{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"institution":[{"name":"medRxiv"}],"indexed":{"date-parts":[[2026,1,16]],"date-time":"2026-01-16T11:45:09Z","timestamp":1768563909162,"version":"3.49.0"},"posted":{"date-parts":[[2023,7,13]]},"group-title":"Health Systems and Quality Improvement","reference-count":71,"publisher":"openRxiv","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"accepted":{"date-parts":[[2023,7,13]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                <jats:sec>\n                  <jats:title>Introduction<\/jats:title>\n                  <jats:p>To improve healthcare provider knowledge of Tanzanian newborn care guidelines, we developed adaptive Essential and Sick Newborn Care (aESNC), an adaptive e-learning environment (AEE). The objectives of this study were to 1) assess implementation success with use of in-person support and nudging strategy and 2) describe baseline provider knowledge and metacognition.<\/jats:p>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>6-month observational study at 1 zonal hospital and 3 health centers in Mwanza, Tanzania. To assess implementation success, we used the RE-AIM framework and to describe baseline provider knowledge and metacognition we used Howell\u2019s conscious-competence model. Additionally, we explored provider characteristics associated with initial learning completion or persistent activity.<\/jats:p>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>aESNC reached 85% (195\/231) of providers: 75 medical, 53 nursing, and 21 clinical officers; 110 (56%) were at the zonal hospital and 85 (44%) at health centers. Median clinical experience was 4 years [IQR 1,9] and 45 (23%) had previous in-service training for both newborn essential and sick newborn care. Efficacy was 42% (SD\u00b117%). Providers averaged 78% (SD\u00b131%) completion of initial learning and 7%(SD\u00b111%) of refresher assignments. 130 (67%) providers had \u22651 episode of inactivity &gt;30 day, no episodes were due to lack of internet access. Baseline conscious-competence was 53% [IQR:38-63%], unconscious-incompetence 32% [IQR:23-42%], conscious-incompetence 7% [IQR:2-15%], and unconscious-competence 2% [IQR:0-3%]. Higher baseline conscious-competence (OR 31.6 [95%CI:5.8, 183.5) and being a nursing officer (aOR: 5.6 [95%CI:1.8, 18.1]), compared to medical officer) were associated with initial learning completion or persistent activity.<\/jats:p>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>Conclusion<\/jats:title>\n                  <jats:p>aESNC reach was high in a population of frontline providers across diverse levels of care in Tanzania. Use of in-person support and nudging increased reach, initial learning, and refresher assignment completion, but refresher assignment completion remains low. Providers were often unaware of knowledge gaps, and lower baseline knowledge may decrease initial learning completion or activity. Further study to identify barriers to adaptive e-learning normalization is needed.<\/jats:p>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>Key questions<\/jats:title>\n                  <jats:p>\n                    <jats:italic>What is already known on this topic<\/jats:italic>\n                    .\n                  <\/jats:p>\n                  <jats:p>\n                    <jats:italic>Summarize the state of scientific knowledge on this subject before you did your study and why this study needed to be done<\/jats:italic>\n                    .\n                    <jats:list list-type=\"simple\">\n                      <jats:list-item>\n                        <jats:p>- In sub-Saharan Africa, gaps in care quality may contribute to its high neonatal mortality.<\/jats:p>\n                      <\/jats:list-item>\n                      <jats:list-item>\n                        <jats:p>- Provider knowledge is a main driver of care quality, but current conventional in-service education methods are inadequate in adaptivity, reach, effectiveness, and refresher assignments.<\/jats:p>\n                      <\/jats:list-item>\n                      <jats:list-item>\n                        <jats:p>- Hard copies of national guidelines have been disseminated to health facilities expectations are HCPs will learn and adhere to them.<\/jats:p>\n                      <\/jats:list-item>\n                      <jats:list-item>\n                        <jats:p>- Adaptive eLearning, a subdomain of e-learning, holds the potential to overcome limitations to in-service medical education, but the optimal implementation strategy is unknown.<\/jats:p>\n                      <\/jats:list-item>\n                    <\/jats:list>\n                    <jats:italic>What this study adds<\/jats:italic>\n                    .\n                  <\/jats:p>\n                  <jats:p>\n                    <jats:italic>Summarize what we now know because of this study that we did not know before<\/jats:italic>\n                    .\n                    <jats:list list-type=\"simple\">\n                      <jats:list-item>\n                        <jats:p>- Baseline knowledge of essential and sick newborn care was low, mostly due to unconscious incompetence (providers thinking they were correct when they were incorrect).<\/jats:p>\n                      <\/jats:list-item>\n                      <jats:list-item>\n                        <jats:p>- Initial learning completion increased significantly with the use of an in-person program manager and an escalating nudging strategy, and technical issues were not identified as a significant limitation to participation.<\/jats:p>\n                      <\/jats:list-item>\n                    <\/jats:list>\n                    <jats:italic>How this study might affect research, practice, or policy<\/jats:italic>\n                    .\n                  <\/jats:p>\n                  <jats:p>\n                    <jats:italic>Summarize the implications of this study<\/jats:italic>\n                    .\n                    <jats:list list-type=\"simple\">\n                      <jats:list-item>\n                        <jats:p>- Provider self-reporting may underestimate knowledge gaps as most gaps are not known by providers.<\/jats:p>\n                      <\/jats:list-item>\n                      <jats:list-item>\n                        <jats:p>- Adaptive e-learning may be a feasible and acceptable way to disseminate guideline and improve quality of care if an implementation strategy can be identified to increase refresher assignment completion.<\/jats:p>\n                      <\/jats:list-item>\n                      <jats:list-item>\n                        <jats:p>- Once the ideal implementation strategy is identified, effectiveness of adaptive e-learning at scale can be evaluated.<\/jats:p>\n                      <\/jats:list-item>\n                    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