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Article ; Online: Evaluating the documentation of vital signs following implementation of a new comprehensive newborn monitoring chart in 19 hospitals in Kenya: A time series analysis.

Muinga, Naomi / Tuti, Timothy / Mwaniki, Paul / Gicheha, Edith / Paton, Chris / Beňová, Lenka / English, Mike

PLOS global public health

2023 Volume 3, Issue 11, Page(s) e0002440

Abstract: Multi-professional teams care for sick newborns, but nurses are the primary caregivers, making nursing care documentation essential for delivering high-quality care, fostering teamwork, and improving patient outcomes. We report on an evaluation of vital ... ...

Abstract	Multi-professional teams care for sick newborns, but nurses are the primary caregivers, making nursing care documentation essential for delivering high-quality care, fostering teamwork, and improving patient outcomes. We report on an evaluation of vital signs documentation following implementation of the comprehensive newborn monitoring chart using interrupted time series analysis and a review of filled charts. We collected post-admission vital signs (Temperature (T), Pulse (P), Respiratory Rate (R) and Oxygen Saturation (S)) documentation frequencies of 43,719 newborns with a length of stay > 48 hours from 19 public hospitals in Kenya between September 2019 and October 2021. The primary outcome was an ordinal categorical variable (no monitoring, monitoring 1 to 3 times, 4 to 7 times and 8 or more times) based on the number of complete sets of TPRS. Descriptive analyses explored documentation of at least one T, P, R and S. The percentage of patients in the no-monitoring category decreased from 68.5% to 43.5% in the post-intervention period for TPRS monitoring. The intervention increased the odds of being in a higher TPRS monitoring category by 4.8 times (p<0.001) and increased the odds of higher monitoring frequency for each vital sign, with S recording the highest odds. Sicker babies were likely to have vital signs documented in a higher monitoring category and being in the NEST360 program increased the odds of frequent vital signs documentation. However, by the end of the intervention period, nearly half of the newborns did not have a single full set of TPRS documented and there was heterogenous hospital performance. A review of 84 charts showed variable documentation, with only one chart being completed as designed. Vital signs documentation fell below standards despite increased documentation odds. More sustained interventions are required to realise the benefits of the chart and hospital-specific performance data may help customise interventions.
Language	English
Publishing date	2023-11-01
Publishing country	United States
Document type	Journal Article
ISSN	2767-3375
ISSN (online)	2767-3375
DOI	10.1371/journal.pgph.0002440
Database	MEDical Literature Analysis and Retrieval System OnLINE

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Article ; Online: Implementing a comprehensive newborn monitoring chart: Barriers, enablers, and opportunities.

Muinga, Naomi / Abejirinde, Ibukun-Oluwa Omolade / Benova, Lenka / Paton, Chris / English, Mike / Zweekhorst, Marjolein

PLOS global public health

2022 Volume 2, Issue 7, Page(s) e0000624

Abstract: Documenting inpatient care is largely paper-based and it facilitates team communication and future care planning. However, studies show that nursing documentation remains suboptimal especially for newborns, necessitating introduction of standardised ... ...

Abstract	Documenting inpatient care is largely paper-based and it facilitates team communication and future care planning. However, studies show that nursing documentation remains suboptimal especially for newborns, necessitating introduction of standardised paper-based charts. We report on a process of implementing a comprehensive newborn monitoring chart and the perceptions of health workers in a network of hospitals in Kenya. The chart was launched virtually in July 2020 followed by learning meetings with nurses and the research team. This is a qualitative study involving document review, individual in-depth interviews with nurses and paediatricians and a focus group discussion with data clerks. The chart was co-designed by the research team and hospital staff then implemented using a trainer of trainers' model where the nurses-in-charge were trained on how to use the chart and they in turn trained their staff. Training at the hospital was delivered by the nurse-in-charge and/or paediatrician through a combined training with all staff or one-on-one training. The chart was well received with health workers reporting reduced writing, consolidated information, and improved communication as benefits. Implementation was facilitated by individual and team factors, complementary projects, and the removal of old charts. However, challenges arose related to the staff and work environment, inadequate supply of charts, alternative places to document, and inadequate equipment. The participants suggested that future implementation should be accompanied by mentorship or close follow-up, peer experience sharing, training at the hospital and in pre-service institutions and wider stakeholder engagement. Findings show that there are opportunities to improve the implementation process by clarifying roles relating to the filing system, improving the chart supply process, staff induction and specifying a newborn patient file. The chart did not meet the need for supporting documentation of long stay patients presenting an opportunity to explore digital solutions that might provide more flexibility and features.
Language	English
Publishing date	2022-07-25
Publishing country	United States
Document type	Journal Article
ISSN	2767-3375
ISSN (online)	2767-3375
DOI	10.1371/journal.pgph.0000624
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Article ; Online: Development of a small and sick newborn clinical audit tool and its implementation guide using a human-centred design approach newborn clinical audit process and design.

