Healthcare Professionals' Perceptions of the Benefits and Challenges of a Teleconsultation Service in the Amansie-West District of Ghana

Abstract

Objectives: A teleconsultation service was introduced in the Amansie-West District, Ghana, in 2010 linking health center–based community health nurses (CHNs) with a teleconsultation center (TCC) at the district hospital. This study aimed to assess healthcare professionals' perceptions of the benefits and challenges of this service and to identify possible areas for improvement. Materials and Methods: Qualitative semistructured interviews were conducted with eight CHNs and three TCC healthcare professionals to find their views on the benefits, challenges, and recommendations for improving the service. The data were analyzed using qualitative content analysis. Results: Interviewees were generally positive when describing the use of the teleconsultation service. They were of the opinion that the service had improved the quality of care at health centers, thus reducing the need to refer patients to the district hospital. Practical problems, such as inadequate information provided over the phone, delays in responding to calls, and the additional workload for teleconsultation staff, were viewed as important challenges to the success of the project. Interviewees identified several possible options for improving the service through extension to other levels of the healthcare system or by adding additional functionalities to their phones. Conclusions: Teleconsultation services have the potential to improve quality of care in rural communities. However, practical problems in the operation of the service have to be taken seriously as they threaten sustainability of the intervention. Adequate training in phone-based clinical reporting appears to be essential. Teleconsultation staff should be compensated for additional workload through a reduction of other work-related tasks.

Introduction

In sub-Saharan Africa, there is increasing evidence suggesting that the use of teleconsultation services can contribute to improving the quality of care in rural communities, especially in war-torn areas.^1,2 It offers an opportunity for supervision, continuing education, and exposure to medical development and can support a potential shift from specialist-based care to primary care.^3
–5 However, teleconsultation services still remain limited mostly to pilot projects in the region.⁶ It is thought that one reason for this is the reluctance of healthcare professionals (HCPs) to integrate telemedicine into their routine clinical work.^7,8

HCPs often perceive teleconsultation services as burdensome due to the additional workload created.⁹ The limited evidence for cost-effectiveness and the skepticism about patients' confidentiality may also play a role.^10,11 But, more importantly, most HCPs in Africa are said to be unfamiliar with telemedicine, and due to inadequate training, they are slow in embracing advancements in technology.^12
–14 Nevertheless, the views and experiences of HCPs in Africa about the benefits and challenges of using teleconsultation services have rarely been explored.

In 2010, the Novartis Foundation for Sustainable Development and the Millennium Villages introduced a teleconsultation service in the Amansie-West district of Ghana with the aim of improving quality of care, minimizing patients' referrals, and strengthening human resources.^6,15 The project is intended as a pilot project to allow the Ministry of Health to gather experience for the national implementation of telemedicine in Ghana.¹⁶ Although teleconsultation services are used in some African countries, such services still remain relatively new in sub-Saharan Africa.¹⁷ Therefore, this project, linking primary care providers in rural areas with a district-level teleconsultation center (TCC), has considerable interest also for policy-makers in other countries.

However, published information on the effects of the new teleconsultation service remains unavailable. In addition, the views of HCPs using the service have not yet been studied, despite the important role that they play for the success of the project and for future scale-up.

Therefore, we conducted a qualitative study that aimed at understanding the perceptions of HCPs using this newly introduced teleconsultation service. More specifically, the objectives were to assess HCPs' perceptions (1) of the benefits of the teleconsultation service, (2) of the challenges experienced during operation of the service, and (3) of possibilities to improve the service.

Materials and Methods

Setting and Intervention

The Amansie-West District is located in the Ashanti region of Ghana and has a population of about 134,000 inhabitants. The district is characterized by heavy rainforest, tropical climate, and poor road networks. The most important health problems include malaria, anaemia, malnutrition, buruli ulcer, tuberculosis, human immunodeficiency virus/AIDS, and occupational hazards.^15,18

–21 There are 22 health centers and clinics, and there is only one hospital—St. Martin's District Hospital—at Agroyesum. The number of HCPs is generally considered to be insufficient.¹⁹

In 2010, a TCC was set up at the district hospital, and each of the 12 community health nurses (CHNs) working in seven health facilities received mobile phones, enabling them to make calls to the TCC in case of difficulties when treating patients. At the TCC, nurses or midwives respond to questions with the help of a paper-based protocol designed for diagnosing and treating the most prevalent diseases in the district. This protocol ensures a structured consultation, guiding TCC nurses and midwives through the most important questions that have to be answered in order to facilitate evaluation and diagnosis of patients and to help make decisions on whether a patient should be referred to the hospital.¹⁵ If needed, TCC nurses or midwives can seek advice from physicians.

