Anticipated Acceptability of Blended Learning Among Lay Health Care Workers in Malawi: Qualitative Analysis Guided by the Technology Acceptance Model

Introduction

While Malawi is making substantial progress in achieving the Joint United Nations Programme on HIV and AIDS (UNAIDS) 95-95-95 targets by 2030, the first target (HIV status awareness by persons living with HIV) has not been reached [Malawi Ministry of Health. Malawi final report 2020-2021. Dec 1, 2022. URL: https://phia.icap.columbia.edu/malawi-final-report-2020-2021/ [Accessed 2025-03-12] 1]. To find persons living with HIV unaware of their HIV status, the World Health Organization (WHO) promotes HIV index case testing (ICT), in which contacts of individuals living with HIV are identified, counselled, offered HIV testing, and linked to care [World Health Organization. Guidelines on HIV Self-Testing and Partner Notification: Supplement to Consolidated Guidelines on HIV Testing Services. World Health Organization; 2016. ISBN: 92415498662]. Specifically, WHO recommends an option for voluntary assisted partner notification, in which health care workers help index clients invite their contacts for HIV testing, an approach that has been incorporated into Malawian standard of care [Rosenberg NE, Mtande TK, Saidi F, et al. Recruiting male partners for couple HIV testing and counselling in Malawi’s option B+ programme: an unblinded randomised controlled trial. Lancet HIV. Nov 2015;2(11):e483-e491. [CrossRef] [Medline]3-Tembo TA, Kim MH, Simon KR, et al. Enhancing an HIV index case testing passive referral model through a behavioural skills-building training for healthcare providers: a pre-/post-assessment in Mangochi District, Malawi. J Int AIDS Soc. Jul 2019;22 Suppl 3(Suppl Suppl 3):e25292. [CrossRef] [Medline]5].

Despite these recommendations, health care workers (HCWs) have limited counseling capacity that hinders full realization of voluntary assisted partner notification. For instance, formative work in Malawi identified limited counselling capacity among HCWs as a major challenge to enhancing the implementation of ICT [Tembo TA, Kim MH, Simon KR, et al. Enhancing an HIV index case testing passive referral model through a behavioural skills-building training for healthcare providers: a pre-/post-assessment in Mangochi District, Malawi. J Int AIDS Soc. Jul 2019;22 Suppl 3(Suppl Suppl 3):e25292. [CrossRef] [Medline]5]. ICT is offered by lay HCWs, cadres who lack professional training but are expected to perform select tasks within the health care system based on brief in-service training. Standard ICT training for lay HCWs is centralized, in-person, and delivered didactically. However, such approaches are logistically challenging and costly. A blended learning implementation package, which can be offered in a decentralized manner, asynchronously, and with nondidactic components is a promising alternative training approach for HCWs.

