Evaluating the Experience of Training Through Videoconferences in Primary Care

Abstract

Introduction: The technological innovations that are a part of organizational realities allow for new possibilities in social processes. In Belo Horizonte, Brazil, the municipality established a system of training through videoconferences in primary care connecting professors and professionals from primary care units to discuss assistance problems in medicine, nursing, and dentistry. Objective: An evaluation of the professionals' perception regarding the system of training through videoconferences in primary care. Methods: The study involved 148 basic health units in the city of Belo Horizonte. A structured survey was applied to a sample of 373 people who used the system in 2008. Results: According to the survey data, 58.6% of the professionals participated in more than three videoconferences in 6 months, whereas 30.3% did not participate in any type of face-to-face training activity; 98% considered the topics interesting and 70% affirmed that the topics discussed helped them when performing assistance tasks. Other aspects that were evaluated as excellent or good include: 36.6% approved the sound quality of the videoconferences, 46.4% approved the image quality, and 43.9% approved the system stability. These results highlight some problems. Nevertheless, 90.2% evaluated the telehealth project as being excellent or good and 96.7% would recommend the implementation of the project in other units. Conclusions: The system of educational training videoconferences can contribute to improving the competence of primary healthcare attention.

Introduction

The implementation of telehealth projects in Brazil has occurred within a perspective that seeks to contribute to the structuring of the national health system. The main problems associated with the implementation process are related to the existence of a curative and hospital-centered assistance model currently established and continuously reinforced by conventional educational institutions. In addition, there are problems related to precarious investments in public health that compromise the quality and scope of services offered to the population. The implementation of telehealth projects in this context contributes to processes that seek to improve the training of qualified professionals who will work with primary healthcare attention.

Distance education is a feature that allows large numbers of students to attend more effectively without risk of reducing the quality of services offered. From the sixties, distance education began to distinguish itself as an unconventional form of education that could respond with agility, efficiency, and quality requirements of universal knowledge. Among the various forms of distance education and training, there is videoconferencing that is an appropriate resource for continuous upgrading of the knowledge generated so each more intense especially in the medical field. Investment in education and training of personnel in healthcare entails noticeable gains in relation to productivity and cost reduction at the primary healthcare level.

The Belo Horizonte Telehealth (BHTelehealth) project established in the city of Belo Horizonte, Brazil, in 148 primary care units is characterized by the incorporation of telehealth resources through videoconferences.

These videoconferences are structured according to three committees. They involved professionals from the City Health Department who coordinate these activities, in addition to faculty members from the Federal University of Minas Gerais Schools of Medicine, Nursing, and Dentistry. During the implementation of the project, one of the important aspects observed was the need for using multipoint communication software, making it possible real-time interaction by using audio and image resources in addition to chats. These resources were shared by all the units and by the lecturers. This aspect of allowing professionals belonging to this health network to interact among themselves and with university professors was perceived as a process that would allow for the effective training of the professionals.

When adopting a technological innovation for an organization, the individual, organizational, and technological contexts are the main aspects taken into consideration, according to the theory of diffusion of innovation.¹ The Individual Dimension considers informational behavior, competence, values, and beliefs. The Organizational Dimension includes aspects related to culture and the organization's environment as well as knowledge management. Some authors also highlight structural and contextual characteristics of the healthcare units as influential factors in the process of adopting telehealth systems.²

The Diffusion of Innovations theory provides elements for understanding the individuals and groups that participate in processes mediated by technology and the other attributes of technological innovation.³ This means that telehealth should be considered as a network of actors, who are not restricted by technological tools that mediate the actions of health professionals, but belong to a universe where the established relations among the actors receive hybrid mediations and each actor influences him/herself, others and the very universe in question.⁴ This theory considers the relative advantages regarding the social and economic aspects, characterizing the social systems involved and the channels of communication utilized.⁵

Several studies related to educational videoconferencing indicate that social influence processes modulate the relationship between mode of communication and group effectiveness.⁶

In telehealth projects involving remote areas in Alberta, videoconferencing was considered useful in overcoming the barriers of distance and that small physician numbers create a positive environment for adult learning.⁷ It is also already well established that videoconferencing is a useful adjunct to traditional educational delivery modes, and can enable quality education opportunities that would be prohibitive due to time, travel, and cost constraints.⁸

These distinct approaches point to factors that impact on the implementation of telehealth projects. However, the literature is scarce when it comes to telehealth projects focusing on training of healthcare professionals of different areas for the organization of primary care services.

