A comparison of telehealth and face-to-face presentation for school professionals supporting students with chronic illness

Introduction

A child with a chronic illness is one who has a condition which lasts for more than three months and may limit daily activities. ¹ This includes illnesses such as asthma, allergies, diabetes, cancer, sickle cell disease, cystic fibrosis, congenital heart disease and AIDS. In the US some 15–30% of children have a chronic illness, or up to 20 million. ^2,3

Parents and teachers agree that school provides benefits for students with chronic health conditions, including opportunities for skill acquisition, socialization and respite care for families. ⁴ However, hospitalizations, long periods of time at home and frequent health-care appointments for chronic illness result in high rates of absenteeism, which can be detrimental to the child's academic success and psychosocial wellbeing. In addition, peers, siblings, parents, teachers and other educational staff members have their own concerns. Fear and lack of knowledge may immobilize them, creating avoidance and more difficulty for the child with a chronic illness and other stakeholders. ⁵ Therefore, providing school staff with information regarding chronic illness in children may have important, long-term benefits.

In Kansas, many rural schools have VC-supported distance learning classrooms. Thus, it would be feasible to use telehealth to support the educational and emotional needs of children with chronic illnesses. Although there is a substantial literature on the use of telehealth for clinical and educational purposes, there appear to be no reports about telehealth being used for children with chronic illness, their school teachers, family and friends, especially in the school context. Telehealth was considered a promising approach because Kansas is significantly rural, with nearly half of its population living in rural areas. ⁶ In addition, the Kansas University Center for Telemedicine and Telehealth (KUCTT) had long experience in developing telemedicine and distance learning applications. Finally, a statewide, high-speed, private broadband network, Kan-ed, was being created to link all schools, hospitals, libraries and higher education institutions. One of the benefits of the Kan-ed network is that it supports high bandwidth videoconferencing.

The purpose of the present study was to compare videoconferencing (VC) and face-to-face (FTF) presentation for the delivery of education about chronic illness to school staff. The research questions were:

Does VC offer a satisfactory alternative to FTF for the delivery of chronic illness education to school professionals?

Methods

In 2003, the KUCTT implemented a service called Connected Kansas Kids. The main component of the service involved presentations for school personnel about the needs of the chronically ill child. A total of 45 presentations related to chronic illness and could be presented in either VC or FTF formats. Each presentation was designed to last approximately one hour and when delivered by VC, typically occurred at 384 kbit/s. Categories and sample topics are shown in Table 1.

All presentations were delivered via VC or FTF by a single paediatric educator who developed and coordinated the sessions. The presentations were non-randomized and were scheduled by VC or FTF depending on whether the receiving site had VC capabilities or not. After viewing and listening to each presentation, participants were asked to complete a brief questionnaire. A 5-point response scale was used (1 = strongly disagree to 5 = strongly agree). The assessment instrument evaluated satisfaction and several other general perceptions. For example, participants were asked to indicate their level of satisfaction with the quality of instruction, how difficult they believed information on special needs children was to obtain, and if they felt better prepared to deal with children with special needs after the presentation. The items are shown in Table 2. Completed survey forms were collected by the presenter after FTF sessions or mailed to the presenter after VC-delivered sessions.

A one-way analysis of variance (ANOVA) was used to compare the means of the VC and FTF groups across the 10 items in the survey instrument. The ANOVA procedure is often conducted on data that are quantitative and have multiple means for comparison. In addition, linear regression analysis was performed to determine if any of the perception items accurately predicted satisfaction levels. Linear regression is typically used with multiple independent variables to assess which variables or combination of variables most influences the dependent variable. Finally, a reliability analysis of the survey tool was conducted using Cronbach's alpha. This test measures the internal consistency of survey tools and the properties of individual items.

Results

Between 2003 and 2006, 181 sites received a total of 223 presentations. One hundred and twenty-five of the sites received 162 FTF presentations and 56 sites received 61 VC presentations. Ninety-one of 181 sites were rural, 36 were suburban and 54 were urban.

