 Hello welcome everyone and thank you for joining this session on Healthy Foundation's blended learning program for Ethiopian midwives during the pandemic. My name is Daphna Elversen. I'm project manager at Healthy Foundation and I've been involved in the implementation and evaluation of this blended program. Before I dive into this specific program, its aims, results and our lessons learned, I would first like to introduce you to Healthy Foundation and the work that we do. Healthy Foundation is a not-for-profit organization based in Amsterdam, the Netherlands, and we have a strong network mainly in sub-Saharan Africa and a 20-year track record in digital health solutions. We were founded in 2003 to educate and strengthen the skills of healthcare professionals in resource restricted settings and we did so using e-learning so that they didn't have to leave their clinics unattended. Over the years we broadened our scope and now we do not only provide digital education and knowledge for healthcare professional but we also provide information to community members directly using digital tools like SMS, interactive voice response services and mobile apps and we do this all with the aim to improve the quality of care and to promote informed decision-making and healthy self-management at large scale in resource restricted settings. So now I covered about the first three steps of this timeline of Healthy Foundation but as we all know COVID-19 drastically changed the world around us and this both forced and inspired Healthy Foundation to change the way we work. We've been working with a closed source home-based LMS up until 2020 but due to the pandemic we wanted to move more responsibility and ownership to our local partners. That's when we started looking for a new learning management system based on certain requirements like being swarm compliant, open source and having offline functionality. We selected Moodle as our LMS and we were so happy with this change that we completely faced out our home-based LMS and we're since March 2022 working on Moodle LMS only. So what we see in the future 2023 and beyond is more and more locally owned digital solutions and Healthy Foundation will focus more on capacity strengthening of our local partners to own and maintain their own courses on the Moodle LMS. So whereas the COVID pandemic has positively changed the way of working for Healthy Foundation, it unfortunately negatively influenced our progress, world's progress towards achieving the sustainable development goals. Among others for STD-3, good health and well-being and STD-5, gender equality. We see that due to the COVID pandemic a decade of progress in maternal health, reproductive health and child health could be stalled or reversed. We also see that healthcare professionals who are already short in supply, mainly in sub-Saharan Africa, have been stretched to their limits due to the pandemic and finally we see that violence against women and girls has spiraled because of the pandemic. And this is mainly or also the case in Ethiopia where we see a mortality, maternal mortality ratio of 401 per 100,000 life births which is for strongly exceeding the target of 70 which we aim to achieve by 2030. The same applies for the neonatal mortality ratio which is as 27 and should be 12 by 2030. Also healthcare professionals in Ethiopia have been stretched to their limits, both because of the COVID-19 pandemic as well as the humanitarian conflict in Ethiopia. This points to a dire need to strengthen healthcare services in Ethiopia and to provide training opportunities for healthcare professionals. And that is why we've developed SRHRE education and the pandemic e-response courses for future midwives or in-service midwives in Ethiopia, zooming in on the SRHRE education and pandemic e-response courses. These are blended learning programs that were implemented from 2020 up to 2022 for a group of 539 future midwives in Ethiopia. I say future in between brackets because we targeted both in-service midwives who were already on the job but also pre-service midwives who are still studying at university. We created learning content with international authors and we worked with our local partners to contextualize the training according to the Ethiopian context. Here you see an overview of the modules that were made available in the course and they're all related to maternal health, COVID-19, gender-based violence and essential newborn care. All with the aim to strengthen the knowledge and skills of midwives to safely perform their core tasks during the pandemic and ultimately contribute to realizing the STG targets including the indicators shown here, reducing maternal mortality, neonatal mortality and ending violence against girls and women. But before I move on to the results of our program I would first like to introduce you to our partners. Healthy Foundation always works in strong partnerships with local partners and in this case we collaborated with the Ethiopian Midwives Association, EMLA, to develop the e-learning content and implement the program at four collaborating universities in Ethiopia, in Addis Ababa, Debra Birgen, Wolkite and GIMA. We also collaborated with Viamo to create an interactive voice response service where community members could get free health information about COVID-19, maternal health and domestic violence during the pandemic. This service was called Tena which means health in Amharic. Finally we received financial support from Nafik and Diorofte. And of course I would also like to introduce you to our learners. These are passionate midwives, both in-serves and pre-service, who are motivated to update their knowledge and skills and strengthen the services and information they provide to community members. So moving on to the blended learning concept. Why did we choose for blended learning and what do we mean with a blended learning approach? Healthy Foundation typically works with a blended learning approach that consists of three phases. We start off with a face-to-face kickoff session where we initiate a group of learners and get together in an offline setting. We invite some guest speakers and have a closer look at some key topics. And we use the opportunity to do a little bit of digital literacy skills building and introduce the learning cohort to the learning management system. Then we move on to a second phase, the self-study phase that typically is around to three to four months where people take the course at their own pace and in their own time using the Mudo elements. Then finally we have a follow-up workshop or a closing session where we get the learning group together once more in offline setting where we reflect on lessons learned, exchange learnings and handout certificates. One important element to mention still with the second phase is that we typically invite blended learning students to also do some community outreach activities during the self-study period where they can put their new knowledge and skills into practice immediately and they can share these experiences during the follow-up workshop. This blended learning approach has a lot of advantages for both Healthy Foundation and our learners because our learners are typically healthcare professionals working in resource restricted settings which means that they face a couple of challenges like limited internet connection, limited digital literacy and limited time available during office hours. Using e-learning provides them the opportunity to learn any time anywhere and using the setup that we chose allows them to learn on their smartphone, tablet, computer both with and without internet connection. Having these offline elements added to it in a kickoff and follow-up work session also ensures that they are motivated and belong to a group of learners. So it's really the ideal combination for both us and our learners. So