Ogola, Muthoni / Wainaina, John / Muinga, Naomi / Kimani, Wairimu / Muriithi, Maureen / Aluvaala, Jalemba / English, Mike / Irimu, Grace

PLOS global public health

2023 Volume 3, Issue 2, Page(s) e0001577

Abstract: Clinical audits are an important intervention that enables health workers to reflect on their practice and identify and act on modifiable gaps in the care provided. To effectively audit the quality of care provided to the small and sick newborns, the ... ...

Abstract	Clinical audits are an important intervention that enables health workers to reflect on their practice and identify and act on modifiable gaps in the care provided. To effectively audit the quality of care provided to the small and sick newborns, the clinical audit process must use a structured tool that comprehensively covers the continuum of newborn care from immediately after birth to the period of newborn unit care. The objective of the study was to co-design a newborn clinical audit tool that considered the key principles of a Human Centred Design approach. A three-step Human Centred Design approach was used that began by (1) understanding the context, the users and the available audit tools through literature, focus group discussions and a consensus meeting that was used to develop a prototype audit tool and its implementation guide, (2) the prototype audit tool was taken through several cycles of reviewing with users on real cases in a high volume newborn unit and refining it based on their feedback, and (3) the final prototype tool and the implementation guide were then tested in two high volume newborn units to determine their usability. Several cycles of evaluation and redesigning of the prototype audit tool revealed that the users preferred a comprehensive tool that catered to human factors such as reduced free text for ease of filling, length of the tool, and aesthetics. Identified facilitators and barriers influencing the newborn clinical audit in Kenyan public hospitals informed the design of an implementation guide that builds on the strengths and overcomes the barriers. We adopted a Human Centred Design approach to developing a newborn clinical audit tool and an implementation guide that we believe are comprehensive and consider the characteristics of the context of use and the user requirements.
Language	English
Publishing date	2023-02-23
Publishing country	United States
Document type	Journal Article
ISSN	2767-3375
ISSN (online)	2767-3375
DOI	10.1371/journal.pgph.0001577
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Article ; Online: Lessons from the design, development and implementation of a three-dimensional (3D) neonatal resuscitation training smartphone application: Life-saving Instruction for Emergencies (LIFE app).

Wanyama, Conrad / Nagraj, Shobhana / Muinga, Naomi / Tuti, Timothy / Edgcombe, Hilary / Geniets, Anne / Winters, Niall / English, Mike / Rossner, Jakob / Paton, Chris

Advances in simulation (London, England)

2022 Volume 7, Issue 1, Page(s) 2

Abstract: Neonatal mortality remains disproportionately high in sub-Saharan Africa partly due to insufficient numbers of adequately trained and skilled front-line health workers. Opportunities for improving neonatal care may result from upskilling frontline health ...

Abstract	Neonatal mortality remains disproportionately high in sub-Saharan Africa partly due to insufficient numbers of adequately trained and skilled front-line health workers. Opportunities for improving neonatal care may result from upskilling frontline health workers using innovative technological approaches. This practice paper describes the key steps involved in the design, development and implementation of an innovative smartphone-based training application using an agile, human-centred design approach. The Life-saving Instruction for Emergencies (LIFE) app is a three-dimension (3D) scenario-based mobile app for smartphones and is free to download. Two clinical modules are currently included with further scenarios planned. Whilst the focus of the practice paper is on the lessons learned during the design and development process, we also share key learning related to project management and sustainability plans, which we hope will help researchers working on similar projects.
Language	English
Publishing date	2022-01-10
Publishing country	England
Document type	Journal Article
ISSN	2059-0628
ISSN (online)	2059-0628
DOI	10.1186/s41077-021-00197-7
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Article ; Online: Evaluation of Adaptive Feedback in a Smartphone-Based Game on Health Care Providers' Learning Gain: Randomized Controlled Trial.