Departing from the approach of the theory of diffusion of innovation, which considers this process as a social construction, in which the actors involved have centrality, this study seeks to evaluate the perception of the city's health professionals in relation to the system of educational videoconferences in primary healthcare in Belo Horizonte, Brazil.

Materials and Methods

The study considered 148 primary care units distributed in nine sanitary districts of the city of Belo Horizonte. There have been 10,693 participations during that period, involving 720 professionals. Quantitative methodology was used through the application of a structured questionnaire with a sample size of 373 people who have used the system. The sample was chosen according to the participation in the videoconferences held from 2006 to 2007, considering all the professional categories for which the project is directed—medicine, nursing, and dentistry, using a sampling error of 5%, and its projected size for 99% reliability. The data collection occurred in 2008. Thirteen questionnaires were discarded given the fact that the question regarding the participation in videoconferences had not been answered. Hence, only 360 questionnaires were analyzed. The SPSS version 17.0 statistical software was used for analyzing the data. Hypotheses were tested to evaluate the differences between the various categories in relation to the benefit of the videoconferences to assist in their performance and also the application of the content broadcasted for the improvement of care.

Results

In the sample analyzed, 61.9% of the people were between the ages of 30 and 49, with a median age of 42; among these 71.1% have a university degree. The participants' professional classifications are presented in Table 1.

Table 1.

Overview of Participants' Professional Classification

PROFESSIONAL CLASSIFICATION	NUMBER	%
Dental surgeon	55	15.3
Dental hygiene technician	12	3.3
Dental assistant	19	5.3
Nurse	86	23.9
Auxiliary nurse	69	19.2
Nurse technician	6	1.7
Medical doctor	16	4.4
General practitioner	47	13.1
College level technician	49	13.6
Did not answer	1	0.3
Total	360	100.0

The sample analyzed contemplated the people who participated in at least one videoconference. Having as a reference point the 6 months before the study, one observed that 60.3% of the professionals participated in more than three videoconferences, whereas 30.3% of these professionals had not participated in any face-to-face training in the same period. These results indicated that the project increased access to educational training (Table 2).

Table 2.

Distribution of the Number of Participants in Videoconferences and Face-to-Face Training, 2008

	PARTICIPANTS VIDEOCONFERENCES		PARTICIPANTS FACE-TO-FACE TRAINING
NUMBER OF VIDEOCONFERENCES	NUMBER	%	NUMBER	%
Zero			109	30.3
1 to 2	139	38.6	122	33.9
3 to 4	127	35.3	61	16.9
5 to 7	61	16.9	30	8.3
8 to 10	23	6.4	18	5.0
11 or more	6	1.7	12	3.3
Did not answer	4	1.1	8	2.2
Total	360	100.0	360	100.0

Considering that eight videoconferences were held in nursing and dentistry, and seven videoconferences in medicine, the different professional categories have participated unevenly in the videoconferences, with 50.1% of the participation of 1.8, 2.6, and 1.6, respectively. A little over 50% (50.1%) of dentists participated in more than three videoconferences compared to 9.9% among physicians.

According to the professionals' evaluation, the interaction provided by the videoconference system is considered satisfactory or partially satisfactory for 85.5% of the participants. There were 37.5% who considered that the videoconferences also improved the interaction among staff members in the same unit, given that it fostered discussions related to the structuring of assistance process in their environment.

Within the context of the videoconferences, the most used form of interaction was chats, generally with a significant number of questions. The survey found that 52.8% claimed to feel totally comfortable participating in videoconferences, whether it was asking questions or making interventions and 27.8% felt inhibited, but participated nonetheless. This led to a total of 80.65% of participation; 10. 9% of the people in this sample claimed they felt inhibited and did not interact.