zooming in on our e-learning products we chose for a combination of Mudo as LMS and Articulate Rise as the authoring tool and this offers a couple of advantages for us. For instance the simple and straightforward design and interactive distance-based learning. We make use of interactive elements like drag-and-drop questions, scenarios, embedded videos and we still allow for a simple journey in the learning system. Moreover it's multi-device compatible so the screen size adjusts automatically for a tablet, a smartphone, a smartphone and a desk tool and maybe even most importantly it's open access and SCORM compliant so we can generate the SCORM content once and then exchange it with other partners without any modification they can upload it on their own LMS. Then over to the results we performed a survey among the SRHRE education cohort consisting of 391 participants and these results show that most users have access to cores via their smartphone. This is a group of 73 percent. Interesting to note is that a strong majority of this group of smartphone users used their web browser on their phone to access the cores. It's not the Mudo app. This means that it still required internet access. Most users prefer the blended learning format over e-learning only or traditional classroom education only. This is a group of 79 percent and then finally we see that nearly all participants 96 percent report that they still apply their knowledge and skills into practice and that they've improved their digital literacy skills. Then over to some quotes of our learners and I'm especially grateful for the quote that is right in the middle. I'm impressed how the world is changing into one village. With e-learning we can update our knowledge and it's simple and understandable. I can especially relate to this quote because stepping over from a home based LMS to an open source LMS also felt a bit like changing our world into a village. We can now engage with the Mudo community online. We can participate in a Mudo academy and we can even join in this conference of Mudo moods and we see that the answer to a technical hiccup is now just an online search or phone call wave. Then the evaluation of our results. So the survey points out a couple of strengths of this setup. A strength is that the course can be accessed on smartphones. It has a smooth user journey. It is interactive. The combination of online and offline elements is appreciated. It is shown to be effective in transferring skills among other digital literacy skills and the design is inclusive for most of our participants. But we've also identified some weaknesses. For instance related to the offline functionality in particularly of the app. Some restrictions related to monitoring and evaluation which I will zoom in on in the next slide as well. And some issues related to core size device requirements of smartphones tablets and laptops and internet connectivity. So a little bit about our learning curve implementing blended learning using the Mudo LMS. We see that features and functionalities in the LMS and the authoring tool are strongly interrelated. Solving one challenge might create another one or multiple even. And I have numerous examples of this but we can start off with the first one. Offline functionality versus M&E. If you want to allow for a full offline journey you can put no restrictions in the course. That means that our learners will download all the content during the kickoff workshop where we have Wi-Fi connection. And they download the pre-test, the e-learning content in SCORM and the post-test and they can just continue everything in one go in the self-study period of four months. And then bring their device back to the follow-up workshop, connect with Wi-Fi again and upload all their progress. Full offline learning journey for our participants but healthy foundation can do no monitoring evaluation throughout the journey. We cannot see whether they've completed the courses, what they did with the pre- and post-test. So if we turn it around we put more emphasis on the M&E. We would place certain restrictions in the course. We would say you can only enter the learning content if you've completed the pre-test. Thank you. But this does not allow people to have a full offline learning journey. They have to connect with internet over and over again to show that they completed a certain test. So this is really a balancing act of allowing offline learning versus doing monitoring evaluation. Another example is for instance related to the SCORM size and uploaded media. We want to be as inclusive and accessible as possible. So to allow our participants with devices with limited data storage to learn we need to ensure that the SCORM size is as low as possible. To do so you can for instance make use of YouTube videos or links instead of embedded uploaded media. The SCORM size stays low but the problem is that people with limited internet connection cannot watch the video. So then you can choose for uploaded media. Make sure that people without internet connection can still participate in the video but then the SCORM size increases. So there again it's still a balancing act and really seeing what is most fitting for your target audience and what need is more important for your target audience compared to the other one. And that brings me to my conclusion which may sound like an open door but eLearning is not one size fits all. To be as inclusive and accessible as possible one should stay away from a one size fits all solution and you should really try to address the needs, the specific needs of your learning audience and to find eLearning options that really are responsive and adaptive to those needs. I hope this session has been informative for your own blended or eLearning projects and I would just want to thank the Moodle community. Let's continue to partner up and contribute to achieving the sustainable development goals. Thank you. So with the blended aspects do you have anyone on the sites who are sort of leaders or teachers that you sort of train to you know help with the students or is it all you know your team how does that work? Yeah so before COVID usually one of our team members would go to the target country and work with a local partner to do those training sessions together or do a sort of training of trainer session but due to the pandemic we completely shifted all responsibilities to our local partners so for this particular case we work with the Ethiopia Midwives Association who are very experienced in training and involved in the midwifery curriculum for Ethiopia so they were in charge of hosting the kickoff workshops and follow-up workshops and we were more the technical yeah technical partner so to say. That's a very good question no actually we do not really register or register the offline components in Moodle. So the kickoff workshop yeah there are attendance lists that our local partner keeps track of and to make sure that everyone has a username and a password so to say we can have a sort of administration who was there but the offline workshops are more based on PowerPoint presentations, guest speakers, sometimes more skills building and not really yeah translated into the learning management system. Another question? So your learning content courses made available for free and are you looking for people to sort of add resources or partner with you? Well we have a couple of open access courses available on our platform but most of the courses are still restricted and based on donor funding so this particular project was funded by NAFIC which is part of the Dutch Ministry of Foreign Affairs and Diorofte and with with that funding we were able to create this this learning content and to implement it because especially the blended elements of the offline interaction yeah there's some subsidy involved in arranging that.