Tuti, Timothy / Winters, Niall / Edgcombe, Hilary / Muinga, Naomi / Wanyama, Conrad / English, Mike / Paton, Chris

Journal of medical Internet research

2020 Volume 22, Issue 7, Page(s) e17100

Abstract: Background: Although smartphone-based emergency care training is more affordable than traditional avenues of training, it is still in its infancy, remains poorly implemented, and its current implementation modes tend to be invariant to the evolving ... ...

Abstract	Background: Although smartphone-based emergency care training is more affordable than traditional avenues of training, it is still in its infancy, remains poorly implemented, and its current implementation modes tend to be invariant to the evolving learning needs of the intended users. In resource-limited settings, the use of such platforms coupled with gamified approaches remains largely unexplored, despite the lack of traditional training opportunities, and high mortality rates in these settings. Objective: The primary aim of this randomized experiment is to determine the effectiveness of offering adaptive versus standard feedback, on the learning gains of clinicians, through the use of a smartphone-based game that assessed their management of a simulated medical emergency. A secondary aim is to examine the effects of learner characteristics and learning spacing with repeated use of the game on the secondary outcome of individualized normalized learning gain. Methods: The experiment is aimed at clinicians who provide bedside neonatal care in low-income settings. Data were captured through an Android app installed on the study participants' personal phones. The intervention, which was based on successful attempts at a learning task, included adaptive feedback provided within the app to the experimental arm, whereas the control arm received standardized feedback. The primary end point was completion of the second learning session. Of the 572 participants enrolled between February 2019 and July 2019, 247 (43.2%) reached the primary end point. The primary outcome was standardized relative change in learning gains between the study arms as measured by the Morris G effect size. The secondary outcomes were the participants individualized normalized learning gains. Results: The effect of adaptive feedback on care providers' learning gain was found to be g=0.09 (95% CI -0.31 to 0.46; P=.47). In exploratory analysis, using normalized learning gains, when subject-treatment interaction and differential time effect was controlled for, this effect increased significantly to 0.644 (95% CI 0.35 to 0.94; P<.001) with immediate repetition, which is a moderate learning effect, but reduced significantly by 0.28 after a week. The overall learning change from the app use in both arms was large and may have obscured a direct effect of feedback. Conclusions: There is a considerable learning gain between the first two rounds of learning with both forms of feedback and a small added benefit of adaptive feedback after controlling for learner differences. We suggest that linking the adaptive feedback provided to care providers to how they space their repeat learning session(s) may yield higher learning gains. Future work might explore in more depth the feedback content, in particular whether or not explanatory feedback (why answers were wrong) enhances learning more than reflective feedback (information about what the right answers are). Trial registration: Pan African Clinical Trial Registry (PACTR) 201901783811130; https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=5836. International registered report identifier (irrid): RR2-10.2196/13034.
MeSH term(s)	Adult ; Double-Blind Method ; Feedback ; Female ; Health Personnel/trends ; Humans ; Learning Health System/trends ; Male ; Smartphone/instrumentation ; Smartphone/standards ; Video Games/psychology
Language	English
Publishing date	2020-07-06
Publishing country	Canada
Document type	Journal Article ; Randomized Controlled Trial ; Research Support, Non-U.S. Gov't
ZDB-ID	2028830-X
ISSN	1438-8871 ; 1439-4456
ISSN (online)	1438-8871
ISSN	1439-4456
DOI	10.2196/17100
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Article ; Online: Digital health Systems in Kenyan Public Hospitals: a mixed-methods survey.

Muinga, Naomi / Magare, Steve / Monda, Jonathan / English, Mike / Fraser, Hamish / Powell, John / Paton, Chris

BMC medical informatics and decision making

2020 Volume 20, Issue 1, Page(s) 2

Abstract: Background: As healthcare facilities in Low- and Middle-Income Countries adopt digital health systems to improve hospital administration and patient care, it is important to understand the adoption process and assess the systems' capabilities. This ... ...