The suiting of the topics to the reality of primary healthcare, favoring the update of the professionals' knowledge, was a relevant point of the project. It was seen as being able to contribute to the qualification of actions developed by the staff in this area of assistance. According to the study, 98% considered the topics of the videoconferences interesting or very interesting, 73.1% of the participants claimed that the topics were well developed and 70% affirmed that the topics helped in performing care practices in the units, since the methodology used to address theoretical issues and practical examples in each videoconference is intended so that the professionals have subsidies to improve their care practice. Considering everyday problems in the primary healthcare units, the themes were appropriate for 53.1% of the participants (Table 3).

Table 3

Distribution of Adequacy of the Topics Discussed in Relation to Everyday Problems in Primary Healthcare Units

OPINION	NUMBER	%
Adequate	191	53.1
Partially adequate	136	37.8
Inadequate	8	2.2
Did not answer	25	6.9
Total	360	100.0

No statistical significance was found between the categories considering the benefit of the videoconferences to assist in their performance and also the application of the content broadcasted for the improvement of care (χ ²=0.41, p=0.81; χ ²=3.79, p=0.29, respectively). The themes chosen also contributed to the process of updating 73.9% of the participants' knowledge and 85.3% believed the themes added to their existing knowledge. In addition, 66.7% of the participants felt that the 60 min reserved for the videoconferences was an adequate time, though 19.7% claim it could be less. Furthermore, 66.1% considered the news about the videoconferences good or excellent. With regard to the educational material, some problems come to light given that 43.9% of the participants did not have access to the material. As for the technological dimension of the project, only 49.4% considered it easy to access the system and watch the videoconference.

Only 36.6% of the participants evaluated the quality of the sound as excellent or good; 46.4% found the quality of the image good or excellent; 62.8% found the technical support good or excellent; 58.8% found the quality of the software good or excellent and the stability of the system was evaluated as good or excellent by 43.9% (Table 4).

Table 4.

Distribution of Quality of Sound, Image, Technical Support, Software, and Stability of the Videoconferencing System, 2008

	SOUND		IMAGE		TECHNICAL SUPORT		SOFTWARE		STABILITY
QUALITY	NUMBER	%	NUMBER	%	NUMBER	%	NUMBER	%	NUMBER	%
Excellent	21	5.8	23	6.4	36	10	34	9.4	24	6.7
Good	111	30.8	145	40.3	190	52.8	178	49.4	134	37.2
Fair	127	35.3	140	38.9	80	22.2	74	20.6	112	31.1
Poor	73	20.3	38	10.6	13	3.6	7	1.9	31	8.6
Bad	21	5.8	4	1.1	6	1.7	1	0.3	5	1.4
Did not answer	7	1.9	10	2.8	35	9.7	66	18,3	54	15
Total	360	100	360	100	360	100	360	100	360	100

With regard to a more general evaluation of this project, the results are presented in Table 5 and one can observe a good approval rating.

Table 5.

Distribution of the Evaluation of the Telehealth Project Implemented in Primary Healthcare Units in Belo Horizonte

OPINION	NUMBER	%
Excellent	153	42.5
Good	172	47.8
Fair	24	6.7
Poor	1	0.3
Bad	1	0.3
Did not answer	9	2.5
Total	360	100.0

Discussion

The analysis of the professionals' perception of the educational videoconference system for primary healthcare, focusing on nursing, dentistry, and medicine, presents various interesting aspects.

The structuring of new social processes, stemming from the absorption of technological innovation, creates new educational dimensions along with the training videoconferences. This new process makes it possible to build a network of discussion based on the problems encountered. In this sense, actors influence each other and establish a process of educational training geared toward assistance practices. This is facilitated by the implemented system that allows for interaction, the construction of collective processes, and the perception of problems stemming from distinct places such as universities, central levels, and primary healthcare units.

According to the perception of the professionals, this profoundly innovative process has contributed by updating knowledge and applying learned information to the assistance network. In addition, it stimulates certain processes of discussion within the very primary unit. The limits of this kind of interaction are only perceived by a few professionals who gradually become more familiar with these new technologies. The study also found the following: a certain stability of participation in educational activities, the increase in access to the educational training of professionals not present in face-to-face training, the increase in discussion among professionals with regard to an exchange of experiences through chats, and the increase in debates regarding the proposed topics without having to leave the job location. The learning process gains new configurations, despite the various problems present in the technological dimension such as the quality of the sound, the quality of the image, technical support, and access to educational materials.

