Telemedicine in Greenland: Citizens' Perspectives

Abstract

Background: Telemedicine may have the possibility to provide better access to healthcare delivery for the citizens. Telemedicine in arctic remote areas must be tailored according to the needs of the local population. Therefore, we need more knowledge about their needs and their view of telemedicine. Objective: The aim of this study has been to explore how citizens living in the Greenlandic settlements experience the possibilities and challenges of telemedicine when receiving healthcare delivery in everyday life. Materials and Methods: Case study design was chosen as the overall research design. Qualitative interviews (n = 14) were performed and participant observations (n = 80 h) carried out in the local healthcare center in the settlements and towns. A logbook was kept and updated each day during the field research in Greenland. Observations were made of activities in the settlements. Findings: Data collected on citizens' views about the possibilities of using telemedicine in Greenland revealed the following findings: Greenlandic citizens are positive toward telemedicine, and telemedicine can help facilitate improved access to healthcare for residents in these Greenlandic settlements. Regarding challenges in using telemedicine in Greenland, the geographical and cultural context hinders accessibility to the Greenlandic healthcare system, and telemedicine equipment is not sufficiently mobile. Conclusion: Greenlandic citizens are positive toward telemedicine and regard telemedicine as a facilitator for improved access for healthcare in the Greenlandic settlements. We have identified challenges, such as geographical and cultural context, that hinder accessibility to the Greenlandic healthcare system.

Introduction

The aim of telemedicine in the Arctic Regions is to deliver healthcare to populations in remote areas and ensure equality in delivery of care and treatment. In rural and remote regions, there are many similarities between service delivery and organizations, although each region is unique in terms of its specific context and other factors. A literature review identified the need for cultural sensitivity and development of local capacity and community-led programs as essential when implementing new solutions in rural and remote healthcare systems.¹ Studies of the effectiveness of telemedicine applications in remote areas often focus on the effects of utilization of healthcare services, such as number of readmissions or length of stay. Telemedicine may have the possibility to provide better access to healthcare delivery for the citizens.^2

–5 However, when used in arctic remote areas, telemedicine needs to be tailored to the needs of the local population. Therefore, we need more knowledge about their needs and attitudes toward telemedicine. The aim of this study has been to explore how citizens living in the Greenlandic settlements experience the possibilities and challenges of using telemedicine when receiving healthcare delivery in everyday life.

Telemedicine in Greenland

In Greenland, telemedicine has been used for many years, starting in the 1990s with the implementation of teleradiology. Telemedicine was implemented mainly to provide contact between Greenlandic health personnel and specialists in Denmark.³ In 2011, the Greenlandic healthcare system underwent a reform to create and increase coherence within the healthcare system. The goal was to ensure that all regions would be able to provide uniform, high quality healthcare services to all citizens regardless of geographical location within the existing financial plan.⁶ The reform generated new interest in the possibilities of using telemedicine to increase cohesion in the healthcare system between outlying settlements and towns and from general practitioner to specialist. Today, the Greenlandic healthcare system faces challenges, such as the geographical distance between towns and settlements, infrastructural barriers when physicians have to travel between towns and settlements by boat or air, high turnover of healthcare professionals, and high cost for acute evacuation of sick citizens.^2,4,7,8

In 2008, a store-and-forward computer-based telemedicine system called “Pipaluk” was implemented in settlements with populations of more than 50 inhabitants. The technical implementation was finalized in 2010 and ∼70 Pipaluk units were installed.⁹ The aim of the Pipaluk system was to provide citizens living in rural or remote areas, who had limited access to physicians, the possibility to gain easier access to healthcare and medical consultations through the Pipaluk's applications and video conference.⁶

The Pipaluk is a computer-based system connected to various medical devices that can monitor vital signs such as electrocardiography (ECG), saturation, blood pressure, and weight. The unit has a capacity for spirometry and includes a stethoscope, an otoscope, and an examination camera. The Pipaluk is able to provide the healthcare professional in the settlement guidance and information for clinical assessment and diagnosis.^3,5,10,11