Abstract	Background: As healthcare facilities in Low- and Middle-Income Countries adopt digital health systems to improve hospital administration and patient care, it is important to understand the adoption process and assess the systems' capabilities. This survey aimed to provide decision-makers with information on the digital health systems landscape and to support the rapidly developing digital health community in Kenya and the region by sharing knowledge. Methods: We conducted a survey of County Health Records Information Officers (CHRIOs) to determine the extent to which digital health systems in public hospitals that serve as internship training centres in Kenya are adopted. We conducted site visits and interviewed hospital administrators and end users who were at the facility on the day of the visit. We also interviewed digital health system vendors to understand the adoption process from their perspective. Semi-structured interview guides adapted from the literature were used. We identified emergent themes using a thematic analysis from the data. Results: We obtained information from 39 CHRIOs, 58 hospital managers and system users, and 9 digital health system vendors through semi-structured interviews and completed questionnaires. From the survey, all facilities mentioned purchased a digital health system primarily for administrative purposes. Radiology and laboratory management systems were commonly standalone systems and there were varying levels of interoperability within facilities that had multiple systems. We only saw one in-patient clinical module in use. Users reported on issues such as system usability, inadequate training, infrastructure and system support. Vendors reported the availability of a wide range of modules, but implementation was constrained by funding, prioritisation of services, users' lack of confidence in new technologies and lack of appropriate data sharing policies. Conclusion: Public hospitals in Kenya are increasingly purchasing systems to support administrative functions and this study highlights challenges faced by hospital users and vendors. Significant work is required to ensure interoperability of systems within hospitals and with other government services. Additional studies on clinical usability and the workflow fit of digital health systems are required to ensure efficient system implementation. However, this requires support from key stakeholders including the government, international donors and regional health informatics organisations.
MeSH term(s)	Health ; Hospitals, Public ; Humans ; Kenya ; Medical Informatics ; Surveys and Questionnaires
Language	English
Publishing date	2020-01-06
Publishing country	England
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	2046490-3
ISSN	1472-6947 ; 1472-6947
ISSN (online)	1472-6947
ISSN	1472-6947
DOI	10.1186/s12911-019-1005-7
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Article ; Online: Designing paper-based records to improve the quality of nursing documentation in hospitals: A scoping review.

Muinga, Naomi / Abejirinde, Ibukun-Oluwa Omolade / Paton, Chris / English, Mike / Zweekhorst, Marjolein

Journal of clinical nursing

2020 Volume 30, Issue 1-2, Page(s) 56–71

Abstract: Background: Inpatient nursing documentation facilitates multi-disciplinary team care and tracking of patient progress. In both high- and low- and middle-income settings, it is largely paper-based and may be used as a template for electronic medical ... ...

Abstract	Background: Inpatient nursing documentation facilitates multi-disciplinary team care and tracking of patient progress. In both high- and low- and middle-income settings, it is largely paper-based and may be used as a template for electronic medical records. However, there is limited evidence on how they have been developed. Objective: To synthesise evidence on how paper-based nursing records have been developed and implemented in inpatient settings to support documentation of nursing care. Design: A scoping review guided by the Arksey and O'Malley framework and reported using PRISMA-ScR guidelines. Eligibility criteria: We included studies that described the process of designing paper-based inpatient records and excluded those focussing on electronic records. Included studies were published in English up to October 2019. Sources of evidence: PubMed, CINAHL, Web of Science and Cochrane supplemented by free-text searches on Google Scholar and snowballing the reference sections of included papers. Results: 12 studies met the eligibility criteria. We extracted data on study characteristics, the development process and outcomes related to documentation of inpatient care. Studies reviewed followed a process of problem identification, literature review, chart (re)design, piloting, implementation and evaluation but varied in their execution of each step. All studies except one reported a positive change in inpatient documentation or the adoption of charts amid various challenges. Conclusions: The approaches used seemed to work for each of the studies but could be strengthened by following a systematic process. Human-centred Design provides a clear process that prioritises the healthcare professional's needs and their context to deliver a usable product. Problems with the chart could be addressed during the design phase rather than during implementation, thereby promoting chart ownership and uptake since users are involved throughout the design. This will translate to better documentation of inpatient care thus facilitating better patient tracking, improved team communication and better patient outcomes. Relevance to clinical practice: Paper-based charts should be designed in a systematic and clear process that considers patient's and healthcare professional's needs contributing to improved uptake of charts and therefore better documentation.
MeSH term(s)	Adolescent ; Adult ; Aged ; Australia ; Child ; Documentation ; Electronic Health Records ; Female ; Hospitals ; Humans ; Infant, Newborn ; Male ; Nursing Records
Language	English
Publishing date	2020-11-07
Publishing country	England
Document type	Journal Article ; Review
ZDB-ID	1159483-4
ISSN	1365-2702 ; 0962-1067 ; 1752-9816
ISSN (online)	1365-2702
ISSN	0962-1067 ; 1752-9816
DOI	10.1111/jocn.15545
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Article ; Online: The hidden emotional labour behind ensuring the social value of research: Experiences of frontline health policy and systems researchers based in Kenya during COVID-19.