Blended learning, which combines face-to-face with digital modalities [Picciano AG. Blended learning: implications for growth and access. OLJ. 2006;10(3):95-102. [CrossRef]6-Sakina R, Kulsum EM, Uyun AS. Integrating technologies in the new normal: a study of blended learning. ijqrm. 2020;1(4):181-193. URL: https://journal.rescollacomm.com/index.php/ijqrm/issue/view/9 [CrossRef]8], is often more effective than digital or face-to-face training alone [Means B, Toyama Y, Murphy R, Baki M. The effectiveness of online and blended learning: a meta-analysis of the empirical literature. Teachers College Record: The Voice of Scholarship in Education. Mar 2013;115(3):1-47. [CrossRef]9-Singh H. Building effective blended learning programs. In: Challenges and Opportunities for the Global Implementation of E-Learning Frameworks. IGI Global; 2021:15-23. [CrossRef]11]. In recent years, the use of digital and blended educational approaches have increased, especially with COVID-19–driven pivots to remote learning [Skulmowski A, Rey GD. COVID-19 as an accelerator for digitalization at a German university: Establishing hybrid campuses in times of crisis. Hum Behav Emerg Technol. Jul 2020;2(3):212-216. [CrossRef] [Medline]12-Nacaroğlu O, Kızkapan O, Demir H. Middle school students’ motivations and learning competencies in science: mediating role of digital literacy. Psychol Sch. 2025. [CrossRef]17]. Blended learning has promoted student motivation, skill-building, and achievement in several contexts [Islam S, Baharun H, Muali C, et al. To boost students’ motivation and achievement through blended learning. J Phys: Conf Ser. Nov 1, 2018;1114:012046. [CrossRef]18-World Health Organization. WHO Guideline: Recommendations on Digital Interventions for Health System Strengthening: Web Supplement 2: Summary of Findings and GRADE Tables. World Health Organization; 2019. 20]. However, blended learning has not been fully evaluated for implementation outcomes, especially among lay HCWs in low- and middle-income countries (LMICs) with limited technological literacy [Kenney J, Newcombe E. Adopting a blended learning approach: challenges encountered and lessons learned in an action research study. OLJ. 2011;15(1):45-57. [CrossRef]21,Tembo TA, Mollan K, Simon K, et al. Does A blended learning implementation package enhance HIV index case testing in Malawi? A protocol for A cluster randomised controlled trial. BMJ Open. Jan 22, 2024;14(1):e077706. [CrossRef] [Medline]22]. Thus, there is limited evidence as to whether lay cadres would find blended learning to be acceptable. We thus developed a cluster randomized controlled trial to assess the impact of a blended learning implementation package compared with the standard of care training on implementation, effectiveness, and cost-effectiveness outcomes [Hamilton AB, Finley EP. Qualitative methods in implementation research: An introduction. Psychiatry Res. Oct 2019;280:112516. [CrossRef] [Medline]23]. Before developing this package, we conducted formative research to understand factors that may influence the acceptability of blended learning among lay HCWs in LMICs with limited technological literacy [Elsey H, Khanal S, Manandhar S, et al. Understanding implementation and feasibility of tobacco cessation in routine primary care in Nepal: a mixed methods study. Implementation Sci. Dec 2015;11(1):1-12. [CrossRef]24,Marangunić N, Granić A. Technology acceptance model: a literature review from 1986 to 2013. Univ Access Inf Soc. Mar 2015;14(1):81-95. [CrossRef]25]. This formative work uses in-depth interviews (IDIs) to assess lay HCWs’ perceptions of a blended learning approach to ICT training. Our analysis was guided by the Technology Acceptance Model (TAM).

Methods

Conceptual Framework

To explore the anticipated acceptability of a proposed blended learning implementation package, we used the TAM to guide data analysis. TAM is a theoretical model that examines constructs influencing the acceptance or rejection of technologies [Wallace LG, Sheetz SD. The adoption of software measures: A technology acceptance model (TAM) perspective. Information & Management. Mar 2014;51(2):249-259. [CrossRef]26]. The model proposes that acceptability of any technology can be predicted by 2 factors: perceived usefulness and perceived ease of use (Figure 1). Perceived usefulness refers to the belief that a certain technology would increase an individual’s job performance. Perceived ease of use is a belief that the use of the new technology would be effortless [Medical doctors (per 10,000). World Health Organization; 2020. URL: https:/​/www.​who.int/​data/​gho/​data/​indicators/​indicator-details/​GHO/​medical-doctors-(per-10-000-population) [Accessed 2023-04-12] 27]. TAM proposes that a populations’ perceptions of usefulness and ease of use of a technology impact the population’s intention to use the technology, which in turn influences the population’s actual usage of the technology. Furthermore, the key constructs of perceived usefulness and perceived ease of use are influenced by external factors, such as pedagogy, digital literacy, infrastructure, and the learning environment. Understanding these external factors is essential for designing a such a package. We used the TAM in this formative sub-study to guide the analysis of the relevant external factors influencing perceived usefulness and perceived ease of use surrounding blended learning in the context of ICT.

‎

Setting

This study was conducted at health centers in Balaka and Machinga, two districts in Southeastern Malawi. Malawi is a country in Southeastern Africa with an adult HIV prevalence of 8.9% [Malawi Ministry of Health. Malawi final report 2020-2021. Dec 1, 2022. URL: https://phia.icap.columbia.edu/malawi-final-report-2020-2021/ [Accessed 2025-03-12] 1]. Although Malawi has met the second two UNAIDS 95-95-95 targets, it has not yet reached the first 95% HIV testing target, with only 88.3% of adults living with HIV aware of their HIV status at the time of the study [Malawi Ministry of Health. Malawi final report 2020-2021. Dec 1, 2022. URL: https://phia.icap.columbia.edu/malawi-final-report-2020-2021/ [Accessed 2025-03-12] 1]. Simultaneously, Malawi has one of the lowest rates of qualified HCWs globally with less than 1 medical doctor per 10,000 people [Flick RJ, Simon KR, Nyirenda R, et al. The HIV diagnostic assistant: early findings from a novel HIV testing cadre in Malawi. AIDS. Jun 1, 2019;33(7):1215-1224. [CrossRef] [Medline]28], resulting in task shifting of HIV services to lay cadres with less formal training [Network readiness index 2023-malawi. Portulans Institute; 2023. 29]. Particularly relevant to the proposed blended learning strategy, is the fact that Malawi has one of the lowest digital literacy levels (having the necessary skills and knowledge to confidently and effectively use technology) globally ranking 131 out of 134 countries by Network Readiness Index [Clarke V, Braun V, Hayfield N. Thematic analysis. In: Qualitative Psychology: A Practical Guide to Research Methods. Vol 3. Sage Publications; 2015:222-248.30].