In the context of educational training in primary healthcare, the objective of structuring a network, with the capacity for creating symbols and rules of behavior by experts in the assistance area and coming from universities interacting with the service, has progressively contributed to the consolidation of improvements at this level of assistance. Being that it is part of a social construction, the videoconferences, with its interactive dimensions, have structured themselves in a greater network where individuals interact among themselves, in their job locations, with lecturers and with other health units and end up mutually influencing each other.⁹

The implemented project between the university and service structured itself so that the two would be present and integrated when contributing to the discussions of the topics. This presupposes a continuous dialog between the health department coordinators who organize assistance activities and university professors. This process would coincide with the problems of structuring of family health programs (Programa de Saúde da Família, in Portuguese) in the country, where the initiatives for training of specific skills in primary healthcare are still precarious.

The methodology used for the presentation of topics in videoconferences included the discussion of theoretical aspects (generally presented by the professors) followed by the presentation of practical and relevant experiences (generally by the service professionals) was positively evaluated by the participants in the study. Both the topics considered and the application to real-life situations were also positively evaluated.

The characteristics of the project, structured according to the use of a multipoint communication software, which allowed for real-time interaction by using audio and image resources in addition to chat, and shared by all was not considered a problem for the interactive process, as the study reveals. Most of the professionals have no problem using these new technologies; however, an expressive number of participants still have limitations to use its full potential.

The incorporation of information technologies is something procedural and follows a distinct path. In this case, the project achieved success in that there was no technician or other information technology professional in the health units to guide the participants. The professionals themselves were the ones who dealt directly with the equipment. These are important aspects that should be observed given the complexity of the systems that incorporate telehealth resources. In general, these factors can create obstacles in the process of implementing projects in the area since they require technical knowledge about the tools being used, user familiarity with information technology applied in medicine, user friendly equipment, and facility for using the equipments and resources.¹⁰

Considering this point and dealing with the matters concerning access and use, some authors place the facility of the use of services as one of the main incentives for doctors and other users.¹¹ They further highlight the importance of developing user-friendly information technology and of promoting training opportunities to operate the system. The ease in using new technologies is one of the factors related to the speed of disseminating changes and enabling a better adoption among the users.

According to the technological dimension, the results of the study showed that professionals identified problems that can compromise the project. Overcoming such factors is considered important to establish an effective process of incorporating information technology in any environment. Structural aspects are the ones that impact on the results achieved.¹² These findings, compared with a positive assessment of this project, raise important elements for reflection. In general, some technical aspects of easy handling (quality of sound, images, and system stability) had negative ratings. Despite this, the professionals were able to clearly see the benefits of implementing the project. Since one of the greatest obstacles for the use of telemedicine is still the lack of recognition its benefits, attributed in part to the ability of the systems in making visible the benefits generated by the adoption of the system, one can infer that the professionals are starting to adopt a solution in the experience analyzed.¹³

This study focused on the attributes of the innovations, classified by various authors, that influence the use and adoption of technologies.¹⁴ The professionals recognize the consistency of the project and of this innovation by positively evaluating it. They recognize the complexity of the process. They can also see the results by highlighting the concrete possibilities of applying this knowledge to assistance practices. Furthermore, the professionals recommend the expansion of the project to other primary healthcare units.

This study demonstrates that videoconferencing is an important training tool for primary care approach to reconcile actual and conceptual discussions focused on practical experience of family health teams. The interactions between health professionals and academics, from different places and experiences, potentiate learning. To better understand the impact of videoconferencing on professional qualification, it is important to establish in detail the technical problems. Furthermore, qualitative focus groups could add important data.

These results gain great relevance in the Brazilian context, given the fact that the model analyzed served as a reference for structuring the national telehealth project established in Brazil and now covering 900 towns.

Conclusions

The present study indicates that a telehealth project that focuses on the implementation of videoconferences for the discussion of assistance problems contributes to the activities in primary healthcare. The incorporation of these new technologies allowed for both the construction of a network of discussions and the establishment of a process of qualification for assistance practices. In the perception of the professionals involved in this interactive network, composed of university faculty and healthcare employees, it has guaranteed improvements in the assistance process. Despite the identification of technological problems, the professionals have positively evaluated the project and recommend its implementation in other units.

Footnotes

Disclosure Statement

No competing financial interests exist.

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