Data Collection

Eleven HCPs were interviewed in July 2013. The sample included eight CHNs (one or two from each of the seven health facilities) and three HCPs—a physician, midwife, and nurse—from the TCC. The CHNs were recruited at a 1-week telemedicine refresher training workshop organized for the 12 CHNs using the teleconsultation service. Of the nine CHNs who attended, eight were interviewed, and one was excluded due to no experience with the service. Information on the HCPs is noted in Table 1. The sample were predominantly female (55%), the majority of them were between 25 and 29 years of age, and they had an average of 2.1 years of working experience with the teleconsultation service.

Table 1.

Descriptive Data of the Healthcare Professionals

PARTICIPANT ID NUMBER	SEX	AGE RANGE (YEARS)	OCCUPATION	YEARS OF EXPERIENCE
CHN1	Female	25–29	Community health nurse	3
CHN2	Female	25–29	Community health nurse	1.3
CHN3	Male	30–34	Community health nurse	2
CHN4	Male	25–29	Community health nurse	2
CHN5	Male	25–29	Community health nurse	3
CHN6	Female	25–29	Community health nurse	2.5
CHN7	Female	25–29	Community health nurse	2
CHN8	Female	25–29	Community health nurse	1
TCC nurse	Male	25–29	Registered general nurse	2
TCC doctor	Male	25–29	General physician	1
TCC midwife	Female	25–29	Midwife	3

Field data from 2013 are given.

CHN, community health nurse; TCC, teleconsultation center.

A semistructured interview guide derived from the concepts in the background literature was used to interview the HCPs. Questions were asked about the uses and benefits of the teleconsultation service as well as challenges experienced. In addition, HCPs were asked to make recommendations on how the service could be improved. Field notes were taken, and follow-up interviews were scheduled when clarifications of certain aspects of the interview were required.^22,23

Ethics approval was obtained from the Committee on Human Research, Publication and Ethics, School of Medical Sciences/Komfo Anokye Teaching Hospital, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana. The HCPs provided their written consent to be interviewed.

Data Analysis

Data were analyzed thematically using qualitative content analysis.²⁴ The initial phase of the analysis involved the development of a coding frame to organize the data into main categories and subcategories. Five main categories were deduced from the topics in the interview guide: factors affecting healthcare services, use of telemedicine in different areas of primary care, benefits of telemedicine, challenges of telemedicine, and recommendations for improvement. The subcategories were derived inductively from the data gathered during the interviews. The data were segmented thematically and assigned to subcategories. The coding was reviewed after 14 days to check the reliability and validity of the categories and subcategories.²⁴

This article focuses on the data assigned to the three main categories—“benefits,” “challenges,” and “recommendations for improvement”—and their 22 subcategories. Details of the subcategories can be found in the Appendix in Figure A1.

Results

Benefits of the Teleconsultation Service

Interviewees thought that the most important benefit of the teleconsultation service is that it has limited the number of referrals. The CHNs said that they do not need to refer minor (mostly obstetric) cases if they receive advice from the TCC, and the same was confirmed by the TCC nurse, midwife, and physician:

The biggest advantage is to cut short or to limit unnecessary referrals. (CHN3)

[…] previously we were referring cases, now the referral cases have reduced. (CHN5)

[…] those cases we get in reproductive health like patients in labour, we manage most of them there without bringing them except those that we encounter complications that we suspected might need serious monitoring or even sometimes caesarean section. (TCC nurse)

Another important point mentioned by several CHNs is that by avoiding referrals, the teleconsultation service also contributes to reducing travel costs and saving time for patients:

It reduces cost because as far as telemedicine is concerned as soon as you call, all treatment can be given without wasting money in terms of going to the hospital or clinic. (CHN2)