Study Design and Population

This formative work was conducted to inform a cluster randomized controlled trial designed to examine the implementation, effectiveness, and cost-effectiveness of a blended learning ICT package [Hamilton AB, Finley EP. Qualitative methods in implementation research: An introduction. Psychiatry Res. Oct 2019;280:112516. [CrossRef] [Medline]23]. Data for this qualitative substudy were generated through IDIs conducted with lay HCWs between November and December 2021. This formative study purposively selected facilities from both districts (Machinga and Balaka) and different levels of care (dispensaries, health centers, and hospitals) for purposes of generalizability. To be eligible for participation, HCWs had to be at least 18 years old, work full-time at one of the health facilities, and be involved in counseling index clients or tracing contact clients. With engagement from facility supervisors, the research team identified up to 2 eligible participants in each facility. These individuals were actively involved in ICT at the time of the study. A research team member visited all the eligible participants in the 14 facilities to give them more details about the study and to seek their consent. Contact details of all consenting participants were shared with one of the research team members who made arrangements with the participants for the date and time of the interviews.

Data Collection

IDIs were conducted by 3 trained Malawian qualitative interviewers in Chichewa, the local language. All interviews were conducted by 3 female external interviewers. Among them, 1 interviewer had a doctoral degree in social sciences and 2 had bachelor’s degrees in social sciences. The interviewers were trained on techniques of normalization and probing to reduce the risk of socially desirable response bias and had previous training and experience in qualitative data collection and research positions within the organization (postdoctoral fellow, senior research officer, and research officer). Furthermore, interviews were conducted in a private setting at the facilities, with only the interviewers and participants present. Interviews were conducted using a semistructured guide developed for the study through a series of rigorous, iterative discussions among the research team. The questions for this analysis focused on feasibility and acceptability of a blended learning implementation package.

After consenting and before conducting the interview, the research staff introduced themselves and their role, explained the purpose of the interview, and reiterated that they could refuse to answer questions, that all data would be anonymized, and that responses would have no consequences on their employment. Interviewers first asked questions about participants’ views of the standard training. Interviewers then provided participants with a brief description of the planned blended learning approach, explaining that it involved tablet-based asynchronous lessons modeling counseling approaches, as well as interactive synchronous in-person group sessions to practice the skills learned. Finally, they asked about perceived feasibility, probing on potential barriers. Before the start of the IDIs, the interview guides were translated, back translated, and pilot tested with iterative refinement. Interviews were conducted over the phone or face-to-face and lasted approximately an hour long. Repeat interviews were not carried out. Interviewers summarized each IDI immediately after it was conducted. Audio recordings were transcribed verbatim in both Chichewa and translated to English by professional transcribers. Transcriptions were not returned to the participants.

Data Analysis

The team took a thematic approach to coding [Kelly RF, Mihm-Carmichael M, Hammond JA. Students’ engagement in and perceptions of blended learning in a clinical module in a veterinary degree program. J Vet Med Educ. Apr 2021;48(2):181-195. [CrossRef] [Medline]31]. First, the team read the summaries to identify key themes and observed that they were framed by TAM. The research team then developed a qualitative codebook based on a focused examination of the transcripts, debrief reports, and interview summaries. The codebook consisted of both deductive codes from the interview guides and inductive codes that mapped onto TAM constructs. In addition, 2 trained research analysts (TEM and CJM) applied codes to transcript text using the Dedoose (SocioCultural Research Consultants) web application. As a first step, each analyst independently coded the same transcript and compared code applications to ensure agreements in the coding process. The analysts discussed and resolved any coding disparities, updating the codebook as needed to facilitate a shared understanding of all codes. The analysts then met weekly throughout the coding process, which provided space to review code applications and address any challenges. After coding was completed, analysts reviewed the coded text to extract key themes through the identification of patterns, naming and defining themes and refining the identified themes. Analysis was organized by factors that influence the TAM’s constructs: perceived usefulness (what participants perceived as gained or lost by the blended learning implementation package) and perceived ease of use (what participants perceived as facilitators or barriers to acceptance of the blended learning implementation package). The findings were not shared with the participants for their feedback.