Nzinga, Jacinta / Oliwa, Jacquie / Oluoch, Dorothy / Jepkosgei, Joyline / Mbuthia, Daniel / Boga, Mwanamvua / Musitia, Peris / Ogola, Muthoni / Muinga, Naomi / Muraya, Kui / Hinga, Alex / Kamuya, Dorcas / Kelley, Maureen / Molyneux, Sassy

PLOS global public health

2023 Volume 3, Issue 8, Page(s) e0002116

Abstract: Health policy and systems research (HPSR) is a multi-disciplinary, largely applied field of research aimed at understanding and strengthening the performance of health systems, often with an emphasis on power, policy and equity. The value of embedded and ...

Abstract	Health policy and systems research (HPSR) is a multi-disciplinary, largely applied field of research aimed at understanding and strengthening the performance of health systems, often with an emphasis on power, policy and equity. The value of embedded and participatory HPSR specifically in facilitating the collection of rich data that is relevant to addressing real-world challenges is increasingly recognised. However, the potential contributions and challenges of HPSR in the context of shocks and crises are not well documented, with a particular gap in the literature being the experiences and coping strategies of the HPSR researchers who are embedded in health systems in resource constrained settings. In this paper, we draw on two sets of group discussions held among a group of approximately 15 HPSR researchers based in Nairobi, Kenya, who were conducting a range of embedded HPSR studies throughout the COVID-19 pandemic. The researchers, including many of the authors, were employed by the KEMRI-Wellcome Trust Research Programme (KWTRP), which is a long-standing multi-disciplinary partnership between the Kenya Medical Research Institute and the Wellcome Trust with a central goal of contributing to national and international health policy and practice. We share our findings in relation to three inter-related themes: 1) Ensuring the continued social value of our HPSR work in the face of changing priorities; 2) Responding to shifting ethical procedures and processes at institutional and national levels; and 3) Protecting our own and front-line colleagues' well-being, including clinical colleagues. Our experiences highlight that in navigating research work and responsibilities to colleagues, patients and participants through the pandemic, many embedded HPSR staff faced difficult emotional and ethical challenges, including heightened forms of moral distress, which may have been better prevented and supported. We draw on our findings and the wider literature to discuss considerations for funders and research leads with an eye to strengthening support for embedded HPSR staff, not only in crises such as the on-going COVID-19 pandemic, but also more generally.
Language	English
Publishing date	2023-08-29
Publishing country	United States
Document type	Journal Article
ISSN	2767-3375
ISSN (online)	2767-3375
DOI	10.1371/journal.pgph.0002116
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Article ; Online: Using a human-centred design approach to develop a comprehensive newborn monitoring chart for inpatient care in Kenya.

Muinga, Naomi / Paton, Chris / Gicheha, Edith / Omoke, Sylvia / Abejirinde, Ibukun-Oluwa Omolade / Benova, Lenka / English, Mike / Zweekhorst, Marjolein

BMC health services research

2021 Volume 21, Issue 1, Page(s) 1010

Abstract: Introduction: Job aids such as observation charts are commonly used to record inpatient nursing observations. For sick newborns, it is important to provide critical information, intervene, and tailor treatment to improve health outcomes, as countries ... ...