As seen in other information technology projects, the Greenlandic healthcare system was not able to ensure continuous focus on the implementation on all levels in the organization.³ In 2012, a new approach to the implementation of the Pipaluk was undertaken. The new strategy focused on training healthcare workers in the settlements and on learning how to utilize the Pipaluk system.³ In 2014, the Department of Health and Infrastructure published its Healthcare Strategy, which had renewed focus on overcoming the challenges in the Greenlandic healthcare system.¹² The strategy focused new attention on using the Pipaluk to meet the challenges in the Greenlandic healthcare system. However, the Pipaluk is still not used consistently throughout Greenland. This problem has not been explored from a citizen's perspective.³ Exploring the citizen's perspective on the usage of telemedicine was inspired by an idea initiated by the Arctic Telehealth Research Network (ATTRN), a research network operating under the umbrella of the Transatlantic Telehealth Research Network (TTRN) and the Joint Committee. ATTRN seeks to create a strategic research network to study telehealth in the Arctic Regions, bringing together academic and clinical partners in the United States, Denmark, and Greenland.

Materials and Methods

Design

Case study design was chosen as the overall research design.¹³ Citizens' views on challenges and possibilities were obtained in the context of the Greenlandic settlements.¹³ This case study used an ethnographic approach, involving direct and sustained contact with individuals and their surroundings.¹⁴

Theoretical Framework

To explore the citizens' perspectives on using telemedicine in Greenland, this study was inspired by the e-Health Lily model. The e-Health Lily model focuses on analytical and context specific literacies, both of which are required to engage with health resources. E-health literacy is influenced by a person's present health issue, educational background, health status at the time of the e-health encounter, motivation for seeking the information, and the technologies used. E-health literacy combines facets of traditional literacy, health literacy, information literacy, scientific literacy, media literacy, and computer literacy skills and then applies them to e-Health promotion and healthcare.¹⁵ Taken together, these six types of literacy combine to form the foundational skills required to fully understand consumers' experiences with e-health. E-health literacy entails the ability to seek, find, understand, and appraise health information from electronic sources and apply the knowledge gained to addressing or solving health-related problems.^16,17

Setting and Informants

Data were collected at two settlements and one town in the Kujalleq municipality, located in southern Greenland, over the course of ten days in April 2015. The sites were selected based on access to a Pipaluk, population size, and remoteness of location to reflect the diversity of settlements and access to the Pipaluk and healthcare in Greenland. To guide in identifying and selecting the two settlements and a town, a local healthcare professional with knowledge of the Pipaluk locations was contacted. Two settlements, each with populations of less than 70 inhabitants, were selected as sites of field research. One of the settlements had a functioning Pipaluk system, the other did not. The third field site was a town with a population of 1,500 inhabitants. The town contained a small hospital and was equipped with the Pipaluk system. Travel between the settlements and the town was carried out by boat and helicopter. Informants to be interviewed were recruited using a flyer inviting the citizens to Kaffemik (local tradition where coffee and cakes are served to welcome visitors to the settlement), held at the local community house. The informants at the Kaffemik were informed of the purpose of the study and data collection techniques, and interested citizens could make an appointment for an interview. Only adults above 18 years old could participate in the interviews. The informants did not receive any form of payment for their participation. See Table 1 for a description of the informants. The Helsinki Declaration on ethical principles for medical research involving human subjects was followed, and all informants in the study signed an informed consent form (in Greenlandic and Danish).^18,19

Table 1.

Description of Informants

INFORMANT	AGE	GENDER	LANGUAGE SKILLS	IN A RELATIONSHIP	SITE	TECHNOLOGIES AT HOME
1	52	Female	Greenlandic	Yes	Settlement	TV, radio, computer, Internet, smartphone
2	49	Male	Greenlandic	Yes	Settlement	TV, radio, computer, Internet, smartphone
3	32	Female	Greenlandic, Danish, English, and German	Yes	Settlement	TV, radio, computer, Internet, smartphone
4	58	Male	Greenlandic and Danish	Yes	Settlement	TV, radio, computer, Internet, smartphone
5	44	Female	Greenlandic, Danish, and English	Yes	Settlement	TV, radio, computer, Internet, mobile phone
6	26	Female	Greenlandic, Danish, and English	Yes	Settlement	TV, radio, computer, Internet, smartphone
7	52	Female	Greenlandic	No	Settlement	TV, radio, computer, Internet, smartphone
8	56	Female	Greenlandic, Danish, English, and German	Yes	Settlement	TV, radio, computer, Internet, smartphone
9	30	Male	Greenlandic and some Danish	Yes	Settlement	TV, radio, computer, Internet, smartphone
10	47	Male	Greenlandic, Danish, some English, some German	No	Settlement	TV, radio, computer, Internet, smartphone
11	51	Male	Danish, English, some Greenlandic	No	Town	TV, radio, computer, Internet, smartphone
12	38	Female	Greenlandic, Danish, English, some German	Yes	Town	TV, radio, computer, Internet, smartphone
13	55	Female	Greenlandic, Danish, some English	Yes	Town	TV, radio, computer, Internet, smartphone
14	57	Female	Greenlandic and Danish	No	Town	TV, radio, computer, Internet, smartphone

Qualitative Data Collection Techniques

A triangulation of different qualitative data collection techniques was used in the case study.