Ethical Considerations

Ethical clearance was provided by the University of North Carolina at Chapel Hill institutional review board (#20‐1810), the Malawi National Health Sciences Research Committee (#20/06/2566) and the Baylor College of Medicine institutional review board (H-48800). Interviewers obtained written informed consent from all participants before starting the IDIs, reminding participants that their participation was voluntary and could be withdrawn at any time. Participants were compensated the equivalent of US $10 per interview. All data were deidentified to protect participant confidentiality.

Results

Demographic Summary

A total of 14 facilities participated in the IDIs. Among those, 2 of the facilities were district hospitals, 9 were health centers, and 3 were dispensaries. Furthermore, 9 facilities were in Machinga and 5 were in Balaka. In total, 26 HCWs participated in the IDIs. A total of 7 were female and 19 were male. Furthermore, 16 participants were from Machinga and 10 were from Balaka. There were no participants that refused to participate. All the participants were involved in both screening and counselling index clients and conducting contact tracing and had previous exposure to standard ICT training.

Themes

Our analysis identified two sets of factors influencing perceived usefulness: (1a) opportunity for self-guided learning through digital portions and (1b) opportunity for social exchange through face-to-face interactions. We identified 5 factors influencing perceived ease of use. In addition, 2 factors; (2a) need for orientation to the digital technology and (2b) accessibility of devices were related to perceived ease of use to the technology itself, while 3 factors (2c) communication around training schedules, (2d) support for logistical arrangements, and (2e) monetary compensation were related to perceived ease of use of the training approach (Figure 2). The following sections develop these themes, and Table 1 shows the illustrative quotes.

‎

Perceived Usefulness

Opportunity for Self-Guided Learning Through Digital Portions

Participants viewed the digital portion of blended learning as an opportunity for self-guided instruction. Some participants expected that a tablet-led training would allow them to learn ICT content better than facilitator-led training. This stemmed from a desire to review the training content at their own time and pace with no disturbances and to repeat difficult sections as needed. Participants expected they would keep the tablets at their facilities for future reference, an appealing feature.

Opportunity for Social Exchange Through Face-to-Face Interactions

Participants viewed opportunities to interact with facilitators and colleagues in-person as a central part of learning. Although participants were interested in individual learning, almost all also wished for social interaction during the learning process. Most participants were worried that working on the tablet would be like “talking to oneself” with no feedback mechanisms. They expected they would not get immediate feedback and clarifications. Participants viewed face-to-face sessions as essential for seeking clarification. In addition, participants felt face-to-face learning would allow them to practice and receive feedback. Practicing the skills with a facilitator and colleagues was considered useful because it would help them reinforce content and ultimately facilitate acquisition of knowledge and skills. It was also a time in which participants could receive support from their peers and facilitators on areas they needed to strengthen. In addition, participants considered the sharing of experiences with colleagues as integral.

Perceived Ease of Use

Need for Orientation to the Digital Technology

Orientation to the technology was highlighted as a key factor that would facilitate the ease of use of the blended learning implementation package. Conversely, some participants expressed fear about using a tablet for training without proper orientation due to not being well acquainted with the technology. To this end, participants suggested that they needed orientation on the use of the tablet as well as the applications that would be used during the training since technological skills varied across participants.

Accessibility of Devices

Equipment access was a significant factor influencing perceived ease of use. Participants typically did not have personal tablets and assumed a tablet would be provided. Participants had several questions regarding the availability of the tablets within their facility, such as the duration when they would be available and whether they would be assigned to individuals or the facility. In addition, participants identified tablet storage, tablets running out of power, and poor network connectivity as key challenges that would affect tablet access. Participants feared that that the tablets were at risk of being lost at the facility, thus having appropriate tablet storage measures was suggested. Furthermore, participants were concerned that in seasons with frequent power blackouts, they would have challenges to charge the tablets if they ran out of power. Some participants stated that poor mobile network connectivity in some facilities could affect their ability to complete a tablet-based training.

Communication Around Training Schedules

Participants emphasized the need for open communication regarding training arrangements. They noted that training attendance can evoke envy among colleagues. To address this, participants suggested ensuring prior communication to all health care workers about the selection process and purpose of training, especially for tablet training, to minimize work disruption and misunderstandings.