Abstract	Introduction: Job aids such as observation charts are commonly used to record inpatient nursing observations. For sick newborns, it is important to provide critical information, intervene, and tailor treatment to improve health outcomes, as countries work towards reducing neonatal mortality. However, inpatient vital sign readings are often poorly documented and little attention has been paid to the process of chart design as a method of improving care quality. Poorly designed charts do not meet user needs leading to increased mental effort, duplication, suboptimal documentation and fragmentation. We provide a detailed account of a process of designing a monitoring chart. Methods: We used a Human-Centred Design (HCD) approach to co-design a newborn monitoring chart between March and May 2019 in three workshops attended by 16-21 participants each (nurses and doctors) drawn from 14 hospitals in Kenya. We used personas, user story mapping during the workshops and observed chart completion to identify challenges with current charts and design requirements. Two new charts were piloted in four hospitals between June 2019 and February 2020 and revised in a cyclical manner. Results: Challenges were identified regarding the chart design and supply, and how staff used existing charts. Challenges to use included limited staffing, a knowledge deficit among junior staff, poor interprofessional communication, and lack of appropriate and working equipment. We identified a strong preference from participants for one chart to capture vital signs, assessment of the baby, and feed and fluid prescription and monitoring; data that were previously captured on several charts. Discussion: Adopting a Human-Centred Design approach, we designed a new comprehensive newborn monitoring chart that is unlike observation charts in the literature that only focus on vital signs. While the new chart does not address all needs, we believe that once implemented, it can help build a clearer picture of the care given to newborns. Conclusion: The chart was co-designed and piloted with the user and context in mind resulting in a unique monitoring chart that can be adopted in similar settings.
MeSH term(s)	Hospitalization ; Hospitals ; Humans ; Infant ; Infant, Newborn ; Inpatients ; Kenya ; Monitoring, Physiologic
Language	English
Publishing date	2021-09-24
Publishing country	England
Document type	Journal Article
ISSN	1472-6963
ISSN (online)	1472-6963
DOI	10.1186/s12913-021-07030-x
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Article: Evaluation of Adaptive Feedback in a Smartphone-Based Serious Game on Health Care Providers' Knowledge Gain in Neonatal Emergency Care: Protocol for a Randomized Controlled Trial.

Tuti, Timothy / Winters, Niall / Muinga, Naomi / Wanyama, Conrad / English, Mike / Paton, Chris

JMIR research protocols

2019 Volume 8, Issue 7, Page(s) e13034

Abstract: Background: Although smartphone-based clinical training to support emergency care training is more affordable than traditional avenues of training, it is still in its infancy and remains poorly implemented. In addition, its current implementations tend ... ...

Abstract	Background: Although smartphone-based clinical training to support emergency care training is more affordable than traditional avenues of training, it is still in its infancy and remains poorly implemented. In addition, its current implementations tend to be invariant to the evolving learning needs of the intended users. In resource-limited settings, the use of such platforms coupled with serious-gaming approaches remain largely unexplored and underdeveloped, even though they offer promise in terms of addressing the health workforce skill imbalance and lack of training opportunities associated with the high neonatal mortality rates in these settings. Objective: This randomized controlled study aims to assess the effectiveness of offering adaptive versus standard feedback through a smartphone-based serious game on health care providers' knowledge gain on the management of a neonatal medical emergency. Methods: The study is aimed at health care workers (physicians, nurses, and clinical officers) who provide bedside neonatal care in low-income settings. We will use data captured through an Android smartphone-based serious-game app that will be downloaded to personal phones belonging to the study participants. The intervention will be adaptive feedback provided within the app. The data captured will include the level of feedback provided to participants as they learn to use the mobile app, and performance data from attempts made during the assessment questions on interactive tasks participants perform as they progress through the app on emergency neonatal care delivery. The primary endpoint will be the first two complete rounds of learning within the app, from which the individuals' "learning gains" and Morris G intervention effect size will be computed. To minimize bias, participants will be assigned to an experimental or a control group by a within-app random generator, and this process will be concealed to both the study participants and the investigators until the primary endpoint is reached. Results: This project was funded in November 2016. It has been approved by the Central University Research Ethics Committee of the University of Oxford and the Scientific and Ethics Review Unit of the Kenya Medical Research Institute. Recruitment and data collection began from February 2019 and will continue up to July 31, 2019. As of July 18, 2019, we enrolled 541 participants, of whom 238 reached the primary endpoint, with a further 19 qualitative interviews conducted to support evaluation. Full analysis will be conducted once we reach the end of the study recruitment period. Conclusions: This study will be used to explore the effectiveness of adaptive feedback in a smartphone-based serious game on health care providers in a low-income setting. This aspect of medical education is a largely unexplored topic in this context. In this randomized experiment, the risk of performance bias across arms is moderate, given that the active ingredient of the intervention (ie, knowledge) is a latent trait that is difficult to comprehensively control for in a real-world setting. However, the influence of any resulting bias that has the ability to alter the results will be assessed using alternative methods such as qualitative interviews. Trial registration: Pan African Clinical Trials Registry PACTR201901783811130; https://pactr.samrc.ac.za/TrialDisplay. aspx?TrialID=5836. International registered report identifier (irrid): PRR1-10.2196/13034.
Language	English
Publishing date	2019-07-26
Publishing country	Canada
Document type	Journal Article
ZDB-ID	2719222-2
ISSN	1929-0748
ISSN	1929-0748
DOI	10.2196/13034
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