, Ernakulam, Kerala, India 
2. Rijo M Choorakuttil, National Coordinator for Samrakshan IRIA, AMMA Center for Diagnosis and Preventive Medicine, Kochi, Kerala, India  
3. Rajalingam Bavaharan, Fetocare Magnum Imaging and Diagnostics, Trichy, Tamil Nadu, India
4. Palanisamy Devarajan, Nethra Scans and Genetic Clinic, Tiruppur, Tamil Nadu, India
5. Praveen K Nirmalan, Chief Research Mentor, AMMA ERF, AMMA Center for Diagnosis and Preventive Medicine, Kochi, Kerala, India

Corresponding Author: Rijo M Choorakuttil, National Coordinator for Samrakshan IRIA, AMMA Center for Diagnosis and Preventive Medicine, Kochi, Kerala, India. E-mail: rijomc@gmail.com   

Key words: Mobile Learning, Education, Samrakshan IRIA, Fetal Radiology, India

Mobile Learning (mLearning) can be defined as learning across multiple contexts, including social and content interactions, using personal portable electronic devices. [1] mLearning can thus be considered to include educational interventions using handheld, mobile devices connected through wireless connections to deliver educational content to healthcare professionals in order to remove the constraints of physical infrastructure, distance and time from learning and teaching. The construct of mLearning covers educational approaches, concepts, methods and technologies [2]. 

In 2013, the World Health Organization (WHO) had estimated a shortage of 2.6 million doctors worldwide exacerbated by migration from rural to urban areas within countries and migration between countries. [3,4] An important influence on the disproportionate distribution of health care professionals is the mismatch of content of training programs with the necessary skills, competencies, and experience for the context in which trainees will work [5]. Focused information and communication technologies (ICT) are increasingly recognized as platforms that can build robust, dynamic education and training platforms for health professionals addressing relevance and quality. [6,7]

Samrakshan is a nationwide program of IRIA that aims to reduce perinatal mortality in India. The program envisages a holistic and synergistic approach with other programs and approaches in India that are working towards reducing perinatal mortality with a proactive approach by fetal radiologists in India. Samrakshan aims to scale up the use of trimester specific Doppler studies that can help estimate risk for pre eclampsia and fetal growth restriction on an individual basis using a competing risk Bayesian model based algorithm. [8,9]  Samrakshan identified three immediate priorities for the scale up a) Standardizing definitions and protocols for pre eclampsia and fetal growth restriction b) Standardizing Doppler protocols including image quality and interpretations and c) improving use of the Bayesian model based algorithms for risk estimation at an individual level. 

A SWOT analysis was performed to identify potential strengths, weaknesses, opportunities and threats to the scale up at the national level.  The SWOT analysis is presented in brief. 

The identified strengths included (but not limited to)

• Support from the Indian Radiological and Imaging Association, the professional nodal organization of Radiologists in India that has approximately 17,000 members spread across India
• Radiology Curriculum that includes a detailed understanding of medical physics, fetal anatomy, ultrasound and other modes of examination
• Trainers certified and familiar with the use of the Bayesian model based algorithms
• Potential for State Level Instructors who can lead the training sessions for their states
• State and District level branches or chapters of the parent organization, IRIA, that can lead and organize micro level training
• Diversity of clinical material 
• Increased penetration of internet and digital services in India
• Increased uptake of portable electronic devices

Weaknesses

• Time, physical space and distance were identified as weaknesses for a traditional learning model that involved face to face interactions in a physical space (CMEs, Workshops)
• Busy clinical schedules and backlog of patients waiting for consultations 
• Unavailability or limited availability of qualified personnel who could cover in the absence of consultants
• Annual schedule packed with different CME and workshops
• Connectivity, Travel Time and distance to conference/workshop/CME sites
• Follow up support after CMEs and other educational initiatives limited by time, space and physical infrastructure

Opportunities

• Developing nationwide standards
• Standardizing and harmonizing clinical protocols nationwide
• Reaching out to individual practitioners in remote, rural areas enhancing their knowledge and skills
• Developing 24×7 learning teaching modules accessible to every practitioner
• Developing state level trainer of trainers

Threats

• Instrument upgradation may be required
• Software upgradation may be required
• Changing habits with respect to protocol based clinical exams
• Changing mind set regarding clinical practice applications already being done and acceptance by other health care professionals involved in fetal and maternal care.

Based on this analysis, it was decided to develop an educational model incorporating case studies from Indian contexts that can be used to demonstrate and educate on the various aspects of Samrakshan. The Need for a 24×7 accessible platform and content that is available through the country was identified. The limitations of CMEs and workshops to provide were considered and it was decided to integrate CMEs with other educational and pedagogical approaches rather than having them as stand alone exercises. The possibility of recording live sessions that can be downloaded, stored and viewed offline was considered. The best possible solution was identified as an internet or cloud based platform that can host content pertaining to different pedagogical approaches relating to all aspects of Samrakshan . These include support for audio visual content, documents, an online library, discussion forums and ability to assess progress of learners through assignments, quizzes and image audits. Several steps were initiated to develop a free learning module accessible to IRIA members 24×7 through electronic devices with the potential to store content offline. These include

• Development of a core pool of trainers
• Development of trimester specific modules
• Content focused on Doppler based exams and components of trimester specific exams
• Case studies
• Use of a Bayesian model based algorithm for risk estimation
• 1st trimester preventative and prognostic management of pre eclampsia
• 3rd Trimester stage based management of Fetal Growth Restriction 
• Online Data collection forms
• Image Audits

Till date, from inception in July 2019, a team of 17 instructors has been formed and content pertaining to 1st and 3rd trimester focused on Doppler studies focused on pre eclampsia and fetal growth restriction have been uploaded. 16 cases have been discussed in the forums covering diverse cases relevant to the course content and sourced from clinical material in India. Two hundred and seventy radiologists have registered for the courses in the learning platform. Eight hundred and twenty one data forms have been submitted. One hundred and seven pregnant women were identified as high risk for preterm pre eclampsia and 77 women as high risk for fetal growth restriction in the 1st trimester and started on low dose aspirin 150mg once daily at bedtime. Abnormal Doppler studies were present in 97 pregnant women in the 3rd trimester who were managed according to the stage based management protocol for fetal growth restriction followed in Samrakshan. Thirty five pregnancy outcome forms  have been submitted; there were no maternal deaths and one neonatal death (identified with fetal acidemia and Stage 4 FGR on 3rd trimester Doppler and ultrasound study, referred for immediate delivery to a higher center, live born but neonate succumbed a few days after delivery). The online learning platform has been supplemented by the creation of specific groups on WhatsApp (currently three groups are formed after CME programs in Madhya Pradesh,  Tamilnadu and Uttar Pradesh with 64, 77 and 57 members) and a WhatsApp group for the core committees (72 members) of Samrakshan. The WhatsApp groups provide another platform for instant clarifications, information about posting of new educational material, case discussions and focused peer-to-peer interactions within states. 

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