Support for Logistical Arrangements

Time and location for both portions of the training were highlighted as key logistical considerations that would drive ease of use. Most participants considered having digital training at their place of work or a nearby location acceptable. They also were open to having portions of the training over the weekend or during workdays, with pros and cons for each of these different locations and times. Weekend training was considered desirable by some as it would not disrupt work schedules, but others noted it infringed on their personal commitments. Some participants explained that having the training on-site involved less effort for travel and would not disrupt the work schedule at the facility. However, to some individuals, having the training offsite was important because it created a mindset of higher excitement, motivation, and a sense of purpose for participants. They also noted that participants in offsite training would experience fewer distractions than in a work environment, allowing participants to fully focus on the training content.

Monetary Compensation

Provision of a training allowance (ie, monetary compensation) was noted as a contributor to ease of use of a blended training. The norm in the Malawian context is to receive an allowance to cover accommodation and meals when attending a centralized face-to-face training. Participants were asked to share their views regarding such allowances under a decentralized blended learning approach. The general perception was that they would still expect to receive an allowance. In fact, some participants indicated that they preferred offsite trainings, specifically because of the certainty of an allowance. They described how allowances act as a motivating factor that allows people to focus on training content and apply what they learn. In addition, allowances were perceived as important because they support the basic expenses for their household needs without detracting from their family’s financial commitments while they were in the training. Participants preferred to receive a monetary allowance, rather than meals and accommodation, because it provided them with the possibility to save some of the money for other purposes. Participants voiced a desire for allowances to be disbursed equally across organization type, distance travelled, and rank. Although most participants noted allowances as important, many emphasized that this was not their sole ore even primary motivation for training.

Discussion

This study explored the anticipated acceptability of blended learning among lay HCWs in Malawi. Interest in self-guided learning was a key factor underlying perceived usefulness in digital learning. The desire for interaction was an important consideration for in-person learning. With respect to ease of use, blended learning could be facilitated through orientation, accessibility of digital devices, communication, and consideration of training logistics and compensation.

This study is among the first to examine perceived acceptability of a blended learning implementation package within the context of in-service training among lay HCWs in LMICs. Our study suggests that the use of technology could be acceptable among HCWs in this setting despite low digital literacy, as long as there is sufficient orientation and device access. The study revealed positive perspectives from HCWs on the use of the digital component as it would allow participants to learn the training content better at their own time, place, and pace. Consistently, studies that have used digital technology in tertiary education throughout health professions have reported positive perspectives [Bhat S, Madi̇ M. Blended learning in undergraduate dental education. Cumhuriyet Dent J. 2022;25(1):91-93. [CrossRef]32-Jiang W. Interdependence of roles, role rotation, and sense of community in an online course. Distance Education. Jan 2, 2017;38(1):84-105. [CrossRef]35], due largely to the ability to review content [Baber H. Social interaction and effectiveness of the online learning – A moderating role of maintaining social distance during the pandemic COVID-19. AEDS. Jan 3, 2022;11(1):159-171. [CrossRef]16]. We posit that if blended learning proves acceptable in a country with one of the lowest digital literacy levels and many technology barriers, it can also be implemented in areas with higher digital literacy and fewer barriers.

