A systematic review of portable electronic technology for health education in resource-limited settings

Abstract

Objective:

The objective of this study is to conduct a systematic review of the literature of how portable electronic technologies with offline functionality are perceived and used to provide health education in resource-limited settings.

Methods:

Three reviewers evaluated articles and performed a bibliography search to identify studies describing health education delivered by portable electronic device with offline functionality in low- or middle-income countries. Data extracted included: study population; study design and type of analysis; type of technology used; method of use; setting of technology use; impact on caregivers, patients, or overall health outcomes; and reported limitations.

Results:

Searches yielded 5514 unique titles. Out of 75 critically reviewed full-text articles, 10 met inclusion criteria. Study locations included Botswana, Peru, Kenya, Thailand, Nigeria, India, Ghana, and Tanzania. Topics addressed included: development of healthcare worker training modules, clinical decision support tools, patient education tools, perceptions and usability of portable electronic technology, and comparisons of technologies and/or mobile applications. Studies primarily looked at the assessment of developed educational modules on trainee health knowledge, perceptions and usability of technology, and comparisons of technologies. Overall, studies reported positive results for portable electronic device-based health education, frequently reporting increased provider/patient knowledge, improved patient outcomes in both quality of care and management, increased provider comfort level with technology, and an environment characterized by increased levels of technology-based, informal learning situations. Negative assessments included high investment costs, lack of technical support, and fear of device theft.

Conclusions:

While the research is limited, portable electronic educational resources present promising avenues to increase access to effective health education in resource-limited settings, contingent on the development of culturally adapted and functional materials to be used on such devices.

Keywords

global health / globalization education (including health education)e-health community-based research / participatory research

Introduction

Resource-limited countries have healthcare systems that are severely understaffed and ill-equipped to care for large patient volumes (1,2). The World Health Organization (WHO) reports an average of 2.5 physicians/10,000 people in low-income countries, whereas the United States has an average of 24.5 physicians/10,000 (3). In addition, African countries bear over 24% of the global disease burden with access to only 3% of the world’s healthcare workers (4). Mitigating this disparity is largely focused on increasing the number of workers, but serious concerns remain regarding the quality and productivity of those workers in resource-limited settings (RLS) (5,6).

The performance and practice of health workers in RLS are influenced by a multitude of factors, such as lack of training, lack of resources, low supervision and feedback, and poor incentives. Various behavioral theories have been explored in creating interventions to improve healthcare workers’ practices; continuing clinical and medical education is often a fundamental aspect to those interventions (7,8).

In RLS, cost-effective and practical methods of medical education are necessary for training healthcare workers in this evolving field (9,10). Information and communication technology (ICT) is one such avenue and shows promise in creating financially feasible solutions for this critically underserved population (11 –15). ICT is an umbrella term describing various forms of technology used for communication or transmission of information, such as cell phones, computers, and tablet computers (16). ICT is effective in providing health education and resources to medical providers in developed countries, which gives promise for RLS as well (17,18). Furthermore, ICT is already prevalent in RLS (3,19,20). Portable ICT devices, such as tablets and smartphones, are another option for providing health education. Portable ICT devices are cheaper than computers, have longer battery life, and their size allows for easy point-of-care access (21).

The utility of ICT may be limited by the low availability of the Internet. In African settings, only half of the rural population is within reach of a mobile cellular network with the potential to connect to the Internet (22). Overall, Internet access, defined as Internet use from any device in the last 12 months, was <10% in low-income countries (23). This limited Internet availability is a barrier to electronic health education (22,24,25). Even when the Internet is available, its cost limits accessibility. Given these constraints, offline functionality is an important feature for portable technologies that provide healthcare workers with resources and medical information.

Little is known about how portable technology may be effectively used in healthcare education within RLS. Understanding how this technology is used and perceived in RLS is an important first step in developing future interventions to improve health workers’ performance, with possible applications to health promoters working in RLS. The objective of this study is to systematically review the literature describing how portable electronic technologies with offline functionality are perceived and used to provide health education in RLS.

