In rural and disadvantaged areas in lower- and middle-income countries, health workers have limited access to education, up-to-date knowledge, and professional networks. These conditions contribute, amongst others, to professional isolation, attrition, poor performance, and emigration (HIFA Report 2010, Hongoro & McPake 2004, WHO 2010). In these settings the mobile phone is often the most reliable technology for health care providers to perform their work (Crow et al. 2012). In fact, in low- and middle-income countries, the use of mobile phones has dramatically increased and is considered to have a large impact on developmental issues. In South Africa this increase includes 94.2 mobile cellular subscriptions per 100 people (The World Bank 2011) and a mobile broadband penetration that had reached 29% by the end of 2013 (ITU 2014).

In this light, United Nations organisations, such as UNICEF, ITU and the World Bank, have great expectations for the potential of mobile phones to support and educate health care providers (Holmes 2010, ITU 2010, The World Bank 2012), and educational institutions have started piloting these tools (Chang et al. 2011).

Internet-enabled mobile phones increasingly permit users to access social network sites. Indeed, statistics allow the conclusion that smart mobile phone users spend considerably more time on social media and social network sites than users of personal computers (Favell 2010). Again, medical and health research has concentrated on the educational use of social media in high income countries (Gray, Annabell & Kennedy 2010). Their findings identify educational benefits as well as risks regarding ethical issues and privacy. However, very little research has been conducted about the use of social software on mobile phones in developing or transitional countries, though their potential is considered to be high (Kolko, Rose & Johnson 2007). Only a few studies have analysed the rich educational potential of the convergence of mobile phones and social networking sites for nursing and medical education in developing countries. A study, for example, illustrates how Asian health professionals are using social network sites on their mobile phones to deliberately engage with explicit forms of educational content, such as quizzes and case presentations, as well as to participate in virtual professional communities that allow for the announcement and negotiation of occupational status and professional identities. Such technologies permit the users’ educational engagement beyond local communities and facilitate loose and ephemeral connections to professional (health) networks (Pimmer, Linxen & Gröhbiel 2012a; Pimmer et al. 2013). A qualitative study in a similar programme setting as this investigation concluded that midwives are using their mobile phones to support authentic problem solving in relation to critical patient cases to facilitate reflective practice and to establish social presence in the form of emotional support and inclusion (Pimmer et al. 2014). As a result of the prevailing qualitative findings it can be concluded that future research must concentrate more attention on analysing such applications. Further research is required to address the extent to which the engagement with such technologies impacts learning and communicating health information.

More than 100 midwives enrolled in a two-year Advanced Midwifery Programme at five rural sites in the KwaZulu-Natal Province of South Africa. The challenge for the teaching staff of the programme was to connect these midwives to the university in real time and to ensure that they had ready access to all learning materials and resources. Though lectures were provided by means of videoconferencing and midwives reported that they had access to computers, it was clear that uptake of the learning management systems had been low (Chipps et al. 2015). A previous study concluded that, despite the high possibility of phone ownership (Pimmer et al. 2014), it was not clear what the use for, and perceptions about, the functionality of mobile phones for educational and work-related activities had been.

ICTs: ICTs are information and communication technologies that include hardware, such as computers (desktop and laptop) and mobile phones (smartphones and traditional mobile phones), as well as software applications and communication functions, such as calling and messaging.

Mobile phones: A subset of ICTs includes smartphones (e.g. iPhone, Blackberry) that have additional functions to basic phoning and SMS (text messaging), such as Internet access and a range of applications, and mobile phones without Internet access.

Facilitators: Facilitators were Registered Educators and Midwives employed by the university to support students clinically and academically in rural areas.

The context of the study was the Advanced Midwifery Training Programme at the University of KwaZulu-Natal, South Africa, which was presented at five remote rural hospital sites and one university site. Because the midwifery students were living, working, and studying locally a blended educational programme had been designed to address their educational needs with the aim of not removing them from their local setting for educational purposes. That included weekly in-person videoconferencing lectures from the university to the local rural hospitals and the appointment of local facilitators to support the midwives at those rural sites. Programme material in four subjects had also been placed online by utilising an open source learning management system; however, most of the material and resources were photocopied and posted to the rural sites.

A quantitative survey on the use and effectiveness of mobile phones, computers and social networks for work and educational purposes was conducted in the second half of 2012 by means of a structured questionnaire. This survey was the second component of a mixed method study to investigate mobile phone and social media usage for educational purposes in lowly resourced settings (Pimmer et al. 2014).

The population of the study comprised 113 advanced midwifery nursing students enrolled in the two-year programme at the time of the survey; 69 respondents were second year students whilst 44 of them were first year students. No sampling was done and all midwives were eligible to participate in the study, resulting in 56 valid respondents (49.6% response rate): 45 from the second year (65.2%) and 11 from the first year (25.0%). Participation varied across sites, ranging from 100% at one rural site to 27.5% at the university attendance site (Table 1).

The questionnaire was developed and refined based on the findings of previous qualitative studies, mainly from an interview-based investigation from the same programme setting (Pimmer et al. 2014) and, additionally, from a qualitative study from a different low resourced context (Pimmer, Linxen & Gröhbiel 2012b). In addition, items were adopted from an extensive survey with established validity and reliability that had examined the use and perception of information technology by undergraduate students (EDUCAUSE 2011). The questionnaire was in English and took approximately 20 to 30 minutes to complete.