Instead of [patients] moving from my place [the health center] to Agroyesum [the hospital], their transportation is saved, their time is saved. (CHN4)

CHNs also said that they are better able to treat their patients with the help of the teleconsultation service. In particular, advice from TCC nurses or midwives was felt to be useful when treating more complicated cases, such as convulsions or pregnancy-related complications. For example, a TCC midwife described that it was possible to manage postpartum hemorrhage over the phone. Furthermore, CHNs found advice from TCC nurses or physicians to be particularly helpful after initial treatment failure, when they were unsure about how to deal with persisting health problems:

A child was brought with convulsion. […] I inserted […] suppository first and then I was not sure whether I should add diazepam or not. I called them and they said I should add the diazepam for the child to be stabilized for a while and when I added that one the child slept for a while and after that the convulsion just left her and I started treating for malaria. (CHN3)

I was called to manage PPH-postpartum hemorrhage […] the uterus wasn't well contracted. She didn't check because she wasn't a midwife and then I asked her to expel some clots […] and then examine if there are perineal tears. But there were no perineal tears but just that the uterus was not well contracted so she gave Oxytocin 20 Units […] 10IM and 10 was the infusion. She was massaging the uterus […] so the bleeding subsided and I asked her to pad […] Later on she removed it and then she called to tell me that the bleeding has stopped. (TCC midwife)

[…] sometimes the person will come with a complaint that we have given a treatment. The person will go and come back with the same complaint then you have to call the telemedicine for her and that will be all. (CHN2)

Finally, several CHNs indicated that the continuous guidance and feedback received from doctors, midwives, and nurses via the teleconsultation service improve their knowledge and help them to develop the necessary skills to appropriately treat their patients:

[…] when […] I have to conduct the delivery and I cannot or there is something which I don't understand, I have to call for them to give me the necessary skill or knowledge and apply while the patient is before me. (CHN3)

[…] there was this child with a cleft palate […] so I had to call the doctor […] and the way the doctor was explaining things to me, I was even happy myself. (CHN1)

Regarding the use of the paper-based protocols for the teleconsultation service, the HCPs at the TCC indicated that they are able to ascertain the most relevant information that would lead them to make appropriate diagnoses and treatments. In addition to the protocols, their experiences in healthcare practice aid them in this regard:

We've got some protocols here that we use in managing the cases. It gives us a format as to what questions to ask a patient so that it sort of narrows the conditions and symptoms down for you the person receiving the call. So there are no unnecessary distractions. But these protocols are not hard and fast rules, so to say. So we also take into account the experiences from our professional fields to also help the patients. (TCC nurse)

Challenges of the Teleconsultation Service

One fundamental challenge to the teleconsultaton service mentioned by both the nurse and the midwife working at the TCC is the possibility of an incorrect diagnosis and/or treatment due to inaccurate or inadequate information. Nurses, midwives, and physicians at the TCC depend on the information given to them by the CHNs to make a diagnosis. However, the information provided may be incorrect, which can have negative consequences for patients. In the words of the interviewed TCC nurse:

One [challenge] that I have personally identified is […] wrong information or wrong history which totally affects the whole process […] with teleconsultation; it's not like having the patient in front of you where you can make certain observations. You're listening to observations per another health professional […] so usually we can't say the information we get are 100% accurate and personally I think that is a challenge to the system […] (TCC general nurse)

More practical challenges were also identified, but they were viewed very differently by health center–based CHNs and by the nurses and midwives at the TCC. For CHNs, the most important problem is that they do not always get a quick response to their calls. This was described as very frustrating and problematic, especially when assistance was needed for the treatment of emergencies:

Ok sometimes you call and it will take some time before you get an answer […] let's say there is an emergency that you desperately need an answer but no one is picking the call so sometimes you become worried. (CHN1)

They have to make sure one person is there […] so that anytime we call the TCC there is a person who can pick the call […] (CHN6)

The nurse and midwife at the TCC agreed that a quick response was essential. However, they thought that a delayed response to calls was mostly related to the additional workload, limited personnel, and inadequate incentives for TCC nurses and midwives (when compared with the financial compensation received by physicians):