Semistructured interviews

Semistructured interviews were carried out with Greenlandic citizens from the two settlements and the town (n = 14). The semistructured interviews were conducted to obtain the citizens' perspectives on the challenges and possibilities connected with the use of telemedicine in Greenland.²⁰ An interview guide in Danish and Greenlandic was used for the interviews. The questions were based partly on the theoretical framework and consisted of open-ended and exploratory questions. The interviews were conducted in various locations, such as the community houses, a youth hostel, a settlement healthcare clinic, and a meeting room. The average time per interview was around 30 min. recorded. Three interviews were done using a translator.

Participant observation

Participant observation¹⁴ was carried out at the local healthcare center in the settlements and town. At the three healthcare centers, the observations were conducted for a total of 80 h.

Logbook

During the field research in Greenland, a logbook was kept and updated each day with information from observations and collected documentation.

Visual ethnography

Visual documentation augments¹⁴ data collecting by capturing the activities of subjects in a real-life context. Photographs and video recordings were made daily, trying to capture the activities in the town and the settlements and the physical setting of the healthcare center. Photos and video recordings ensured a high level of validity and reliability when analyzing data.^14,21

Data Analysis

Data were uploaded into NVivo 10 as text files, videos, images, and audio files. The recorded semistructured interviews and the transcriptions were reviewed and validated by a professional Greenlandic-Danish interpreter. Once validated, the data were analyzed by two researchers, each working independently, using NVivo 10. Using the Lily model of e-Health literacy as a theoretical framework, data were coded in an iterative process, by dividing and expanding the created nodes and then creating new emergent nodes and child nodes. The digital data files were coded five times until the analysis found consistent main themes and subthemes; see Tables 2 and 3. The analysis was inspired by Kvale's three stages of interpretation as follows: Self-understanding, critical common sense, and theoretical understanding.²⁰

Table 2.

Citizens' Views of Possibilities for Using Telemedicine in Greenland

MAIN THEMES	SUBTHEMES	QUOTATIONS
Greenlandic citizens are positive toward telemedicine	Internet as a tool for access to healthcare information	“I google symptoms of illness in the Netdoktor and such, so I fairly know what could be wrong” (Inf.8)
		“Netdoktor. I use it often to see if there is anything like I have experienced [symptoms] or something similar (…) it is not often that I get sick, but, for example, if someone else has been sick, then I check Netdoktor” (Inf.3)
Telemedicine as a facilitator for improved access in the Greenlandic settlements	Possibilities to obtain access to healthcare professionals from Greenlandic settlements	“It's much better if we can use [Pipaluk] to say that it is responsible when they [the doctors] decide things” (Inf.10)
		“I think it is very necessary if we use Pipaluk here. It is beneficial for Greenland and for the people.” (Inf.6)

Table 3.

Citizens' Views On Challenges In Using Telemedicine In Greenland

MAIN THEMES	SUBTHEMES	QUOTATIONS
Geographical and cultural context hinders accessibility to the Greenlandic healthcare system	Cultural and language barriers	“Then they asked somebody who was washing the floor to interpret, and the patient, while at the doctor, could hear that the interpretation was wrong, but was not able to say how else it should have been interpreted.” (Inf.8)
	Infrastructural challenges, especially when ill	“When you live outside the town and we cannot get there. We have experienced this many times, and then it takes many hours the get an approval [for evacuation]. It is difficult to make the doctor understand that we need help”. (Inf.10)
Telemedicine equipment is not mobile	The citizens' experiences with possible limitations of telemedicine	“Of course the Pipaluk helps, but it is not like ‘whoops’ if you have it, then the doctors can make a decision.” (Inf.5)

Findings

Our findings revealed both possibilities and challenges in using telemedicine, as illustrated in Tables 2 and 3. Tables 2 and 3 list the main themes, subthemes, and selected quotations from the coding process. These are further interpreted by each subtheme connected to either the possibilities for using telemedicine in Greenland or the challenges in using telemedicine in Greenland.