Methods

We searched several bibliographic databases, including Ovid MEDLINE (1946–30 March 2016), EMBASE (1947–30 March 2016), Cochrane Database of Systematic Reviews (1995–30 March 2016), Educational Resources Information Center (ERIC) (1966–30 March 2016), and PsycINFO (1957–30 March 2016), as well as bibliographies of pertinent articles. These databases were chosen after consultation with a medical librarian, to increase our yields in international, educational, health-related research publications. We used an extensive search strategy combining Medical Subject Headings with keywords related to portable technologies in RLS (Appendix 1). Search terms were only written in English, and only articles in English were extracted. Duplicate versions of publications were removed. Three authors (LJF, YC, MSM) reviewed the titles and abstracts of retrieved articles to identify those that involved portable technology use in RLS settings. Based upon this initial screen, articles were immediately excluded if they were not conducted in a low- or middle-income country as defined by the World Bank classification (26) or did not involve portable electronic technology.

After the title and abstract exclusion process, three authors (LJF, YC, MSM) independently reviewed the remaining articles to determine whether articles met predetermined inclusion criteria. To meet inclusion criteria, the study needed to involve portable electronic devices used as educational health-related resources in a RLS that did not require a continuous cellular network or Wi-Fi for delivering information. Educational resources included medical information for providers or patients and/or clinical decision support. When discussing methods of use, a clinical decision support tool was defined as an instrument that provided individuals with person-specific knowledge, which was intelligently filtered or presented at appropriate times, to enhance healthcare (27). In addition, inclusion required design of case studies, cohort studies, or randomized controlled trials (RCTs) in a peer-reviewed journal. Studies conducted in RLS using portable electronic technologies solely for non-educational, health-related purposes (e.g. Electronic Medical Records) were excluded. Published abstracts without associated full-text publications were excluded. Disagreements were resolved by discussion, and consensus was achieved.

The following variables were extracted from the manuscripts, and these were synthesized qualitatively: study population; study design and type of analysis; type of technology used; method of use; setting of technology use; impact on caregivers, patients, or overall health outcomes; and reported limitations.

The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 Checklist was followed during protocol development (28). Due to the nature of the heterogeneous interventions and outcomes, some aspects of PRISMA-P were not appropriate for this review. These excluded checklist items included: risk of bias in individual studies, meta-biases, and confidence in cumulative evidence.

Results

Our systematic literature search identified 7530 titles. OVID MEDLINE yielded 2592, EMBASE yielded 2999, Cochrane yielded 940, ERIC yielded 575, and PsycINFO yielded 424. After duplicate records were removed, 5513 titles remained. One additional article was included after bibliography search. Upon initial screen of titles and abstracts, 5440 articles were excluded because they did not meet the basic inclusion criteria of involving portable electronic devices and being conducted in a low- or middle-income country. The reviewers then assessed the remaining 75 full-text articles. Ten articles were identified that met all inclusion criteria (25,29 –37) (Figure 1). The most common reasons for exclusion included study design (not an RCT, cohort, or case series), use of portable electronic technology in a non-educational manner, not RLS by World Bank classification, or the educational value of the device being dependent on text messaging or continuous access to the Internet.

Figure 1.

Flow chart depicting systematic review process.

The 10 studies that met all inclusion criteria varied widely in study design, intervention, and outcome measures. Of the 10 included articles, three were conducted at the University of Botswana; however, different study populations were evaluated in each study (29,32,35). Other studies were conducted in Peru, Kenya, Thailand, Nigeria, India, Ghana, and Tanzania (25,30,31,33,34,36,37). All articles included were published in 2010 or later, with a sharp increase in articles published within 1 year of our search.

Topics addressed included the development of healthcare worker training modules, clinical decision support tools, patient education tools, perceptions and usability of portable electronic technology, and comparisons of technologies and/or mobile applications. While specific educational materials and applications varied by study, most of the included studies addressed at least two of these areas (Table 1).

Table 1.

Study characteristics.