For now we are four people who run three shifts a day [at the TCC]; morning, afternoon and evening. And let me just give you a practical thing that happens. I work at the emergency unit. You know in this profession we work with the shift system. So when I'm off duty, say I finish my morning shift there, I possibly can run an afternoon shift here [at the TCC] or a night shift. Now I am sitting here [at the TCC], they've brought a child to my unit but […] my other colleagues there find it difficult […] and they feel that they need my assistance. Humanly, I wouldn't say because I am sitting here waiting for a call, that child should be lying there and wait until I've done my shift. There are a number of times I have to leave this place […] to help maybe resuscitate certain patients. (TCC nurse)

With telemedicine being included, it's like we are running double duties. I go for my normal ward duties then after that I come here [TCC], depending on the shift that I am. You see telemedicine if you miss a call the life of somebody is at risk, so with our extra duties we are doing at the ward and taking our shift here […] you can record a missed call […] somebody's life would be in danger […] (TCC midwife)

There are quite a number of wards with few medical officers. We are five in number and we are usually overloaded. At any point in time outside the regular duties you may be called. Some days you may not be called. (TCC doctor)

We attend to most of the cases we receive through telemedicine without further consultations with a doctor. What pains me is the little remuneration we receive at the end of the month. (TCC midwife)

Areas for Improvement of the Teleconsultation Service in Primary Care

The interviewees provided a broad range of recommendations about how the service could be improved. However, one common theme of many recommendations was related to a desire of the interviewees that the scope of the teleconsultation service should be expanded—to incorporate other applications, to include higher levels of care, and to enable patients' involvement:

If maybe it can be in the form of online chatting with those at Agroyesum [HCPs at the TCC…], like ‘WhatsApp’ or video call […] so that the doctor would be able to see whatever is going on at your end there so that he would be able to make appropriate interventions. (CHN4)

[…] as much as what we have now is good, we are challenged in the fact that we wish we could extend it beyond […] so that we can save the patients [further referrals…] to Kumasi-Komfo Anokye teaching hospital. (TCC doctor)

The fact that patients also can't access it is also a problem […] because sometimes some patients can be even more open about what is wrong with them than somebody who is representing them. (TCC doctor)

In addition to these specific suggestions about how to improve the teleconsultation service, interviewees also indicated that basic infrastructural resources are an essential prerequisite for the service to work. For example, they highlighted the importance of a functioning telecommunications network, good roads, and ambulance services. Several nurses mentioned problems of the telecommunications network, which ultimately undermine the functioning of the entire intervention. One nurse, in particular, noted a recent interruption of the service resulting from a conflict between the telecommunication agency and a landowner on whose land the satellite pole was erected:

[…] the network [has to] be restored […] We had a pole but there has been some misunderstanding […] So now the network is no more functioning […] (CHN5)

If we can all make it so that we have basic facilities available, […] at least if the TCC room has good internet connection, you can send your information across quickly. But until then, we would always have certain lapses. (TCC doctor)

Discussion

The results of our qualitative interviews with 11 HCPs using the teleconsultation service implemented in the Amansie-West District show that the service is generally viewed very positively. CHNs find that the service has improved their ability to treat patients at the health center, and, consequently, it was seen to have contributed to reducing referrals. At the same time, the continuous exchange of information between health center–based CHNs and hospital-based nurses, midwives, and physicians was viewed by CHNs as useful for further developing their professional knowledge and skills. However, our results also show that practical problems in the operation of the project, such as inaccurate or inadequate information provided over the phone, delays in responding to calls, and additional workload for HCPs working at the TCC, are viewed as important challenges to the success of the project. Furthermore, interviewees identified a range of possible options for improving the service through extension to other levels of the healthcare system or by adding additional functionalities to their phones.