Possibilities

Internet as a tool for access to healthcare information

All the informants in the study had access to the Internet using either a mobile device or a computer as access point. They used the Internet to search for information regarding healthcare issues. Many of them used a Danish webpage with healthcare information called Netdoktor. In both, the two settlements and the town, the use of technology was common, and further use of technology in the healthcare system did not make the citizens insecure. The sense of security when accessing healthcare information using technology is a strong indication for the further acceptance of healthcare technologies such as telemedicine in the Greenlandic towns and settlements. The citizens' interviewed were prepared for the use of technology as long as it provided benefits for them personally, or for their place of residence (settlement or town).

Possibilities to obtain access to healthcare professionals from Greenlandic settlements

The citizens regard the Pipaluk as necessary and as beneficial for the Greenlandic people. The data indicate that the informants consider the Pipaluk as a productive investment in the Greenlandic healthcare system. The informants felt comfortable with the fact that a physician is supervising the imaging devices transmitted through the Pipaluk system. Having access to a Pipaluk creates a sense of security for the citizens, and they recognize the potential benefits of using telemedicine as a tool for gaining access to various healthcare professionals. The informants' feelings of security about the system can be interpreted as reflecting their view that Pipaluk will provide benefits to them.

Challenges

Cultural and language barriers

The informants described various barriers encountered when in contact with the healthcare system. Cultural and language barriers were themes repeated by many of the informants. Communication between Greenlandic-speaking citizens and Danish doctors created many situations in which important facts could get lost in translation. Furthermore, the use of interpreters had led to situations where the citizens' left a consultation feeling that they were not fully understood, as the interpreters are not always trained in translating health-related issues. This situation could result in clinical errors. Some informants were of the opinion that the health professionals did not understand Greenlandic culture and that this was probably related to the large turnover of staff they experienced.

Infrastructural challenges, especially when ill

The informants expressed the view that traveling to the hospital can be difficult while sick and even more difficult when the patient must go to a specific hospital. In acute situations, where the need for transportation into town is of great importance, it is not always possible to find a proper vehicle for the transportation. The informants explained that it can be difficult to describe symptoms to the on-call doctor who must decide whether an emergency evacuation of the patient is necessary. Emergency helicopter transport to and from the settlement is expensive and not always possible due to weather conditions and lack of equipment for night flying.

The citizens' experiences with possible limitations of telemedicine

Citizens in the settlements discussed the challenges experienced when being without access to Pipaluk and how the technology was not good enough to ensure reliable clinical assessments. Informants without access to telemedicine spoke of living with the insecurity of obtaining an acute or chronic disease. Furthermore, they stated that decisions regarding health should be left to the doctors instead of the medicine depot worker with very limited training. They explained that if the settlement cannot get a doctor or nurse to visit, they must have Pipaluk. The reason for their insecurity may arise not only from not having a Pipaluk system in the settlement but also from the current situation where they are served only by a medicine depot worker.

Discussion

The aim of this study was to understand how people in Greenland experienced the possibilities and challenges of using telemedicine in healthcare delivery in everyday life.

All the informants in this study had some form of access to healthcare information using digital technology. It is unclear if their level of technological literacy indicates a readiness for additional healthcare technology solutions. An exploratory study by Schwarz et al.²² found similar findings through a client survey based on patients recruited through remote fly-in-clinics in Australia. A review by Wakerman et al.²³ found that community readiness is essential to implement successful changes in healthcare delivery in remote or rural areas. A crucial factor in preparing for permanent change in the healthcare infrastructure is the type of telemedicine that will be deployed and that there is a sense of commitment in the community.²³

This study found that citizens felt secure when they had access to the Greenlandic healthcare system and that their views about health would suggest that they would only seek healthcare professionals when directly affected by disease or illness in everyday life. A study by Pedersen et al.²⁴ sought to identify the number of consultations by Greenlanders over a 12-month period (June 2010–May 2011). Pedersen et al. found that 83% of the population (46,802/56,419) had been in contact with the Greenlandic healthcare system. This study shows that case finding of diseases is possible in Greenland. The Pipaluk system could prove to be a vital tool for the Greenlandic people seeking healthcare by providing a local system that can transmit important clinical data to healthcare professionals from outlying areas. The citizens found many benefits in being able to access Pipaluk, especially the feelings of reassurance of having an access point to the Greenlandic healthcare system nearby.