Source	Country	Study population	Study design and analysis	Technology and applications used	Method of assessment	Setting for use	Results related to non-Internet use of devices	Reported limitations
Dway, et al., 2016	Thailand	69 mothers of children <6 years old	Cohort, pre- and post- intervention quantitative design	Smartphone (model not specified)	PET—Knowledge and perception of mothers regarding Expanded Programme for Immunisation pre/post intervention. Intervention consisted of educational animation modules delivered via electronic device	Patient’s or client’s home	Overall good knowledge (based on 6–7/7 correct answers) increased from 24% to 75% from baseline to finish. Overall good perceptions of vaccines (based on 7-question assessment) rose from 44% to 82%. Overall perceived correct practices (based on >5/7 questions) rose from 46% to 84.1%.	Short study period. Potential for instructor effect as interviewers were of same Lisu community as interviewees.
Witt et al., 2016	Botswana	82 medical students	Cohort, mixed quantitative and qualitative	Tablets (unspecified model) pre-loaded with 15 applications (apps)	PUT—App usage data were collected over 6–8 months. Focus group discussions explored perceptions of the usefulness and usability of the tablets, associated training and technical support	Self-directed, clinical settings and home	Apps such as OSCE Trainer, USMLE, and Medscape were used for the longest duration of time. Medscape, uCentral and Skyscape were used the most frequently. Three major benefits noted: convenience, portability, and immediacy. Reported improved medical education and patient care during clinical rotations. Use limited by perceptions of their supervisors and patients, lack of technical support, and fear of the device getting stolen.	Convenience sample. Internet availability varied across the sample, creating variation in how participants used the devices.
McNabbet al., 2015	Nigeria	266 antenatal care (ANC) clients	Cohort, pre- post-intervention study, quantitative	Cell phone (Nokia) or tablet depending on patient load	CDST, PET—A pre/post (1 year later) interview tool used to assess care quality after introduction of the m4Change ANC app. Client exit interview also performed. App tracked client recorders, provided decision support algorithms with care recommendations and included audio-recorded health counseling messages for clients during ANC visits	Clinical settings	The overall quality score increased from 13.33 to 17.15 (p < 0.0001), with the most significant improvements related to health counseling. Half of the elements of the technical domain (i.e. HIV test performed, blood pressure obtained) showed a significant positive change from baseline to endpoint. Client satisfaction increased from 75% to 83% (p < 0.05).	No assessment of impact of health outcome.The app was not designed to manage all aspects of the clinic work, such as commodities management, staffing, and availability of key infrastructure.
Raghu et al., 2015	India	11 Accredited Social Healthcare Activists (SHA) and three physicians	Cohort, quantitative	Tablets (Samsung Galaxy tablet used with physicians, ‘low-cost’ tablet used with SHAs	CDST, PUT—SMARTHealth was developed as part of a mHealth system to assess and manage cardiovascular disease (CVD) risk. Evaluated usage patterns and to highlight diversity in trends among different end-users. Interviews identified barriers to adoption of the technology	Patient’s or client’s home	Over a third of participants screened by health workers were identified by the tool to be high CVD risk and referred to a physician. Clinical decision support features of the application including lifestyle, smoking, and nutrition recommendations were used between 81–96% of the patient encounters. Over 72% of screening procedures performed with the mobile application were reported as easy to use.	Pilot study, limited sample size. Technical challenges of ensuring appropriate patient identification. Infrastructural barriers such as inconsistent electrical supply.
Shao et al., 2015	Tanzania	844 patients in the intervention arm, 623 patients in the control	Controlled non-inferiority trial, quantitative	Smartphone (model not specified)	CDST—Intervention arm seen by study clinicians strictly complying with the Algorithm for the MANAgement of Childhood illness (ALMANACH). Controls were attended by the usual clinicians, receiving the standard of care which is based upon the Integrated Management of Childhood Illness (IMCI) strategy developed by the WHO	Clinical settings	Significantly more children treated using the ALMANACH were cured compared with those using standard of care. Significantly fewer children were prescribed antibiotics compared with the control group. Thus management using ALMANACH improved clinical outcomes and reduced antibiotic prescriptions by 80%	Not all providers in the control group used the IMCI strategy. The new algorithm was implemented in controlled conditions, so it is unclear what the level of uptake and compliance by clinicians will be when not monitored.
Ginsburg et al., 2015	Ghana	7 skilled health care providers	Cohort, mixed semi-quantitative and qualitative	Tablets (Asus Nexus Google 7)	CDST, PUT—Participant task analysis, concurrent think-aloud, retrospective probing techniques, and short questionnaire	Clinical settings	Initial reactions were positive, many without prior experience with tablets. All were able to complete the tasks with the tablet. Several common errors were identified, most relating to user interface design and software navigation buttons. All believed most people could learn to use the application quickly. Overall, participants preferred the tablet application to paper-based decision support tools. Overall satisfaction with the tool increased to a high level by study completion.	No evaluation of clinical effectiveness, sustainable uptake of the device, or cost-effectiveness.
Vedanthan et al., 2015	Kenya	12 nurses, 1 clinical officer	Cohort, qualitative	Tablets (Huawei IDEOS)	CDST, PUT—Measured usability and feasibility of a decision support in nursing management of hypertension, using think-aloud exercises and mock patient encounters	Clinical settings	57 critical incidents were identified, many were due to user interface problems or confusion in wording. Five domains impacting the feasibility of the tool: barriers to implementation, facilitators to implementation, provider issues, patient issues and feature requests	Qualitative, hypothesis-generating study, rather than hypothesis-testing, no cost information, patient perceptions were not included.
Goldbach et al., 2014	Botswana	19 resident physicians	Two-arm comparative crossover trial, quantitative	Smartphone (myTouch 3G HTC)	DTM, CDST, PUT, CTA—Compared answers regarding educational clinical cases with questions between users of phones with locally loaded medical applications (not requiring Internet) and those with PubMed4Hh (requiring Internet) for support.	Not specified	Participants using medical apps correctly answered higher percentage of clinical questions regarding diagnosis/definitions, treatment/management, and drug related compared with those using PubMed4Hh (63% vs. 13%, 33% vs. 12%, and 41% vs. 13%, respectively). Those using PubMed4Hh performed better for epidemiologic questions. No statistical different was found among individuals across residency types.	Small sample size, unable to track which medical applications were used.
Chang et al., 2012	Botswana	7 resident physicians	Cohort, qualitative	Smartphone (myTouch 3G)	PUT, CDST—Use of phones with UCentral, Skyscape, ePocrates Rx. UCentral and Skyscape contained multiple applications including drug references and clinical decision-making resources.	Clinical settings and at home	Increased provider knowledge, increased comfort level with technology, used not only as point-of-care at bedside but also for supplementary reading at home.	Not reported.
Zolfo et al., 2010	Peru	20 physicians	Cohort, qualitative	Smartphone (iPhone, Nokia N95)	PUT, DTM, CTA—Assessed usability of device and ability to access continuing medical education using clinical modules regarding HIV care	Self-directed, office or at home	Most (86.6%) indicated that the ability to perform self-directed educational abilities was beneficial and 94.4% noted accessing the educational content on a portable device was an added value. Similar usability between iPhone and Nokia N95 (88.9% and 87.5%, respectively).	High investment cost, requirement of phone service, lack of IT support, specific issues with one device offer (small screen/keyboard, poor image quality).

DTM: Development of Training Modules (on trainee health knowledge); CDST: Clinical Decision Support Tools; PET: Patient Education Tools; PUT: Perceptions and usability of technology; CTA: Comparison of Technologies/Applications.

Development of training modules for trainees’ health knowledge

Two of the studies developed and assessed novel training modules directed at clinical providers to be accessed via mobile technology (32,36). One study, conducted in Peru, developed 3D animations to teach using specific, interactive clinical scenarios (36). The didactic materials were downloaded using initial Internet connectivity and accompanied by a review session. Another application then asked content-specific questions to track pre-test and post-test knowledge. Most participants (86.6%) indicated that the ability to perform self-directed educational activities was beneficial, and 94.4% noted accessing the educational content on a portable device was an added value.

Another study conducted among resident physicians in Botswana developed a series of eight clinical scenarios and then allowed each physician access to either PubMed4Hh® (the mobile version of PubMed®) or a suite of locally loaded, point-of-care medical reference applications (32). Each clinical scenario was followed by a series of questions to be answered by either of the two assigned point-of-care reference materials. This study found that those who used medical applications had a higher percentage of correct responses compared with those who used PubMed4Hh.

Both studies relied on the development of applicable clinical scenarios for their educational interventions, giving participants access to these scenarios, and then using questions to assess the effectiveness of the training module. In the Peru study, educational content was created specifically for the study, as opposed to the Botswana study, where the primary method involved linking the participant to previously created content via medical applications or primary literature. Neither study evaluated the effects of the educational intervention on overall patient health outcomes. However, both studies reported increased provider knowledge based on interactions with the educational devices.

Clinical decision support tools

Five articles focused on educational mobile technology as clinical decision support tools (25,31,33,34,37). Clinical decision support tools varied in their target patient population and application but were largely reported as being effective. SMARTHealth was developed in India as part of a mHealth system to assess and manage cardiovascular disease (CVD) risk. Over a third of patients screened with this tool were identified as high risk for CVD and referred to a physician (33). A study in Tanzania developed the Algorithm for the MANAgement of Childhood illness (ALMANACH), which was built into a smartphone. Significantly more children treated using the ALMANACH were cured compared with those using standard of care, and significantly fewer children were prescribed antibiotics compared with the control group (34). Management using ALMANACH improved clinical outcomes and reduced antibiotic prescriptions by 80% (34). A study conducted in Nigeria developed the m4Change antenatal care (ANC) application, primarily focusing on decision support for pre-eclampsia and management of obstetric emergencies. Overall quality of the patient encounters was assessed quantitatively via a quality score assessment that increased from 13.33 to 17.15 (p < 0.0001), out of a maximum score of 25, with the most significant improvements related to health counseling (37). Certain domains of the score, such as structure and cost, were not connected to use of the intervention. The remaining two studies assessed user feasibility and initial reactions to tools that were still in development. These studies reported on user interface problems, confusion about wordings, and software navigation buttons (25,31).

Patient education tools

Two studies focused on mobile educational applications targeting specific patient populations (30,37). One study was conducted in Thailand among mothers of young children (30). A novel ‘edutainment’ module was created incorporating key health messages about vaccinations and played on mobile tablets by village health volunteers. Knowledge was then assessed via pre- and post-test questions. Overall knowledge increased from 24% at baseline to 75% at the end of study, overall positive perceptions of vaccines rose from 44% to 82%, and overall perceived correct practices rose from 46% to 84.1% (30). Patient education was also a focus of the Nigerian study on m4Change ANC application (37). In addition to evaluating the clinical decision support elements within the educational module, overall patient satisfaction with the application and its health messages was assessed and found to increase from 75% to 83% (p < 0.05) over one year (37).

Perceptions and usability of technology

Seven of the studies discussed perceptions and usability of mobile technology; these studies reported largely positive results, although the perceptions were not always quantified (25,29,31 –33,35,36). All studies focused on populations of healthcare providers, including community health workers (CHWs), resident physicians, medical students, and physicians. Prior mobile technology use varied widely within these studies and was reported in different metrics. One study reported prior experience with an Internet capable mobile device at 30%, and yet all participants reported positive opinions about the portability and easy access to the educational content in post-study focus group discussions (36). Another study found that 87% (N = 7) of participants had not used a smartphone prior to the study, but by 8 weeks of use, all felt comfortable with the device (29). In one study conducted in Kenya, nurses reported that using a tablet within their workflow and navigating the educational application interface were initially confusing. However, within 1 month of experience with the tablets, most (83%, N = 6) preferred the tablet to prior methods of workflow management (25).

While largely positive, negative perceptions existed surrounding the use of portable electronic technology as health education tools. Barriers and limitations included cost (36), lack of information technology (IT) support (25,36), and fear of the device getting stolen (35). Several barriers to tablet-based educational materials were noted in a study taking place in Kenya (25). Some participants believed using the device within the patient–provider encounter might hinder rapport with the patient (25). There was also some misunderstanding regarding the devices’ capabilities, with some thinking the device was a direct connection to higher-level provider (i.e. telemedicine) when in fact the educational capabilities were limited to decision support software pre-loaded onto the tablets (25).

Comparison of technologies/applications

Two studies compared specific technologies against each other (32,36). One study compared two different portable electronic devices, a Nokia N95 smartphone (with digit buttons) with an iPhone (with a touchscreen), to determine differences in usability and satisfaction (36). This study found the iPhone to be more acceptable than the Nokia. Another study compared the clinical relevance and effectiveness of locally loaded, point-of-care medical applications compared with PubMed4Hh using a developed training module (32). The locally loaded medical applications were shown to produce more correct answers in all question categories except epidemiology, with an overall percentage of fully correct answers of 36% versus 14% respectively (32).

Discussion

This systematic review suggests that health education via portable electronic technology presents a promising opportunity to increase access to health information for medical providers and patients in RLS. While this is still an emerging area of evaluation, the studies located through this review show that portable electronic-based educational solutions have thus far been well received in a variety of RLS, including those already saturated with such technology and those being introduced to such technology for the first time. These technologies were used for the development of training modules to assess knowledge, as clinical decision support tools, and patient education tools. In addition, our limited data suggest this technology is viewed positively and may have educational value for the providers and patients using them, even with static materials that do not require Internet connectivity.

Health education using portable electronic devices may be particularly useful for health promoters. Health promoters work within communities supporting people to increase their control over factors impacting their health. One of the studies within this review focused on village health volunteers’ ability to use these technologies to educate mothers on vaccinations for their children, and it was found to increase knowledge, positive perceptions, and correct practices regarding vaccine use (30). This is one example of how this technology may have useful applications for health promoters or CHWs in global settings. The mobile education tools can be designed for a variety of health topics, such as reducing tobacco use or promoting physical activity. In addition to use by health promoters when working with specific populations, these tools can be used by health promoters and CHWs to aid in their own training and self-directed learning.

The educational value of a device is dependent on the quality, type, and accessibility of educational materials loaded onto it. Some of the studies in this review created content specific for educational purposes in RLS (25,30,31,33,34,36,37), while others adapted existing content to mobile platforms (29,32,35). The WHO and the United Nations High Commissioner for Refugees are two organizations with free downloadable guidelines available on their websites (38,39). However, accessing these materials is a challenge for clinical providers without Internet-connected computers available at point-of-care settings. Our study found that resources available on portable technology with offline capabilities have the potential to improve healthcare provider knowledge, comfort, and quality of care. Making medically relevant resources available offline in a mobile platform is critical for the providers who need them most.

Organizations such as Médecins Sans Frontières (MSF) have also noted the importance of static mobile health reference applications that can be accessed offline (40). MSF converted their Clinical Guidelines Manual into an application called MSF Guidance (40). They recently published an evaluation of their application guidance and found that mobile apps can be used to disseminate health information effectively (40). While this study was not included in our review because it focused solely on the number and locations of application downloads, its widespread usage across the globe is a testament to the desire for health workers to access educational materials through mobile applications with offline functionality. Usage of the MSF app is consistent with our findings that portable technologies with offline capabilities may benefit health workers, including health promoters.

The user interface of a device is also critically important to its usability as an educational tool. Information must be accessed easily and quickly, with intuitive navigation. This is true for busy healthcare providers, health promoters, and patients with minimal literacy, which is true for 37% of the population of low-income countries (3). Participants in this review demonstrated a high level of adaptability in learning new technologies. However, in environments with little IT support and users with limited experience with mobile technology, well-designed and easy-to-navigate programs become especially important.

While the studies in this review often focused on the portable electronic devices as a single intervention, an integrated approach to health education utilizing these devices may be more effective. A recent review highlighted the need for multifaceted interventions to increase the quality of health care, which may include training/continued education plus supervision and feedback (7). In addition, the same review highlighted various behavioral theories that have been used to explain health worker practices. This study focuses on cognitive theory’s role in health, in that undesirable practices and behaviors are caused by a lack of information. However, other theories, such as social influence and power theories, management and system theories, and coercive approaches, should all be considered when developing interventions to improve health workers’ performance (7).

Much of the literature discussed in this review is qualitative, addressing how portable electronic technology was perceived and utilized, rather than quantifying its effectiveness as a learning tool. As costs for this technology continue to drop, its usage will continue to increase. This is evident in our results, with studies on portable electronic technology use sharply increasing in the published literature in recent years. While we found overwhelmingly positive perceptions regarding usability and comfort level, studies quantifying effectiveness will become increasingly important to identify the best applications of portable electronic technology as a health educational tool in low-income countries. In addition, quantifiable outcomes will aid in the exploration of cognitive theory’s role in health workers performance and practices.

This systematic review does have some limitations. One limitation was the scarcity of the articles meeting criteria for inclusion. We were specifically interested in understanding how portable electronic technology could be used for health education when not continually reliant on the Internet in RLS. Having the requirement of offline capabilities limited the number of included articles; however, this focus was deemed necessary to make the review results relevant for the majority of RLS, where affordable Internet connections are not universally available. Another limitation was that we did not search for unpublished trials and conference presentations results, which may have led to a publication bias. However, we wanted to provide the most rigorous evidence available for this emerging technology. Another limitation was the exclusion of non-English studies, which may have excluded some potentially relevant articles.

Conclusions

Adapting mobile technology to be effective as an educational platform in RLS is regarded as a promising area for Health Promotion. These devices have the potential to strengthen the skills and capabilities of clinical and non-clinical practitioners and to provide opportunities to educate the public about health issues. While the research in this area is too limited to make generalizations, the available evidence suggests several important, promising findings that warrant further discussion. Future research should be directed at development of culturally adapted and relevant educational materials to be utilized with portable technology. Furthermore, analysis of portable electronic educational materials should extend beyond assessing feasibility and acceptability and be directed towards understanding the effectiveness of such instruments on educational objectives and health outcomes. Such evidence-based assessments of impact would guide the effective implementation of portable electronic educational resources in these settings.

Footnotes

Declaration of conflicting interests

None declared.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Notes

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