The questionnaires were distributed by the local facilitators and then returned to the research staff at the university. Data were entered in the SPSS version 22.0 computer program and analysed using appropriate descriptive and non-parametric statistics. Frequency of mobile phone usage was estimated out of a possible 365 days a year, with responses assigned the following estimated values to convert frequency of use to a numeric variable: ‘using it more than once a day’ = 356, ‘more than once a week’ = 208 (52 weeks x 4 times a week), ‘more than once a month’ = 48 (12 months x 4 times a month), and ‘once a month’ = 12. Four times was taken as an estimate of use per week or month. Inapplicable data were excluded and missing data were included.

The study received ethical clearance from the Human and Social Science Ethics Committee from the University of KwaZulu-Natal and permission was granted by the School of Nursing at the university to conduct the study. Written informed consent was obtained, anonymity of respondents was maintained and participation in the study was voluntary. Data were not able to be traced back to the respondent.

Fifty-six midwives (49.6%) from four rural sites and one site attached to a university responded to the survey (Table 1); 42 from the second year of training (60.9%) and 11 from the first year of training (25.0%). Of the 56 respondents, only two midwives reported that they were male. The average age was 42.5 years (SD 75) with a range between 30 and 57 years. Only six respondents (10.7%) reported having completed a degree in nursing with the rest having completed diplomas in nursing.

Though respondents in this study did report having access to computers (n = 48; 85.7%), nearly a quarter of them (n = 13; 23.2%) had no computer access at home. In contrast, all respondents excepting two (96.4%) reported owning a mobile phone. Twenty-eight (50.0%) of the respondents reported owning a smartphone. The mobile phone was used most frequently for making phone calls with an estimated average use of 302 days a year (SD 108.9); 41 respondents (73.2%) reported that they made phone calls several times a day. That was followed by SMSs or texting with an estimated use of 250 days a year (SD 135.8). Twenty-nine (51.8%) respondents reported that they sent text messages several times a day; respondents reported sending an average of 4.7 (SD 5.2, median 3, range 0–27) outgoing messages per day and receiving an average of 6.2 (SD 6.4, median 5, range 0–30) messages per day. The WhatsApp messaging application had a general estimated use of 181.8 days a year (167.4) and was used several times a day by 13 (23.2%) respondents; Facebook was used for 127.9.8 days a year (143.8) and was used several times a day by 6 respondents (10.7%); email had an overall general estimated use of 101.6 days a year (143.5) and was used several times a day by 7 respondents (12.5%). There were significant differences by age group for how often they used Facebook functionalities, with only one of the 9 respondents over 50 years old reporting using Facebook at all and then only about once per month (X ² = 20.1 [df = 8], p = .002).

Mobile phones: When examining how mobile phones were used to support learning, three areas were identified: (1) contacting facilitators or peers to discuss topics and tasks from the course, (2) contacting facilitators or peers to discuss work-related topics and tasks, and (3) searching for information and using mobile phones in the clinical context.

Forty-five (80.4%) respondents thought mobile phones were important for contacting programme facilitators, 38 (67.9%) for contacting colleagues, and 40 (71.4%) for contacting their peers or fellow students. The majority of the respondents (n = 47; 83.9%) thought they were important for searching for work-related information, whilst 40 (71.4%) respondents reported using them at least several times a week. Though 31 (55.4%) thought mobile phones were important for work-related clinical care, mobile phones were seldom used to document or share cases by means of images (n = 11; 19.6%).

The most frequent activity reported by respondents was contacting fellow students by phone call (n = 31; 55.4%) followed by SMS messages (n = 26; 46.4%) to discuss study issues. Nearly half (n = 25; 44.6%) used phone calls to contact facilitators for both study and work-related reasons (Table 2).

Social networks: Facebook: The use of Facebook as a social network application on either mobile phone or computer was specifically evaluated as a potential new application to use for educational activities. Regarding the current use of Facebook at the time of the survey, 17 respondents (30.4%) reported accessing social network sites, such as Facebook, using their laptops and 20 respondents (35.7%) reported accessing social networks using their smartphones. Twenty-three respondents (41.1%) agreed that social networking sites were becoming important. However, the use of social networks to reflect on work-related experiences was low with only 10 (17.9%) respondents who reported that they were using social networking sites for that purpose. Obtaining information for medical and clinical support was even lower with only small numbers of respondents using Facebook at least several times a week: for example reading messages from Facebook friends on medical and clinical topics (n = 7; 12.5%), sharing or accessing medical and clinical resource lines in chats (n = 6; 10.7%), as well as sharing medical experiences in chats (n = 5; 8.9%), comments (n = 4; 7.1%), participation in quizzes (n = 2; 3.6%), clinical case presentations (n = 2; 3.6%), and posts (n = 2; 3.6%).

The respondents’ perceptions of the use of technology were examined with regard to the potential of using mobile phones and social networking activities such as Facebook to provide access to information and support learning. The characteristics of the institution (educational learning environment and ICT support) were also examined.

The study had a number of limitations. The main limitation was the 50% response rate which might have influenced the findings as a result of the non-responders’ own disposition towards using ICTs. Likewise, there was uncertainty about whether the respondents clearly understood the dissimilarity between mobile phones with smartphone capacities and traditional mobile phones.

A number of recommendations emerged from this study. Firstly, there is empirical evidence from studies that the potential exists to use mobile phones and social networks more systematically in lowly resourced settings to facilitate nursing education. Institutions should evaluate how mobile phones and social media can contribute to key aspects of education, how to integrate them, and how to support learners to use them effectively. Specifically, orientation and training of older learners should be done to raise their awareness and skills in using mobile and social networks. Nursing education should invest in developing guidelines for the use of mobile phones in the clinical settings (Royal College of Nursing 2012). However, more formal research into possible strategies and interventions to facilitate the uptake of technologies in education in these setting is recommended.