The mCME Project: A Randomized Controlled Trial of an SMS-Based Continuing Medical Education Intervention for Improving Medical Knowledge among Vietnamese Community Based Physicians’ Assistants

Abstract

BackgroundCommunity health workers (CHWs) provide critical services to underserved populations in low and middle-income countries, but maintaining CHW’s clinical knowledge through formal continuing medical education (CME) activities is challenging and rarely occurs. We tested whether a Short Message Service (SMS)-based mobile CME (mCME) intervention could improve medical knowledge among a cadre of Vietnamese CHWs (Community Based Physician’s Assistants–CBPAs) who are the leading providers of primary medical care for rural underserved populations.MethodsThe mCME Project was a three arm randomized controlled trial. Group 1 served as controls while Groups 2 and 3 experienced two models of the mCME intervention. Group 2 (passive model) participants received a daily SMS bullet point, and were required to reply to the text to acknowledge receipt; Group 3 (interactive model) participants received an SMS in multiple choice question format addressing the same thematic area as Group 2, entering an answer (A, B, C or D) in their response. The server provided feedback immediately informing the participant whether the answer was correct. Effectiveness was based on standardized examination scores measured at baseline and endline (six months later). Secondary outcomes included job satisfaction and self-efficacy.Results638 CBPAs were enrolled, randomized, and tested at baseline, with 592 returning at endline (93.7%). Baseline scores were similar across all three groups. Over the next six months, participation of Groups 2 and 3 remained high; they responded to >75% of messages. Group 3 participants answered 43% of the daily SMS questions correctly, but their performance did not improve over time. At endline, the CBPAs reported high satisfaction with the mCME intervention, and deemed the SMS messages highly relevant. However, endline exam scores did not increase over baseline, and did not differ between the three groups. Job satisfaction and self-efficacy scores also did not improve. Average times spent on self-study per week did not increase, and the kinds of knowledge resources used by the CBPAs did not differ between the three groups; textbooks, while widely available, were seldom used.ConclusionsThe SMS-based mCME intervention, while feasible and acceptable, did not result in increased medical knowledge. We hypothesize that this was because the intervention failed to stimulate lateral learning. For an intervention of this kind to be effective, it will be essential to find more effective ways to couple SMS as a stimulus to promote increased self-study behaviors.Trial RegistrationClinicalTrials.gov NCT02381743

mCME project V.2.0: randomised controlled trial of a revised SMS-based continuing medical education intervention among HIV clinicians in Vietnam

“…As described previously, this was intended to balance the difficulties of the baseline and endline examinations and to minimise sharing of answers during the examinations themselves. 1 …”

“…From 2014 to 2015, we conducted a National Institutes of Health (NIH)-supported randomised controlled trial (RCT) of an SMS-based distance learning intervention: the mobile continuing medical education (mCME) project. 1 In that initial study, which we refer to as mCME V.1.0, 638 Vietnamese community-based physician’s assistants (CBPAs), a mid-level cadre of healthcare workers who provide the majority of primary care services nationwide, were randomised to either a comparison group or one of two mCME intervention groups that received either (1) daily text messages presenting medical facts or (2) daily text messages on these same topics but phrased as multiple-choice questions. Unfortunately, while the intervention proved to be well accepted, technically feasible and inexpensive, it failed to achieve our primary objective, which was to improve medical knowledge.…”

“…Rather, they accepted SMS messages quite literally, and many prepared for the exam by studying the answers to the text messages. 1 4 Participants did not increase the overall amount of time they spent on weekly self-study and engaged in ineffective activities for seeking answers to daily questions, such as Google searches, or asking fellow CBPAs for their opinions. While participants generally reported having access to medical textbooks, their use of formal medical texts was low at baseline and did not increase.…”

“…Based on feedback from the participants and discussions with our partners, we modified the intervention in key areas to better promote lateral learning, creating mCME V.2.0 (see table 1 ). 1 4 The updated intervention provided more structure around course content, and, by providing performance feedback SMS messages, strengthened the game-like aspects of the intervention. Here we report the results from this second NIH-supported RCT, conducted during 2016–2017 among Vietnamese HIV clinicians in three provinces.…”

text4peds: a randomised text‐messaging trial

“…There is growing evidence on the efficacy of these patient‐targeted interventions; however, the use of text messaging for medical education has not been well established. A randomised trial in Vietnam using text‐message‐based continuing medical education was well received, but did not show an improvement in knowledge scores . A 2011 randomised trial in China compared text messaging with a traditional lecture or workshop for improving medical knowledge, and showed a benefit in the texting group .…”