A review of the benefits of telehealth in rural Australia²⁵ found that telemedicine facilities provided the rural patients access to specialist healthcare and that local clinical management could reduce general expenses for the patients, such as travel, accommodation, childcare, and food. Telehealth provides rural patients more convenience, in that they do not need to leave home, family, or work to obtain a diagnosis in a far-off town or clinic. This review has shown that it is possible for telemedicine to support the aims of the Greenlandic healthcare system in providing equal access to the population regardless of location. It was also found that the citizens view Pipaluk as a valuable access point to the healthcare system. However, telemedicine in Greenland needs to function in a healthcare system that can deal with the language and cultural barriers identified in this study. Language barriers and cultural attitudes toward health and illness can create difficulties in consultations. In order for health professionals from other countries to use their competencies in the best possible way, they need to be culturally competent before they can provide effective healthcare in Greenland. A study by Seibert et al.²⁶ found that using a cultural sensitivity and awareness checklist was helpful in ensuring that health professionals took into consideration the cultural background of their patients. The checklist can be a valuable tool for health professionals from other countries, helping them to overcome some of the challenges related to language and cultural difference.²⁶ If Pipaluk is to provide an enhanced access to the healthcare system for patients, it is important to face the cultural and language barriers that citizens have identified as a challenge.

A study by Hiratsuka et al.²⁷ found that telemedicine with real-time video and monitoring had the possibility of reducing transportation between rural locations to urban-based healthcare clinics or hospitals by providing rural-dwelling patients the possibility for local treatment.²⁷ The Pipaluk is a store-and-forward system, which means that it might have limited impact in an acute situation, where the status of the patient can change rapidly. In the future, it might be relevant to add live video conferencing and live streaming of vital information from the settlements to provide doctors the possibility to make more rapid assessments regarding emergency evacuation of patients in the settlement.

Our study found that Greenlanders identified potential limitations of the system. They were concerned about the ability of Pipaluk to serve as a reliable tool for clinical assessment, and citizens without access were concerned about their more limited access to healthcare.

Limitations

The population in Greenland is very diverse due to the size of the country, with language barriers from the east to the west coast and cultural differences from north to south; therefore, the findings are specific to the region of southern Greenland. The Greenlandic citizens' attitude toward using technology in everyday life is positive, however, the usage of new technology such as wearables, tablets etc. for management of disease is limited by the expensive costs of Internet in Greenland. Access to the Internet is limited by the available infrastructure, that is, satellite Internet, radio-based Internet, and two towns with cable Internet. The Pipaluk system is store-and-forward, which limits its usage in situations where live data exchange is necessary, however, being store-and-forward the system can function nationally not limited by the different ways of accessing Internet communications in Greenland.

Conclusion

Greenlandic citizens have generally positive attitudes toward telemedicine and see it as a facilitator for improved access to healthcare for those living in outlying settlements. One challenge in using telemedicine in Greenland is the geographical and cultural context, which may hinder accessibility to the Greenlandic healthcare system. The citizens had a positive outlook of the further usage of technology in the Greenlandic healthcare system as long as the quality of care remains the same or improved. This confirms that the current strategy for technology usage by the Greenlandic healthcare system has support from the citizens in Southern Greenland.

Footnotes

Acknowledgments

The authors thank executive medical officer Anne-Marie Ulrik and telemedicine consultant Hannah Højgaard for their assistance in helping us gain access to the Greenlandic healthcare system. The authors also thank healthcare worker Tippu Kleist for her help and guidance in Southern Greenland. Furthermore, the authors thank the people of Tamassa, the Greenlandic association in Aalborg, for providing help in translation and cultural understanding. Finally, the authors thank members of the ATTRN for sharing their experiences and knowledge of telemedicine in remote areas in designing and implementing this study.

Disclosure Statement

The study received funding from the Lauritzen Foundation, Danish Society for Arctic Science and Technology, and the Department of Health Science and Technology at Aalborg University. The authors also thank Mikkel Skovborg, Research Attaché of the Danish Agency for Science, Technology and Innovation, Palo Alto, California, for supporting the Arctic Telehealth Research Network (ATTRN). There has been no conflict of interest in this study.

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