Our findings support previous findings that suggest learners do not want to completely forego human interactions, which they perceive enhance learning [Baber H. Social interaction and effectiveness of the online learning – A moderating role of maintaining social distance during the pandemic COVID-19. AEDS. Jan 3, 2022;11(1):159-171. [CrossRef]16,Nacaroğlu O, Kızkapan O, Demir H. Middle school students’ motivations and learning competencies in science: mediating role of digital literacy. Psychol Sch. 2025. [CrossRef]17,Wu JH, Tennyson RD, Hsia TL. A study of student satisfaction in A blended e-learning system environment. Comput Educ. Aug 2010;55(1):155-164. [CrossRef]36-Koch J, Ramjan LM, Everett B, Maceri A, Bell K, Salamonson Y. “Sage on the stage or guide on the side”-Undergraduate nursing students’ experiences and expectations of bioscience tutors in A blended learning curriculum: A qualitative study. J Clin Nurs. Mar 2020;29(5-6):863-871. [CrossRef] [Medline]38]. While most participants welcomed the idea of digital ICT training, the lack of interaction was highlighted as a major hindrance to the use of technology alone. Hence, participants preferred to also have a face-to-face portion to resolve their unanswered questions and allow them to practice new skills. The desire for face-to-face encounters has also been highlighted in clinical training programs [Bhat S, Madi̇ M. Blended learning in undergraduate dental education. Cumhuriyet Dent J. 2022;25(1):91-93. [CrossRef]32,Suwannaphisit S, Anusitviwat C, Tuntarattanapong P, Chuaychoosakoon C. Comparing the effectiveness of blended learning and traditional learning in an orthopedics course. Ann Med Surg (Lond). Dec 2021;72:103037. [CrossRef] [Medline]39]. These findings around interest in both modalities reinforce the value of blended approaches [Kemp N, Grieve R. Face-to-face or face-to-screen? Undergraduates’ opinions and test performance in classroom vs. online learning. Front Psychol. 2014;5:1278. [CrossRef] [Medline]40] in which participants experience the flexibility of digital self-training and engagement and interactivity in face-to-face sessions [Kassably C, Ashaal A, Tahan S, Bouzakhem N, Youssef S, Ghosn F. Identification of factors influencing educators perception of blended learning and triggering adoption decisions. Migrat Lett. 2024;21(4):126-144. [CrossRef]41]. We incorporated these findings into our package by having a set of digital modules focused on reviewing content, followed by face-to-face modules focused on practicing and receiving feedback.

Orientation was perceived as a key factor to facilitate the ease of use of digital technologies, such as tablets in this setting. Participants came from a setting with low technological literacy. According to the World Bank, mobile phone penetration in Malawi was at only at 60% in 2021, suggesting that digital skills are not as ubiquitous as they are in other settings. Therefore, for a blended learning implementation package to be successful, participants need basic navigation skills before initiation [Batubara HS, Riyanda AR, Rahmawati R, Ambiyar A, Samala AD. Implementasi model pembelajaran blended learning di masa pandemi Covid-19: meta-analisis [Article in Indonesian]. basicedu. 2022;6(3):4629-4637. URL: https://jbasic.org/index.php/basicedu/issue/view/21 [CrossRef]14], as well as technical support to improve ease of use [Nkamleu GB, Kamgnia BD. Uses and abuses of per-diems in africa: a political economy of travel allowances. African Development Bank Group; 2014. 42]. We incorporated these findings into our package training site supervisors on how to use the blended learning package. The site supervisors, in turn, were empowered to orient staff at their site and support those who experienced technology challenges.

Participants had different preferences regarding the time and location of the training, but they unanimously agreed on the desire for allowances, even with this new training modality. In addition, there was consensus around the importance of equity when distributing allowances. Allowances were felt to serve as motivating factors that allow participants to focus on training content. Such allowances are often provided to motivate participants [Vian T, Miller C, Themba Z, Bukuluki P. Perceptions of per diems in the health sector: evidence and implications. Health Policy Plan. May 2013;28(3):237-246. [CrossRef] [Medline]43-Derntl M, Motschnig-Pitrik R. Patterns for blended, person-centered learning: strategy, concepts, experiences, and evaluation. Presented at: Proceedings of the 2004 ACM Symposium on Applied Computing; Mar 14-17, 2004; Nicosia, Cyprus. [CrossRef]45]. However, an appeal of the blended learning approach is its potential to expand the skill set of HCWs in a more economical and less disruptive manner. By offering tablet-based training at or near their workplace, HCWs spend less time away from their other duties, and the overall costs could be reduced if no lodging or transportation expenses were incurred. Our study team took these findings under consideration in the development of a blended learning package that is now being tested in a randomized trial. In the trial, to address equity considerations, we offered the training to all lay health workers at each facility and provided a small allowance to recognize participants’ time.

Our study has several limitations and next steps. The study was conducted before HCWs were exposed to blended learning and evaluated anticipated perceptions; actual perceptions may differ. This is something we will evaluate when we implement our trial. In addition, the study was conducted in a few facilities in 2 districts and perceptions may differ in other settings. However, we sampled from a broad range of districts and facility types and achieved saturation. These facilities are not meaningfully different from other facilities in these districts or the country overall, suggesting that our results may generalize broadly in Malawi.

In summary, our formative study showed that a blended learning implementation package may be an acceptable method of training HCWs in the Malawian setting if program developers attend to contextual factors that affect perceived usefulness and ease of use. Although this work offered immediate insights for our planned trial, we recommend additional research to assess acceptability of blended learning approaches in a range of LMIC settings among lay health workers.