The study group consisted of 1267 women (91%) and 122 men (8%) — 919 viewed FTF presentations and 417 viewed VC presentations. Of those who participated, 452 were teachers (32%), 10 were administrators (0.7%), 58 were support staff (4%), 31 were counsellors (2%) and 635 classified themselves as ‘other’ (45%). The latter included school nurses, bus drivers, paraprofessionals, cafeteria staff and custodial staff.

The reliability of the 10-item survey was high (alpha = 0.77).

Participants at both the FTF presentations (mean 4.6, SD = 0.6) and VC presentations (mean 4.3, SD = 0.7) indicated that they were very satisfied with the instruction they received. The FTF participants were significantly more satisfied than the VC participants (P < 0.001).

Participants who viewed the FTF presentations also reported that they were generally comfortable in using new technology (P < 0.004) and that they would like to see more events offered via videoconferencing (P < 0.001). However, VC participants expressed a stronger urge to access similar information online (P = 0.019). In addition, FTF participants felt better prepared to deal with a child with chronic illness prior to receiving instruction (P = 0.012) and after instruction (P < 0.001) than those in the VC sessions. Finally, the FTF attendees perceived the FTF method as more convenient (P < 0.001) and were more likely to recommend the instruction to others (P < 0.001). Table 2 shows the mean values for all survey items in both conditions.

The linear regressor predicting satisfaction was significant (F = 146.4, P < 0.001, adjusted R ² = 0.44) in the FTF condition. Likewise, the regression analysis was significant (F = 127.9, P < 0.001, adjusted R ² = 0.49) in the VC condition. The significant regression items for each condition are shown in Table 3.

Discussion

Satisfaction with distance learning via telehealth has been demonstrated in a number of contexts. For example, researchers in central New York demonstrated that rural patients were satisfied with a nutrition intervention delivered by VC ⁷ and a school telehealth education programme in rural Arkansas was rated as satisfying by 3319 junior high and high school students. ⁸ In England, VC was used to provide continuing professional education from dental schools to dentists in outlying areas of London. Ninety percent of the 257 participants indicated that they would like to attend future educational sessions delivered by VC and expressed satisfaction about not having to travel for the sessions. ⁹ The results of the current study corroborate these findings and extend them to an audience of school professionals and content related to chronic illness. Together, these studies indicate that using VC for distance learning purposes can be a positive experience for end users in a variety of circumstances.

Interestingly in the present study, satisfaction levels in both the VC and FTF conditions were very high, but levels in the FTF setting were significantly higher. The regression analysis may help to explain this difference. Comfort with the method of presentation was a predictor in the FTF condition, while level of discomfort was a predictor in the VC condition. Most practitioners and educators are accustomed to FTF presentations. They approach them with expectations based on previous experiences. VC presentations, in contrast, are relatively new and users may have limited or uncertain expectations if they are not experienced with this method of delivery. The fact that level of discomfort emerged as a predictor may simply indicate that participants need to be better prepared for what to expect prior to receiving instruction via VC.

Similarly, the FTF attendees reported being generally more comfortable using new technology and expressed an interest in seeing more content offered via VC. Again, expectations may explain these results. Because the surveys were completed after the educational sessions, the FTF participants may have been more positive about technology and video sessions than those who actually had the VC experience. This explanation is consistent with the finding that VC is a generally less satisfying experience than FTF education. Alternatively, those who participated in the FTF sessions may have been trying to indicate that VC would offer them another option for receiving the content they required.

It is unclear why FTF participants felt better prepared to deal with a child with chronic illness than VC attendees prior to the educational sessions. One possibility is that the FTF audience had a higher concentration of professionals trained in special needs issues such as school psychologists or counsellors. Another possibility is that the presence of the presenter in the FTF sessions influenced participants' self-reports of their prior preparation.

Despite the differences between the two methods of delivery for several of the dimensions, the mean values indicate that participants reacted positively to all of the assessment items for both conditions. This suggests that while practitioners and educators may prefer FTF presentations, VC delivery is a viable alternative when FTF is not possible, particularly in rural areas. Because VC has been shown to more efficiently deliver continuing education for physicians while saving time and travel costs for participants and presenters, ^10,11 the benefits could be realized with other audiences for meeting the health education needs of under-served areas.