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research-article2015
PED0010.1177/1757975914567180Original ArticleH. Pinzon-Perez and C. Zelinski
Original Article The role of teleconferences in global public health education Helda Pinzon-Perez1 and Christy Zelinski1
Abstract: This paper presents a global health education program using a ‘Teleconference’ approach. It provides examples of how technology can be used to deliver health education at the international level. Two international teleconferences about public health issues were conducted in 2013 and 2014 involving universities and public health institutions in Colombia, Dominican Republic, Costa Rica, Uganda, and the United States. More than 400 students, faculty, and community members attended these educational events. These teleconferences served as the medium to unite countries despite the geographical distances and to facilitate collaborations and networking across nations. Teleconferences are an example of effective technology-based health education and health promotion programs. Keywords: education (including health education), e-health, global health/globalization, health literacy, health promotion
Introduction International collaborations have become essential in the management of health and disease patterns around the world. An example of such collaboration initiatives is the ‘Global Burden of Disease’ study (GBD) sponsored by the World Bank (WB) and the World Health Organization (WHO). The 2010 GBD study was designed to assess disease patterns among 187 countries between 1990 and 2010. This study revealed that the five leading causes of disease and injuries around the globe were ischemic heart disease, lower respiratory tract infections, stroke, diarrhea, and human immunodeficiency virus-acquired immunodeficiency syndrome (HIV-AIDS) (1). The management of these diseases requires a global effort instead of individualized country-based programs. Health education is a very valuable strategy in global health. Health educators have been at the forefront of international efforts to reduce the burden of disease and to promote health at the international level. Pratt and Lamarre have discussed how global health maladies often involve similar
health behaviors, risk factors, and social determinants across countries and how health educators can help reduce such maladies (2). The GBD study revealed that the leading risk factors for global disease in 1990 and 2010 were high blood pressure, tobacco use, household air pollution, diet low in fruit, alcohol use, high body mass index, and high fasting plasma glucose levels (1). Examples of conditions in which global public health has played a crucial role by reducing these risk factors include smallpox eradication, control of cholera outbreaks, and general reduction of communicable diseases (2). Health education is a professional field that promotes the development of sustainable capacity (3). Examples of programs in which health educators have contributed to the improvement of global health include the cooperative alliance between the International Union for Health Promotion and Education (IUHPE) and the United States (US) Centers for Disease Control and Prevention (IUHPE). This alliance started in 2002 and focused on responding to the challenges of global health
1. Fresno—Department of Public Health, California State University, Fresno, USA Correspondence to: Helda Pinzon-Perez, California State University, Fresno—Public Health, M/S MH 30, 2345 E. San Ramon Ave., Fresno, CA 93740-8031, USA. Email: [email protected] (This manuscript was submitted on 1 July 2014. Following blind peer review, it was accepted for publication on 1 October 2014) Global Health Promotion 1757-9759; Vol 0(0): 1 –7; 567180 Copyright © The Author(s) 2015, Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1757975914567180 http://ghp.sagepub.com Downloaded from ped.sagepub.com at RYERSON UNIV on June 4, 2016
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promotion and disease prevention. Other exemplary global collaborative programs include the Physical Activity Network of the Americas (PANA), the Americas Chronic Disease Surveillance Network (AMNET), and the European Physical Activity Network (2). These programs stimulate the dissemination of evidence-based knowledge. This dissemination has been possible through the use of current technological advances such as the Internet and online platforms for health education. Global health affects us all. Diseases can be spread across boarders in record time; therefore, it is crucial for health educators and clinicians from all over the world to collaborate on prevention strategies, education plans, and treatment options. Globalization introduces challenges and opportunities for public health professionals. In a time of scarce economic resources, health educators have looked for low-cost methods to share evidencebased knowledge across nations. Technology-based health education is one of these methods. Teleconferences can be effective and low-cost ways to bring together health care professionals and students to discuss critical issues regarding the health of their communities. In this article, we discuss an experience using teleconferences for international health education.
Methods The Department of Public Health at a university in California, US, hosts an annual international teleconference on public health and health education. The first step in the design of the teleconference series was to conduct a literature review of Internetlinked conferences to identify the methods used and to learn from their experiences. The literature review was conducted using the electronic databases Cumulative Index to Nursing and Allied Health Literature (CINAHL), ScienceDirect, and PubMed. The key terms used in the search were ‘teleconference,’ ‘international public health,’ ‘public health education,’ and ‘videoconferencing’. All articles gathered in this search were reviewed and taken as references for the development of the first international teleconference in spring 2013. The planning of the first international conference started six months in advance with the participation of a network of public health and health education professors from four universities in Colombia, the
Dominican Republic, and the US. Community members, professors, and students from the schools of medicine and nursing at two universities in Colombia, as well as a research center and the graduate school office at a university in the Dominican Republic, in conjunction with the Department of Public Health at a university in the US, worked together in the development of the March 2013 teleconference. The theme for this first teleconference was selected in consultation with all the members of the planning team. Re-emergent tuberculosis (TB) was a common concern in the participating countries and for that reason was selected as the topic for this inaugural educational event. According to the WHO, TB is a major health problem at the international level. WHO statistics revealed that ‘in 2012, an estimated 8.6 million people developed TB and 1.3 million died from the disease (including 320,000 deaths among HIVpositive people)’ (4). Although progress has been made in the global control of this disease, in reference to the Millennium Development Goals, the authors of the 2013 Global Tuberculosis Report emphasized the unacceptability of TB cases around the world since this disease is preventable (4). It is estimated that one-third of the world’s population are latently infected with Mycobacterium tuberculosis, and that people with compromised immune systems, such as those with HIV-AIDS, are experiencing re-emergent TB (5). TB cases have been increasing not only in Sub-Saharan Africa, Asia, and Eastern Europe, but also in the US (5). The social and economic implications of new emerging cases of TB are enormous. In 2012 a total of 450,000 people developed multidrug-resistant TB and approximately 2 billion USD per year is needed to develop public health programs that address this growing issue (6). On May 19, 2014, the World Health Assembly approved a resolution to encourage countries to develop educational and intervention programs to ‘end the global TB epidemic, with targets to reduce TB deaths by 95% and to cut new cases by 90% between 2015 and 2035, and to ensure that no family is burdened with catastrophic expenses due to TB’ (6). Health educators, public health practitioners, and clinicians need to support this effort and design educational programs that respond to the threat of re-emerging TB. In light of these
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statements, the planning team decided to select ‘re-emergent TB’ as the theme for the 2013 spring teleconference. The March 2013 teleconference included eight presentations in English and Spanish from international experts in the area of re-emergent TB. Presenters were nurse practitioners, medical doctors, bacteriologists, veterinary doctors, epidemiologists, and certified health education specialists. The topics included international public health strategies, health education programs, and clinical management of re-emergent TB. At each of the university sites, planning team members conducted their own advertising of this event and located a central place to convene the audience. This educational event had a length of three hours. After conclusion of the teleconference, planning team members met via online technology to discuss strengths and weaknesses of the event and to elicit suggestions for the second teleconference. The second teleconference took place in March 2014. The theme selected was ‘Best Evidence-Based Practices in Public Health.’ The topic was chosen based on the need to create channels to learn from one another’s experiences and to collaborate on evidence-based public health practice at the international level. Evidence-based public health practice is defined as ‘the careful, intentional and sensible use of current best scientific evidence in making decisions about the choice and application of public health interventions’ (7). The report of the US Secretary Advisory Committee on National Health Promotion and Disease Prevention Objectives 2020 adhered to the definition of evidence-based public health practice as the ‘development, implementation, and evaluation of effective programs and policies in public health through application of principles of scientific reasoning, including systematic uses of data and information systems and appropriate use of behavioral science theory and program planning models’ (8,9). The US Preventive Services Task Force (USPSTF) and the Guide to Community Preventive Services recommend the following hierarchy of evidence to evaluate clinical studies and building evidence-based practice for public health: ‘Category I: Evidence from at least one properly randomized controlled trial; Category II-1: Evidence from well-designed controlled trials without randomization; Category
II-2: Evidence from well-designed cohort or casecontrol analytic studies, preferably from more than one center or research group; Category II-3: Evidence from multiple times series with or without intervention or dramatic results in uncontrolled experiments such as the results of the introduction of penicillin treatment in the 1940s; and Category III: Opinions of respected authorities, based on clinical experience, descriptive studies and case reports, or reports of expert committees’ (8). This hierarchy of evidence was followed when preparing the presentations for the 2014 teleconference. The need for sharing evidence-based practices in public health at the international level is growing because practitioners may use it for program planning, development of health policies, and making funding decisions (10). The Patient Protection and Affordable Care Act (PPACA) in the US is an example of how evidence-based practice was used to produce policy. In the PPACA all services receiving an A or B grading from the USPSTF were recommended for no copayment in the new health care insurance plans (8). The USPSTF suggested the following resources for identifying evidence-based and best practices in public health: the guide to community preventive services, evidence-based practice for public health, Cochrane Public Health group, the National Association for City and County Health Officials (NACCHO) Database of Model Practices in Local Public Health Agencies, Promising Practices Network, Health Impact Assessment: Information and Insight for Policy, Health Impact Assessment Clearinghouse, Learning, and Information Center, and The Center of Excellence for Training and Research Translation (8,11–22). These resources were consulted when designing the 2014 teleconference. The planners of the 2014 teleconference intended to provide the audience with evidence-based successful international public health practices. This teleconference included the participation of five countries (two more than the previous year) from two continents. The participating countries were Colombia, the Dominican Republic, Costa Rica, Uganda, and the US. The planning team included not only university professors, but also representatives from a community-based organization. The March 2014 teleconference included seven presentations in English since it was the common language for all the participating countries. A student IUHPE – Global Health Promotion Vol. 0, No. 0 201X
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assistant from the university in the US translated the presentations into Spanish to ensure comprehensibility among Spanish-speaking participants. The translation into Spanish was verified for accuracy by a professor from the host university in the US. Presenters in the 2014 teleconference were policy makers, health policy experts, health educators, engineers, nurses, medical doctors, and dentists. The topics included exemplary policies in public health, best practices for vector control, tropical diseases, international collaborations in public health, public health research, diabetes management, best practices in health promotion, and oral health programs in indigenous communities. This educational event had a length of four hours. As in the previous year’s teleconference, after the conclusion of the event, planning team members met via online technology to discuss the strengths and weaknesses of the conference and to elicit suggestions for the next teleconference. The 2015 teleconference is scheduled to be centered on the theme of ‘Indigenous Health.’ The technological aspects of the teleconferences included using live streaming with an Internet protocol (IP) address and a telephone number specifically assigned to each teleconference. Participating organizations were given a prompt number that had to be dialed 30 minutes before the time of initiation of the teleconference. K20 videoconference test site instructions were also provided to the participating universities and community-based organizations. A trial day was assigned one month prior to each teleconference to ensure the compatibility of and accessibility to the software and computer equipment needed for these events. Participants were instructed to sign in 30 minutes prior to the official initiation of the teleconferences so any technological or logistic problems could be solved in a timely fashion. Some difficulties experienced in both teleconferences included technological aspects and time differences. The technological challenges were associated with the compatibility of the equipment and videoteleconferencing systems required for these educational events. Videoconferencing systems may vary across universities and the need to have compatible technology was paramount. For both teleconferences, all the participating universities had the K20 videoconferencing system, but the community organization from Uganda did not have it. To solve
this difficulty, the community organization used Polycom software, which is widely available and compatible with K20. To identify and correct technological difficulties, it is essential to set a testing date with all the participating organizations at least a month prior to the actual teleconference. The time difference across participating countries was another challenge experienced in the organization of both teleconferences. The speaker from Uganda made a major effort in order to participate in the 2014 teleconference by making his presentation after midnight. This time difference may have been the reason for the limited number of participants from this country. A possible solution for future teleconferences would be to select an earlier time for the event or to include other mechanisms for presentations such as pre-recorded messages.
Results This section contains two types of results: The first type deals with the database search to identify articles that contained descriptions of experiences related to videoconferences, teleconferences, or Internet-based conferences. The second type of results discussion addresses the outcomes associated with the teleconferences. Regarding the first type of results, 14 articles from 10 peer-reviewed journals were identified. Each article contained a discussion of the use of Internetlinked conferencing in educational settings with topics related to health and clinical practices. The educational settings included undergraduate and postgraduate university courses, continuing education for medical professionals, and strategybuilding presentations for professionals regarding their field of work. According to the literature, Internet-linked conferencing is an effective way to disseminate information across broad geographical areas (23). Various disciplines use this type of technology to reach audiences in rural locations and across borders. When physical travel cannot be accomplished because of limits on time and finances, virtual travel rises as a cost-effective alternative (24). Universities that participate in international teleconferencing offer students a unique perspective on international affairs (24). Zalon and Meehan reviewed case studies that brought nursing students at a university in the US
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and nursing students at a university in Ireland together to discuss predetermined topics related to nursing practices (25). Students themselves were the primary speakers during the teleconference. Their reports about the experience were mostly positive. The overall reaction to the videoconference was that students felt professionally uplifted and stimulated by the experience (25). A similar review was presented by Isawiw et al. describing the experience of uniting Canadian and Norwegian graduate nursing students via videoconference. Their teleconference experience was also satisfactory. The students involved in this educational event reported that they enjoyed the experience and felt a bond with their international counterparts (26). Teleconferencing is also used as an invaluable training tool for medical professionals, including surgeons. Dissemination of the most current knowledge in surgical procedures, skills, and techniques has proven to be primarily slow and inconsistent in remote areas. A virtual form of surgical mentoring, known as telementoring, has been used to reduce this gap. Telementoring is defined as real-time interactive teaching of techniques by an expert surgeon to a student located in a remote site. This form of mentoring is being used throughout the world and has proven to reduce the disparities in medical knowledge and skills among students in rural and urban areas (27). Videoconference has also been used in undergraduate paramedic education (28). In the review of the literature, it was found that this mode of education delivery increases accessibility and reduces cost (26–28). Regarding the second type of results, which are the outcomes generated by the teleconferences, in the 2013 event more than 260 students, faculty, and community members from the participating countries (Colombia, Dominican Republic, and the US) attended this international teleconference. The 2014 teleconference had an audience of more than 200 students, faculty, and health practitioners from Colombia, the Dominican Republic, Costa Rica, Uganda, and the US. These data provide an example of the benefits associated with teleconferences as a mean of delivery for international health education. The estimated cost associated with the use of technology for the two teleconferences described in this article was approximately 750 USD per event. Participants did not pay any registration fee. In the
first teleconference, since a minimum of 260 participants attended, the estimated cost per individual attending the event was 2.89 USD. In the second teleconference since 200 participants were present, the cost per individual was 3.75 USD. Cost savings associated with travel, hotel accommodations, conference registration, food, and other expenses are evident when using teleconference methodologies.
Discussion According to Pratt and Lamarre, there is an increasing need for finding frameworks to share experiences and effective strategies about disease prevention and health promotion with ‘a multidirectional exchange of lessons learned, technical expertise, strategies, and policies’ (2). Teleconferences offer a way for health educators to promote this multi-directional dialogue. A health educator is defined in the Standard Occupational Classification (SOC) as a practitioner who ‘promotes, maintains, and improves individual and community health by assisting individuals and communities to adopt healthy behaviors. They (health educators) collect and analyze data to identify community needs prior to planning, implementing, monitoring, and evaluating programs designed to encourage healthy lifestyles, policies, and environments. Many also serve as a resource to assist individuals, other professionals, or the community, and may administer fiscal resources for health education programs’ (29). These professionals work with individuals and communities under the guidelines of seven areas of responsibility that include ‘conducting needs assessments, planning educational programs, implementing health education interventions, evaluating health education programs, conducting research to enhance the understanding of health education, administering and managing health education programs, serving as resources in health education, and communicating and advocating for the development of the profession and individuals’ health’ (30). Area VI of the role of the health education professional indicates that health educators should serve as resources for health-related information (30). One of the mechanisms that health educators can use to share health-related information is technology. Teleconferences are technological methods that can be used to disseminate health information. IUHPE – Global Health Promotion Vol. 0, No. 0 201X
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Health education professionals around the world are looking for various means to work together in improving the conditions of those who live in poverty and in conditions of health disparities. Teleconferences may help reduce health disparities related to obtaining health information and accessing experts in the field who may be geographically distant. In addition, teleconferences may serve as a medium to improve health literacy. Health literacy is defined by the Institute of Medicine as ‘the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions’ (31). Teleconferences may serve as lowcost mechanisms to empower individuals and health professionals to obtain and understand health information that ultimately will be used in their health-related decision making. In order to continue to expand the work of health educators, it is essential for public health and health education students to develop a solid knowledge base of health-related topics around the world. In addition, they need to be exposed to different cultures in order to develop an understanding and appreciation for cultural diversity. International sharing, via teleconferences, helps enrich global understanding and promotes international collaboration (26). Traditionally, students have gained international experience and knowledge about other cultures through study abroad programs. Although this type of experience is unmatched, these opportunities are limited to those who have the available time and economic means. Internet-linked conferences or teleconferences can be an effective way for students to have a similar experience at a lower cost. Virtual travel via teleconferences can be an effective substitute for physical travel when time and money are in short supply (32). Although teleconferences have multiple benefits, it is also important to recognize their disadvantages. Limitations of this technology include difficulties in coordinating technology compatibility among the geographical sites, time differences across countries, apprehension about appearing on videocamera, interruptions due to technical failures or problems with Internet connections, and concerns about how much learning is actually retained in the absence of a personal and face-to-face interaction (26). In addition, even though international teleconferences
have lower costs as compared to traditional educational methods, they involve other costs such as technological equipment and translation services. Teleconferences would be most effective for countries that have similar time zones, to reduce limitations such as low participation and lack of attendance due to significant time differences. In addition, teleconferences are recommended for exchange of knowledge or information, more than for discussion of complex issues, since there is a natural apprehension to discuss complex situations on videocamera (26). Although the experiences using teleconference systems described in this article are specifically related to the academic environment and involved students, faculty, and community members from the participating countries, this educational methodology is also appropriate for mid-career professionals not in school (23). Teleconferences could be used as a cost-effective mechanism to provide continuing education for mid-career health care workers. It is important to recognize the need to combine teleconference systems with other health education methods, such as classroom instruction and online education. Although teleconferences are costeffective educational mechanisms, they can never replace the one-to-one teacher-student interaction. Teleconferences can be used to supplement classroom and online education. Teleconferences serve as the medium to unite countries despite the geographical distances and to facilitate collaborations and networking across nations. Teleconferences are an example of effective technology-based health education and health promotion programs. Conflict of interest None declared.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
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Kasemsup V. Towards a global framework for capacity-building for non-communicable disease advocacy in low-and middle-income countries. Glob Health Promot. 2013; 20 (Suppl 4): 45–56. 4. World Health Organization (WHO). Global tuberculosis report 2013—Executive summary. Available from: http://www.who.int/tb/publications/ global_report/gtbr13_executive_summary.pdf?ua=1 (accessed July 1, 2014). 5. Sohail M. Tuberculosis: A re-emerging enemy. J Mol Genet Med. 2006; 2: 87–88. 6. World Health Organization (WHO). WHA approves post-2015 global TB strategy and targets. Available from: http://www.who.int/tb/en/ (accessed July 2, 2014). 7. New Mexico Department of Health. Evidence-based public health practice. Available from: https://ibis. health.state.nm.us/resources/EvidenceBased.html (accessed July 4, 2014). 8. US Secretary Advisory Committee on National Health Promotion and Disease Prevention Objectives 2020. Evidence-based clinical and public health: Generating and applying the evidence. Available from: http://www.healthypeople.gov/2020/about/ advisory/EvidenceBasedClinicalPH2010.pdf (accessed July 5, 2014). 9. Brownson RC, Baker EA, Leet TL, Gillespie KN (eds) Evidence-based public health. New York: Oxford University Press. 2003. Public health and information tutorial. Available from: http://phpartners.org/ tutorial/04-ebph/2-keyConcepts/4.2.2.html (accessed July 5, 2014). 10. Jackson SF, Edwards RK, Kahan B, Goodstadt M. An assessment of the methods and concepts used to synthesize the evidence of effectiveness in health promotion: A review of 17 initiatives. Canadian Consortium for Health Promotion Research. Available from: http://www.utoronto.ca/chp/ CCHPR/synthesisfinalreport.pdf (accessed July 7, 2014). 11. National Center for Health Marketing, Centers for Disease Control and Prevention. The guide to community preventive services. Available from: http://www.thecommunityguide.org/index.html (accessed July 10, 2014). 12. University of Massachusetts Medical School. Evidence-based practice for public health. Available from: http://library.umassmed.edu/ebpph/ (accessed July 10, 2014). 13. Cochrane Public Health Group. Available from: http://www.ph.cochrane.org/en/ (accessed July 11, 2014). 14. Cochrane Public Health Group. Proposed registration of a Cochrane-Campbell Public Health Review Group. Available from: http://www.ph.cochrane.org/ Files/Website%20Documents/Overview_Transition. pdf (accessed July 11, 2014). 15. Cochrane Public Health Group. Workshop and events. Available from: http://www.ph.cochrane.org/ en/events.html (accessed July 11, 2014). 16. Cochrane Public Health Group. Resources for review
authors. Available from: http://www.ph.cochrane. org/en/authors.html (accessed July 12, 2014). 17. National Association of County and City Health Officials. NACCHO model practice database. Available from: http://www.naccho.org/topics/ modelpractices/database/ (accessed July 12, 2014). 18. Green E, Ingoglia JN, Phillips C. Share what works: Model practices in local public health agencies. J Public Health Manag Pract. 2004; 10: 180–182. 19. Promising Practices Network. How programs are considered. Available from: http://www. promisingpractices.net/criteria.asp (accessed July 12, 2014). 20. Health Impact Assessment. HIA Policy Reports. Available from: http://www.ph.ucla.edu/hs/healthimpact/reports.htm (accessed July 13, 2014). 21. UCLA Health Impact Assessment Clearinghouse and Information Center. Available from: http://www.ph. ucla.edu/hs/hiaclic/index.htm (accessed July 13, 2014). 22. Center of Excellence for Training and Research Translation. Available from: http://www.center-trt. org/ (accessed July 14, 2014). 23. Britt KL, Hewish S, Rodda J, Eldridge B. The use of videoconferencing to enhance the interprofessional clinical education of allied health students. J Interprof Care. 2012; 104: 333–335. 24. Burke SC, Chaney BH, Kristen W. International videoconferencing for public health: Linking the US and Germany. Amer J Health Educ. 2010; 41: 53–59. 25. Zalon ML, Meehan TC. Merging time zones: Promoting international communication through videoconferencing. Nurse Educ Pract. 2013; 5: 180–186. 26. Iwasiw C, Andrusyszyn M, Moen A, Ostbye T, Davie L, Støvring T, et al. Graduate education nursing leadership through distance technologies: The Canada-Norway Nursing Connection. J Nurs Educ. 2000; 39: 81–86. 27. PrimCareIT. Tele-Mentoring. Available from: http:// www.primcareit.net/tele-mentoring/ (accessed July 14, 2014). B. Internet videoconferencing in 28. Williams undergraduate paramedic education. JEPHC. 2010; 8: 1–9. 29. Society for Public Health Education. What is a health educator? Available from: https://www.sophe.org/ sophe/pdf/what_is_a_health_educator.pdf (accessed September 22, 2014). 30. National Commission for Health Education Credentialing (NCHEC). Responsibilities and competencies for health education specialists. Available from: http://www.nchec.org/credentialing/ responsibilities/ (accessed September 22, 2014). 31. Institute of Medicine—National Network of Libraries of Medicine. 2013. Health literacy. Available from: http://nnlm.gov/outreach/consumer/hlthlit.html (accessed September 22, 2014). 32. Education World. 2014. Virtual fieldtrips: Five interactive science lesson ideas. Available from: http://www.educationworld.com/a_lesson/virtualfield-trips-science.shtml (accessed September 22, 2014). IUHPE – Global Health Promotion Vol. 0, No. 0 201X
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research-article2015
PED0010.1177/1757975914567180Original ArticleH. Pinzon-Perez and C. Zelinski
Original Article The role of teleconferences in global public health education Helda Pinzon-Perez1 and Christy Zelinski1
Abstract: This paper presents a global health education program using a ‘Teleconference’ approach. It provides examples of how technology can be used to deliver health education at the international level. Two international teleconferences about public health issues were conducted in 2013 and 2014 involving universities and public health institutions in Colombia, Dominican Republic, Costa Rica, Uganda, and the United States. More than 400 students, faculty, and community members attended these educational events. These teleconferences served as the medium to unite countries despite the geographical distances and to facilitate collaborations and networking across nations. Teleconferences are an example of effective technology-based health education and health promotion programs. Keywords: education (including health education), e-health, global health/globalization, health literacy, health promotion
Introduction International collaborations have become essential in the management of health and disease patterns around the world. An example of such collaboration initiatives is the ‘Global Burden of Disease’ study (GBD) sponsored by the World Bank (WB) and the World Health Organization (WHO). The 2010 GBD study was designed to assess disease patterns among 187 countries between 1990 and 2010. This study revealed that the five leading causes of disease and injuries around the globe were ischemic heart disease, lower respiratory tract infections, stroke, diarrhea, and human immunodeficiency virus-acquired immunodeficiency syndrome (HIV-AIDS) (1). The management of these diseases requires a global effort instead of individualized country-based programs. Health education is a very valuable strategy in global health. Health educators have been at the forefront of international efforts to reduce the burden of disease and to promote health at the international level. Pratt and Lamarre have discussed how global health maladies often involve similar
health behaviors, risk factors, and social determinants across countries and how health educators can help reduce such maladies (2). The GBD study revealed that the leading risk factors for global disease in 1990 and 2010 were high blood pressure, tobacco use, household air pollution, diet low in fruit, alcohol use, high body mass index, and high fasting plasma glucose levels (1). Examples of conditions in which global public health has played a crucial role by reducing these risk factors include smallpox eradication, control of cholera outbreaks, and general reduction of communicable diseases (2). Health education is a professional field that promotes the development of sustainable capacity (3). Examples of programs in which health educators have contributed to the improvement of global health include the cooperative alliance between the International Union for Health Promotion and Education (IUHPE) and the United States (US) Centers for Disease Control and Prevention (IUHPE). This alliance started in 2002 and focused on responding to the challenges of global health
1. Fresno—Department of Public Health, California State University, Fresno, USA Correspondence to: Helda Pinzon-Perez, California State University, Fresno—Public Health, M/S MH 30, 2345 E. San Ramon Ave., Fresno, CA 93740-8031, USA. Email: [email protected] (This manuscript was submitted on 1 July 2014. Following blind peer review, it was accepted for publication on 1 October 2014) Global Health Promotion 1757-9759; Vol 0(0): 1 –7; 567180 Copyright © The Author(s) 2015, Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1757975914567180 http://ghp.sagepub.com Downloaded from ped.sagepub.com at RYERSON UNIV on June 4, 2016
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promotion and disease prevention. Other exemplary global collaborative programs include the Physical Activity Network of the Americas (PANA), the Americas Chronic Disease Surveillance Network (AMNET), and the European Physical Activity Network (2). These programs stimulate the dissemination of evidence-based knowledge. This dissemination has been possible through the use of current technological advances such as the Internet and online platforms for health education. Global health affects us all. Diseases can be spread across boarders in record time; therefore, it is crucial for health educators and clinicians from all over the world to collaborate on prevention strategies, education plans, and treatment options. Globalization introduces challenges and opportunities for public health professionals. In a time of scarce economic resources, health educators have looked for low-cost methods to share evidencebased knowledge across nations. Technology-based health education is one of these methods. Teleconferences can be effective and low-cost ways to bring together health care professionals and students to discuss critical issues regarding the health of their communities. In this article, we discuss an experience using teleconferences for international health education.
Methods The Department of Public Health at a university in California, US, hosts an annual international teleconference on public health and health education. The first step in the design of the teleconference series was to conduct a literature review of Internetlinked conferences to identify the methods used and to learn from their experiences. The literature review was conducted using the electronic databases Cumulative Index to Nursing and Allied Health Literature (CINAHL), ScienceDirect, and PubMed. The key terms used in the search were ‘teleconference,’ ‘international public health,’ ‘public health education,’ and ‘videoconferencing’. All articles gathered in this search were reviewed and taken as references for the development of the first international teleconference in spring 2013. The planning of the first international conference started six months in advance with the participation of a network of public health and health education professors from four universities in Colombia, the
Dominican Republic, and the US. Community members, professors, and students from the schools of medicine and nursing at two universities in Colombia, as well as a research center and the graduate school office at a university in the Dominican Republic, in conjunction with the Department of Public Health at a university in the US, worked together in the development of the March 2013 teleconference. The theme for this first teleconference was selected in consultation with all the members of the planning team. Re-emergent tuberculosis (TB) was a common concern in the participating countries and for that reason was selected as the topic for this inaugural educational event. According to the WHO, TB is a major health problem at the international level. WHO statistics revealed that ‘in 2012, an estimated 8.6 million people developed TB and 1.3 million died from the disease (including 320,000 deaths among HIVpositive people)’ (4). Although progress has been made in the global control of this disease, in reference to the Millennium Development Goals, the authors of the 2013 Global Tuberculosis Report emphasized the unacceptability of TB cases around the world since this disease is preventable (4). It is estimated that one-third of the world’s population are latently infected with Mycobacterium tuberculosis, and that people with compromised immune systems, such as those with HIV-AIDS, are experiencing re-emergent TB (5). TB cases have been increasing not only in Sub-Saharan Africa, Asia, and Eastern Europe, but also in the US (5). The social and economic implications of new emerging cases of TB are enormous. In 2012 a total of 450,000 people developed multidrug-resistant TB and approximately 2 billion USD per year is needed to develop public health programs that address this growing issue (6). On May 19, 2014, the World Health Assembly approved a resolution to encourage countries to develop educational and intervention programs to ‘end the global TB epidemic, with targets to reduce TB deaths by 95% and to cut new cases by 90% between 2015 and 2035, and to ensure that no family is burdened with catastrophic expenses due to TB’ (6). Health educators, public health practitioners, and clinicians need to support this effort and design educational programs that respond to the threat of re-emerging TB. In light of these
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statements, the planning team decided to select ‘re-emergent TB’ as the theme for the 2013 spring teleconference. The March 2013 teleconference included eight presentations in English and Spanish from international experts in the area of re-emergent TB. Presenters were nurse practitioners, medical doctors, bacteriologists, veterinary doctors, epidemiologists, and certified health education specialists. The topics included international public health strategies, health education programs, and clinical management of re-emergent TB. At each of the university sites, planning team members conducted their own advertising of this event and located a central place to convene the audience. This educational event had a length of three hours. After conclusion of the teleconference, planning team members met via online technology to discuss strengths and weaknesses of the event and to elicit suggestions for the second teleconference. The second teleconference took place in March 2014. The theme selected was ‘Best Evidence-Based Practices in Public Health.’ The topic was chosen based on the need to create channels to learn from one another’s experiences and to collaborate on evidence-based public health practice at the international level. Evidence-based public health practice is defined as ‘the careful, intentional and sensible use of current best scientific evidence in making decisions about the choice and application of public health interventions’ (7). The report of the US Secretary Advisory Committee on National Health Promotion and Disease Prevention Objectives 2020 adhered to the definition of evidence-based public health practice as the ‘development, implementation, and evaluation of effective programs and policies in public health through application of principles of scientific reasoning, including systematic uses of data and information systems and appropriate use of behavioral science theory and program planning models’ (8,9). The US Preventive Services Task Force (USPSTF) and the Guide to Community Preventive Services recommend the following hierarchy of evidence to evaluate clinical studies and building evidence-based practice for public health: ‘Category I: Evidence from at least one properly randomized controlled trial; Category II-1: Evidence from well-designed controlled trials without randomization; Category
II-2: Evidence from well-designed cohort or casecontrol analytic studies, preferably from more than one center or research group; Category II-3: Evidence from multiple times series with or without intervention or dramatic results in uncontrolled experiments such as the results of the introduction of penicillin treatment in the 1940s; and Category III: Opinions of respected authorities, based on clinical experience, descriptive studies and case reports, or reports of expert committees’ (8). This hierarchy of evidence was followed when preparing the presentations for the 2014 teleconference. The need for sharing evidence-based practices in public health at the international level is growing because practitioners may use it for program planning, development of health policies, and making funding decisions (10). The Patient Protection and Affordable Care Act (PPACA) in the US is an example of how evidence-based practice was used to produce policy. In the PPACA all services receiving an A or B grading from the USPSTF were recommended for no copayment in the new health care insurance plans (8). The USPSTF suggested the following resources for identifying evidence-based and best practices in public health: the guide to community preventive services, evidence-based practice for public health, Cochrane Public Health group, the National Association for City and County Health Officials (NACCHO) Database of Model Practices in Local Public Health Agencies, Promising Practices Network, Health Impact Assessment: Information and Insight for Policy, Health Impact Assessment Clearinghouse, Learning, and Information Center, and The Center of Excellence for Training and Research Translation (8,11–22). These resources were consulted when designing the 2014 teleconference. The planners of the 2014 teleconference intended to provide the audience with evidence-based successful international public health practices. This teleconference included the participation of five countries (two more than the previous year) from two continents. The participating countries were Colombia, the Dominican Republic, Costa Rica, Uganda, and the US. The planning team included not only university professors, but also representatives from a community-based organization. The March 2014 teleconference included seven presentations in English since it was the common language for all the participating countries. A student IUHPE – Global Health Promotion Vol. 0, No. 0 201X
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assistant from the university in the US translated the presentations into Spanish to ensure comprehensibility among Spanish-speaking participants. The translation into Spanish was verified for accuracy by a professor from the host university in the US. Presenters in the 2014 teleconference were policy makers, health policy experts, health educators, engineers, nurses, medical doctors, and dentists. The topics included exemplary policies in public health, best practices for vector control, tropical diseases, international collaborations in public health, public health research, diabetes management, best practices in health promotion, and oral health programs in indigenous communities. This educational event had a length of four hours. As in the previous year’s teleconference, after the conclusion of the event, planning team members met via online technology to discuss the strengths and weaknesses of the conference and to elicit suggestions for the next teleconference. The 2015 teleconference is scheduled to be centered on the theme of ‘Indigenous Health.’ The technological aspects of the teleconferences included using live streaming with an Internet protocol (IP) address and a telephone number specifically assigned to each teleconference. Participating organizations were given a prompt number that had to be dialed 30 minutes before the time of initiation of the teleconference. K20 videoconference test site instructions were also provided to the participating universities and community-based organizations. A trial day was assigned one month prior to each teleconference to ensure the compatibility of and accessibility to the software and computer equipment needed for these events. Participants were instructed to sign in 30 minutes prior to the official initiation of the teleconferences so any technological or logistic problems could be solved in a timely fashion. Some difficulties experienced in both teleconferences included technological aspects and time differences. The technological challenges were associated with the compatibility of the equipment and videoteleconferencing systems required for these educational events. Videoconferencing systems may vary across universities and the need to have compatible technology was paramount. For both teleconferences, all the participating universities had the K20 videoconferencing system, but the community organization from Uganda did not have it. To solve
this difficulty, the community organization used Polycom software, which is widely available and compatible with K20. To identify and correct technological difficulties, it is essential to set a testing date with all the participating organizations at least a month prior to the actual teleconference. The time difference across participating countries was another challenge experienced in the organization of both teleconferences. The speaker from Uganda made a major effort in order to participate in the 2014 teleconference by making his presentation after midnight. This time difference may have been the reason for the limited number of participants from this country. A possible solution for future teleconferences would be to select an earlier time for the event or to include other mechanisms for presentations such as pre-recorded messages.
Results This section contains two types of results: The first type deals with the database search to identify articles that contained descriptions of experiences related to videoconferences, teleconferences, or Internet-based conferences. The second type of results discussion addresses the outcomes associated with the teleconferences. Regarding the first type of results, 14 articles from 10 peer-reviewed journals were identified. Each article contained a discussion of the use of Internetlinked conferencing in educational settings with topics related to health and clinical practices. The educational settings included undergraduate and postgraduate university courses, continuing education for medical professionals, and strategybuilding presentations for professionals regarding their field of work. According to the literature, Internet-linked conferencing is an effective way to disseminate information across broad geographical areas (23). Various disciplines use this type of technology to reach audiences in rural locations and across borders. When physical travel cannot be accomplished because of limits on time and finances, virtual travel rises as a cost-effective alternative (24). Universities that participate in international teleconferencing offer students a unique perspective on international affairs (24). Zalon and Meehan reviewed case studies that brought nursing students at a university in the US
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and nursing students at a university in Ireland together to discuss predetermined topics related to nursing practices (25). Students themselves were the primary speakers during the teleconference. Their reports about the experience were mostly positive. The overall reaction to the videoconference was that students felt professionally uplifted and stimulated by the experience (25). A similar review was presented by Isawiw et al. describing the experience of uniting Canadian and Norwegian graduate nursing students via videoconference. Their teleconference experience was also satisfactory. The students involved in this educational event reported that they enjoyed the experience and felt a bond with their international counterparts (26). Teleconferencing is also used as an invaluable training tool for medical professionals, including surgeons. Dissemination of the most current knowledge in surgical procedures, skills, and techniques has proven to be primarily slow and inconsistent in remote areas. A virtual form of surgical mentoring, known as telementoring, has been used to reduce this gap. Telementoring is defined as real-time interactive teaching of techniques by an expert surgeon to a student located in a remote site. This form of mentoring is being used throughout the world and has proven to reduce the disparities in medical knowledge and skills among students in rural and urban areas (27). Videoconference has also been used in undergraduate paramedic education (28). In the review of the literature, it was found that this mode of education delivery increases accessibility and reduces cost (26–28). Regarding the second type of results, which are the outcomes generated by the teleconferences, in the 2013 event more than 260 students, faculty, and community members from the participating countries (Colombia, Dominican Republic, and the US) attended this international teleconference. The 2014 teleconference had an audience of more than 200 students, faculty, and health practitioners from Colombia, the Dominican Republic, Costa Rica, Uganda, and the US. These data provide an example of the benefits associated with teleconferences as a mean of delivery for international health education. The estimated cost associated with the use of technology for the two teleconferences described in this article was approximately 750 USD per event. Participants did not pay any registration fee. In the
first teleconference, since a minimum of 260 participants attended, the estimated cost per individual attending the event was 2.89 USD. In the second teleconference since 200 participants were present, the cost per individual was 3.75 USD. Cost savings associated with travel, hotel accommodations, conference registration, food, and other expenses are evident when using teleconference methodologies.
Discussion According to Pratt and Lamarre, there is an increasing need for finding frameworks to share experiences and effective strategies about disease prevention and health promotion with ‘a multidirectional exchange of lessons learned, technical expertise, strategies, and policies’ (2). Teleconferences offer a way for health educators to promote this multi-directional dialogue. A health educator is defined in the Standard Occupational Classification (SOC) as a practitioner who ‘promotes, maintains, and improves individual and community health by assisting individuals and communities to adopt healthy behaviors. They (health educators) collect and analyze data to identify community needs prior to planning, implementing, monitoring, and evaluating programs designed to encourage healthy lifestyles, policies, and environments. Many also serve as a resource to assist individuals, other professionals, or the community, and may administer fiscal resources for health education programs’ (29). These professionals work with individuals and communities under the guidelines of seven areas of responsibility that include ‘conducting needs assessments, planning educational programs, implementing health education interventions, evaluating health education programs, conducting research to enhance the understanding of health education, administering and managing health education programs, serving as resources in health education, and communicating and advocating for the development of the profession and individuals’ health’ (30). Area VI of the role of the health education professional indicates that health educators should serve as resources for health-related information (30). One of the mechanisms that health educators can use to share health-related information is technology. Teleconferences are technological methods that can be used to disseminate health information. IUHPE – Global Health Promotion Vol. 0, No. 0 201X
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Health education professionals around the world are looking for various means to work together in improving the conditions of those who live in poverty and in conditions of health disparities. Teleconferences may help reduce health disparities related to obtaining health information and accessing experts in the field who may be geographically distant. In addition, teleconferences may serve as a medium to improve health literacy. