Description of studies
The final list of the 29 studies included in our review consisted of 23 studies from high-income countries with the majority of them from United States of America. Only six studies were from LMICs, more specifically from Brazil, Pakistan, Türkiye, and Uganda, as well as two studies that spanned several LMICs.
The target groups were mostly in-service health professionals but there was also a considerable number of studies that included pre-service students of medicine (n = 6) and nursing (n = 6). Among the targeted in-service health professionals, most were nurses (n = 12), followed by doctors (n = 8) and other health professionals (n = 8) including emergency technicians, primary care providers, medical assistants, etc.
Table 2
Study location, target population, study design, and health focus of the 29 included studies. Parenthesis after study location signifies whether the location is in a high-income country (HIC) or in an LMIC.
| Author/s (year) | Study Location | Target Population | Study Design | Health Focus |
| Bermejo-Caja et al. (10) | Madrid, Spain (HI) | Doctors and nurses | Observational | Chronic conditions |
| Block et al. (11) | John Hopkins University, USA (HI) | Medical assistants, nurses | Evaluation | Hypertension |
| Conte et al. (12) | Italy (HI)a | Doctors | Observational | Cardiovascular disease |
| De Silva et al. (2022) | San Diego, California, USA (HI)a | Nursing students | Experimental | Cardiovascular disease |
| Engelman et al. (14) | District Kampala, Uganda (LMIC) | Health workers, nursing students, and nurses | Experimental | Cardiovascular disease |
| Franchi et al. (15) | Italy (HI) | Doctors | Randomized Control Trial | Cardiovascular disease |
| Fuchs et al. (2018) | Israel (HI)a | Medical students | Experimental | Cardiovascular disease |
| Gorchs-Molist et al. (17) | Catalonia, Spain (HI) | Emergency technicians, nurses, and doctors | Observational | Cerebrovascular |
| Hayer et al. (18) | USA (HI) | Doctors, nurses, physician assistants, and medical assistants | Randomized Control Trial | Hypertension |
| Herbert et al. (19) | USA (HI) | Nursing students | Experimental | Cardiovascular disease |
| Hicks and Murano (20) | Texas, United States (HI) | Doctors | Experimental | Diabetes |
| Hjorth-Johansen et al. (21) | Oslo, Norway (HI) | Nursing students and nurses | Randomized Control Trial | Cardiovascular disease |
| Jameison (22) | Manchester, UK (HI) | Medical students | Experimental | Cardiovascular disease |
| Kailin et al. (23) | Texas, United States (HI) | Medical students | Evaluation | Cardiovascular disease |
| Koka et al. (24) | USA (HI) | Paramedics | Randomized Control Trial | Cerebrovascular |
| Lombardi et al. (25) | Latin America (LMIC) | Doctors | Experimental | Renal |
| Lukaschek et al. (26) | Germany (HI) | Doctors | Observational | Cardiovascular disease |
| Okuroğlu and Alpar (27) | Istanbul, Turkey (LMIC) | Nurses, midwives | Randomized Control Trial | Diabetes |
| Padilha et al. (28) | Portugal (HI) | Nursing students and nurses | Observational | Chronic Obstructive Pulmonary Disease |
| Paul et al. (29) | Australia (HI) | Doctors | Randomized Control Trial | Diabetes |
| Phuangngoenmak et al. (30) | Thailand (LMIC) | Nurses | Randomized Control Trial | Diabetes |
| Piya et al. (2022) | Sydney, Australia (HI) | Nurses | Randomized Control Trial | Diabetes |
| Rhodes et al. (32) | Missouri, USA (HI) | School nurses | Observational | Diabetes |
| Santiago et al. (33) | Sao Paulo, Brazil (LMIC) | Nurses | Observational | Diabetes |
| Siddiqui et al. (34) | Islamabad, Pakistan (LMIC) | Nurses | Observational | Cerebrovascular |
| Suppan et al. (2021) | Geneva, Switzerland (HI) | Medical students | Randomized Control Trial | Cerebrovascular |
| Tseng et al. (36) | Taiwan (HI) | Nursing and medical students | Experimental | Cardiovascular disease |
| Walker et al. (37) | USA (HI) | Doctors | Observational | Diabetes |
| Wewer Albrechsten et al. (2017) | Various "developing countries" (LMIC) | Doctors, nurses, midwives, and medical students | Observational | Diabetes |
The majority of the studies in the overall pool used either experimental or observational study designs and gathered data using online questionnaires, interviews, and/or analysis of individual or online interactions between learners. The details about target groups and study designs are shown in Table 2. We use the term experimental for the studies that have no specific information on the randomization of the participants or where randomization has not been done. These studies typically included two groups of the study population, where one group served as an experimental one provided with the intervention and the other with no or some traditional type of intervention. Other than the observational and experimental studies, randomized control trials (RCTs) and evaluation studies were part of our review.
The studies in our review comprised mainly of educational interventions related to diabetes, stroke, hypertension and cardiac disorders.
Assessment of digital educational intervention
Based on the digital education modality that was described, we grouped the studies into three categories: Blended learning, online learning with instructor, and online learning as self-study. In the sub-sections below we present the interventions, study findings, effectiveness and identified challenges of each modality.
Blended Learning
Our review includes seven studies providing blended learning to the health professionals and students. For this purpose, we identify blended learning as any intervention that combines online learning with some form of onsite training or teaching. All the studies report advantages of blended learning over traditional learning and the increase in overall knowledge.
Blended learning was incorporated in various formats in the studies. Some of the studies include the online learning proponent prior to the onsite training. (23, 31) In these, the online learning was provided in modules that could be taken at the participants' own pace before the onsite programme which was characterised by hands-on workshops and lectures. Other studies began with the onsite training followed by an online learning proponent. (13, 27, 30) In these studies, the online proponent consisted of further self-study of the content learned in the prior onsite training. The remaining two studies did not have a set order, but rather had the online proponent as a learning resource that the participants could draw upon among other resources such as tele-education sessions, a local support coach (37) or interactive class-room lectures with group discussions and role play (34).
The studies consisted of both RCTs and observations. The RCT studies mostly highlighted strengthening capacity of nursing professionals. For instance in one RCT study in Thailand, the findings showed the effectiveness of blended learning in strengthening competency in diabetes care among nurses, wherein the levels of perceived self-efficacy, outcome expectancy, knowledge and skills in diabetes management care were statistically and significantly higher at Weeks 4 and 8 compared to the control group (30). In another RCT conducted in Australia, the addition of access to online learning as well as face-to-face education, significantly increased uptake of diabetes education among hospital non-specialist nursing staff (31). A study based in Pakistan gathered information about perceptions about social media as a tool for online training and reported that Facebook with tutor support enabled participants to study the material when their schedule permitted. The online teaching component and facilitation were ideal for their full time working nurses as reflected by their improved post-course test results (34). The detailed findings for studies examining blended learning are provided in Table 3.
Generally, among the health professionals the perception was positive for blended learning. Blended learning was perceived to be beneficial and impactful on knowledge increase. This type of learning makes the learning interactive. However, certain challenges were identified that hampered the online learning, e.g., limited internet connection and computer skills for the participants enrolled in the learning.(34) As many of the participants are health professionals active in work force, the long duration of the working hours makes it difficult to spare time for online learning (27, 31).
Table 3
Findings of studies involving blended learning
| Author/s (Year) | Findings |
| De Silva et al. (2022) | The findings from this research indicate that large gains can be made in both student knowledge attainment and knowledge application if educators move beyond normal classroom/lecture teaching techniques. |
| Kailin et al. (2021) | Benefits to online learning modules was demonstrated for the short and medium-term retention of echocardiographic learning content. Medical learners from around the world who had not been previously exposed to echocardiographic learning content exhibited a clear benefit from this online platform and learning materials |
| Okuroğlu and Alpar (2019) | It was determined that the Web based distance training program was effective at increasing the diabetes-related knowledge and skills of the healthcare professionals. However, the program was not adequate for enhancing the diabetes-related attitudes of health professionals. |
| Phuangngoenmak et al. (2019) | The findings showed the effectiveness of the program in strengthening competency in diabetes care among nurses. In the experiment group, this program significantly increased perceived self-efficacy, outcome expectancy, knowledge and skills in Diabetes Mellitus care at Weeks 4 and 8, compared to the baseline. In addition, when compared to the control group, the levels of perceived self-efficacy, outcome expectancy, knowledge and skills in Diabetes Mellitus care were statistically and significantly higher at Weeks 4 and 8. |
| Piya et al. (2022) | The online ward, but not the Face-to-Face or control wards showed increased number of good diabetes days (GDD). |
| Siddiqui et al. (2018) | Facebook enabled participants to study the material when their schedule permitted. The online teaching and facilitation were ideal for our full-time working nurses as reflected by their improved post-course test results |
| Walker et al. (2021) | Results of this pilot study demonstrate that the blended learning addresses the gaps by equipping more practitioners with the knowledge and resources to support patients with Type 1 diabetes who may not otherwise receive adequate or routine specialty care. |
Online learning with instructor
There were six studies in our review, wherein online learning with instructors was explored. Such online learning includes following a simultaneous schedule allowing for contact between learners and teachers/trainers during the course. Two of the six studies had no control group. All the studies assessed the effects of their online teaching through survey-based questionnaires. A majority of the studies reported that these types of courses are cost effective and can help bypass the geographical barrier. The findings of these studies are given in Table 4.
Regarding instructor involvement, five of the studies used learning platforms such as Moodle or Zuvia for the instructor to organise courses, materials and activities (12, 17, 29, 33, 36). Four of these also had an online forum or messaging app for peer-discussions about the content, two of these also included interactions with faculty and tutor support (17, 29, 33, 36). For instance, a study by Paul et al. (29) had an online request form for specialist advice regarding diabetes. The last study by Hicks and Murano (20) had an instructor-led webinar followed by self-study.
The studies showed a positive effect on practice. A study on cerebrovascular medical emergency management from Spain reported that an inter-professional online training on stroke in the Catalonian Emergency Medical Service (EMS) was effective in increasing the study participants’ knowledge on cerebrovascular medical emergencies. The results encouraged the Catalonian EMS to maintain this training intervention in their continuous education program (17).
Table 4
Findings of studies involving online learning with instructor.
| Author/s (Year) | Findings |
| Conte et al. (2017) | The E-Learning part is useful to introduce the E-Training, as a real innovation of the overall tool. The E-Training represents a challenging way to update knowledge also in expert users, to improve their skills and to compare their opinion with the whole peer-community and with the coordination team over frequently updated tricky clinical cases |
| Gorchs-Molist et al. (2020) | An inter-professional online training intervention on strokes in the Catalonian Emergency Medical Services was effective in increasing the participant’s knowledge on cerebrovascular medical emergencies. Both strengths and areas for improvement were detected for future training opportunities. These results encouraged the Catalonian Emergency Medical Services to maintain this training intervention in their continuous education program, which, starting back in 2015, is delivered twice a year. |
| Hicks and Murano (2017) | This research study demonstrated that online continuing medical education courses launched on state-level medical association platforms improved subject matter knowledge. Ultimately, doctors who couple knowledge basics with practical application tools may more successfully integrate these into their practices. |
| Paul et al. (2017) | Given that the number of doctors completing the online learning module was too few to expect an intervention effect, the intervention trial was discontinued, that is, no follow-up data were collected. |
| Santiago et al. (2021) | It was possible to develop a digital educational technology for care management of Diabetes Mellitus people’s feet. |
| Tseng et al. (2021) | For student performance, there was no significant difference between the experimental and control groups before the course, demonstrating their similarities, but student performance for the knowledge component in the experimental group (innovative instruction) was better than the control group (conventional instruction) after the courses, demonstrating the effectiveness of innovative instruction to boost knowledge-based learning within a short amount of time. |
Online learning as self-study
Of the included papers, 16 were about online learning as self-study. In such an intervention, the learner undertakes an online course/training as flexible self-study. This means the course can be done at any time and does not require any set schedule or contact with teaching staff. Table 5 presents an overview of study findings.
Largely the studies using online learning as self-study reported improvements in learning following the training. For instance, A study across Latin American countries, studied the effects of online training on medical knowledge regarding acute kidney injury (AKI) on nephrologists and primary care physicians. The study reported gains in knowledge equivalent to 36%. It is important to note that the study concluded that the interactive, asynchronous, online courses were valuable and successful tools for continuing medical education in Latin America, reducing heterogeneity in access to training across countries. The application of distance education techniques has proved to be effective, not only in terms of primary learning objectives but also as a potential tool for the development of a sustainable structure for communication, exchange, and integration of physicians and allied professionals involved in the care of patients with AKI (25). However, one study explored the use of online simulations (15). This randomized control trial reported no significant change in the experimental group following an online educational course regarding oral anticoagulants in case of atrial fibrillation. Also, the reading material in certain modules being too dense and lengthy poses a challenge in one study for the participants to complete the learning (36). Another study by Lombardi et al. (25), also questioned whether the knowledge effect is retained on a long-term basis.
Some of the studies emphasise the possibilities that online learning provides. One study indicated that a 6-week internet-based course in diabetes and obesity treatment may serve as an important resource in postgraduate education for medical doctors as well as other health professionals. In a wider perspective, education based on Massive Open Online Courses (MOOC) may assist the professional community by providing the latest evidence-based guidelines in an easily accessible and globally available way (38). An evaluation study in the United States reported that online learning modules, can be developed and maintained with minimal costs and basic technological requirements, and present a unique opportunity to provide essential information in a short timeframe. In addition, these modules can be specifically tailored to address identified knowledge gaps among various groups and can be easily disseminated and can be an effective method for educating nurses in a time- and cost-sensitive manner (32).
The major challenges faced by health professionals or students when participating in online learning by self-study include time constraints, out-of-date or inappropriate hardware and software.(10, 25) Some barriers that online learning can help organisations overcome include logistical difficulties and expense associated with maintaining an adequate pool of educators, coordinating training sessions, standardizing training across sites (11)
Table 5
Findings of studies involving self-study
| Author (Year) | Findings |
| Bermejo-Caja et al. (2019) | The results from this pilot study show that the e-learning application was considered useful for learning how to empower patients. However, attention needs to be paid to technological issues, and the time demands on professionals. |
| Block et al. (2018) | Direct observation data revealed that completing the online training program was associated with improvement in certain steps in the blood pressure protocol, including explaining the protocol to patients, providing a rest period, use of average mode, and recording the average reading in the EMR. |
| Engelman et al. (2017) | In this evaluation of computer-assisted training materials for Rheumatic Heart Disease screening, strong evidence was reported for an increase in knowledge across all required learning areas, as well as increased confidence in core competencies for a group of health workers without previous training in ultrasonography. Use of the training modules may reduce face-to-face teaching times and therefore the human resource requirements for busy clinicians and faculty. |
| Franchi et al. (2019) | In this trial conducted in internal medicine and geriatric wards, an educational course based on a computer-based simulation did not succeed in obtaining an increase in the proportion of patients with Atrial Fibrillation prescribed with any Oral Anti Coagulants at hospital discharge with respect to the usual practice. However, in the intervention arm, there was a greater increase, with respect to the control arm, in the proportion of patients prescribed with Oral Anti Coagulants |
| Fuchs et al. (2018) | This study shows that medical students were able to independently learn how to acquire cardiac ultrasound views by using an e-learning platform in combination with self-practice. Students who trained on their own, with no bedside teaching, combining an e-learning module and self-cardiac ultrasound practice, were overall as good as students who received an already validated, bedside, frontal cardiac ultrasound course. |
| Hayer et al. (2022) | Across all four sites, participants in the intervention group demonstrated significant improvement in both their knowledge and skills after completing the 30-minute e-Learning module. The results confirm the need for BP measurement retraining and the ability to improve provider’s knowledge and skills with a brief 30-minute e-Learning module. |
| Herbert et al. (2021) | When comparing the overall HFA pre-test and post test results, no key learning differences were identified for either the experimental or recorded video lecture groups and overall performance across groups was not as high as we expected. |
| Hjorth-Johansen et al. (2019) | The fact that e-learning was the less time-consuming learning method and that traditional learning was the preferred learning method may imply that blended learning, mixing traditional learning and e-learning may be the most effective learning method. This may address both the need for time effectiveness and the need for interaction with a teacher or an expert. |
| Jameison (2020) | The study met its initial aims and significantly improved participant’s confidence in their understanding of CVD. The study suggests e-learning and student led classroom-based learning are effective methods of teaching, with students commenting that both were engaging and enjoyable. |
| Koka et al. (2021) | E-learning module improves National Institute of Health Stroke Scale (NIHSS) knowledge and skills more efficiently than the traditional didactic video, but the retention of knowledge wanes with time. The decline in performance has been shown to be nonlinear; among participants displaying a significant decline in knowledge retention at 3 months, half of them present a significant decline already after 4 weeks |
| Lombardi et al. (2018) | The interactive, asynchronous, online courses are a valuable and successful tool for continuing medical education in Latin America, reducing heterogeneity in access to training across countries. Reliable information is lacking regarding the impact of these courses on long-term knowledge retention and the ultimate benefit on quality of health. |
| Lukaschek et al. (2019) | The knowledge and skills obtained by the Web-based Myocardial Infarction course were assessed by the participants as being beneficial and appropriate for use in primary care practice. |
| Padilha et al. (2021) | This study shows that independently of age, nurses consider MOOC useful for education and lifelong learning, expressing usefulness and intention to use this educational strategy in the future. Regarding the easiness of use and global quality of the MOOC, specialized nurses, who are older and with expertise in this field, scored higher than nurses and students. These data show that the MOOC is not only directed to younger generations but most importantly are highly beneficial to those who need access to education and lifelong learning as a way to keep up to date. |
| Rhodes et al. (2019) | The results of the present study suggest that these modules can be an effective method for educating school nurses in a time- and cost-sensitive manner. |
| Suppan et al. (2021) | Asynchronous distance learning using a highly interactive e-learning module yielded better results than following the traditional didactic video on the web. |
| Wewer Albrechsten et al. (2017) | The results indicate that a 6-week internet-based course in diabetes and obesity treatment may serve as an important resource in postgraduate education for medical doctors as well other health care professionals. |