These results have important implications for researchers and policy-makers in Ghana and beyond, working on the implementation of teleconsultation services. First, although much has been written about HCPs' reluctance to integrate telemedicine into their routine clinical work,^12
–14 we found that CHNs using the teleconsultation service in the Amansie-West District were, in general, very positive about the service, highlighting numerous benefits that it provided to their patients as well as to their professional development. The CHNs' responses to the continuous guidance they received from the TCC healthcare workers show the potential of the service for continuous education and medical development.⁴

Also, a reduction of referrals was seen as the most important benefit, which was also thought to increase cost-effectiveness of treatment. Existing studies of the introduction of different teleconsultation services in Somalia² and South Africa⁴ found similar benefits of the evaluated interventions. However, further research is needed to quantitatively confirm the identified benefits and to evaluate cost-effectiveness of the use of teleconsultation in primary care.^3,25

Second, policy-makers should take seriously the identified practical challenges related to the operation of the teleconsultation service. The use of the teleconsultation service is associated with the possibility of compromising diagnoses. According to the HCPs at the TCC, they are not able to directly assess patients, and consultations generally take place between the CHNs and HCPs at the TCC. Care may be compromised if CHNs make inaccurate diagnoses or provide incorrect information to the TCC staff. The potential for this to occur is heavily dependent on how well the CHNs are trained in providing the appropriate information.

Again, the new service is considered as an additional workload created for nurses and midwives receiving calls at the TCC, coupled with a perceived inadequacy of financial incentives.

These challenges have the potential to undermine the generally supportive attitude of HCPs toward telemedicine.²⁶ As the government of Ghana is planning to expand the use of telemedicine across the country,¹⁶ it should ensure that the periodic training of CHNs to identify signs of disease conditions also include training on communication skills and approaches to case reporting in order to improve the accuracy and adequacy of information given to the TCC staff.²⁷

It should further ensure that the additional workload created by the introduction of a telemedicine intervention is compensated for with a concomitant reduction of other work-related tasks. In addition, the usefulness of introducing financial incentives with the aim of motivating staff to participate in an intervention may need to be reviewed. It seems difficult to appropriately design financial incentives that do not create discontentment within a larger team, in particular if the size of financial incentives varies across different categories of staff.^28,29

Third, the recommendations of HCPs about how to improve the teleconsultation service can provide inspiration for a future expansion of telemedicine. The inclusion of picture or video functionality could possibly improve the diagnostic ability of HCPs at the TCC. Previous studies have demonstrated the feasibility of teledermatology in Ghana and Uganda.^30,31 Previous research has also demonstrated that linking hospital-based physicians to specialists at higher levels of care (even abroad) can improve diagnosis and treatment of patients.² Therefore, the government of Ghana should explore possibilities for expanding teleconsultation to higher levels of care as suggested by the district hospital physician.

This exploratory qualitative study has certain limitations. The HCPs provided insight into how the service facilitates healthcare delivery in the remote communities they serve, and as such their views are not representative of all HCPs working in the Amansie-West District. A selection bias may have occurred in recruiting the CHNs at a workshop where all those absent were excluded. Nevertheless, the HCPs in this study had experience in using the teleconsultation service, and their perceptions reflect the operational realities of the service. It is, however, acknowledged that the participants are relatively young. The reason for this is that all health workers at the participating facilities were in a young age group. However, we recommend that similar studies should be conducted to assess whether more experienced and older staff at the facilities would be as likely to use the teleconsultation service.

Conclusions

Teleconsultation services have been found to offer great potential for improving quality of care in rural communities,^1,2 but their implementation currently remains limited mostly to pilot projects—supposedly because of resistance from HCPs.^9
–11 Our results show that HCPs in the Amansie-West District of Ghana generally view the implemented teleconsultation service very positively, highlighting that it has improved their ability to treat patients at health centers and avoiding hospital referrals. However, practical problems in the operation of the service, such as inaccurate and/or inadequate information provided by health center–based nurses to TCC staff and the additional workload created for TCC staff, have to be taken seriously. They threaten the success of the entire intervention. In view of this, the implementation or scale-up of teleconsultation services in Ghana and other resource-limited countries should be accompanied by training of health center–based nurses in clinical reporting, and TCC staff should be compensated for the additional workload through a reduction of other work-related tasks.

Finally, because of the limitations of our qualitative study, further (quantitative) research is needed to ascertain the described positive effects of the use of teleconsultation services as well as cost-effectiveness of the intervention.

Footnotes

Acknowledgments

We sincerely thank the MVP-telemedicine project team in Ghana, the Amansie-West District Health Directorate, and particularly the healthcare workers who participated in this study for their cooperation. The study was financially supported as part of a scholarship for a Master's degree program by the German Academic Exchange Service.

Disclosure Statement

No competing financial interests exist.

Appendix

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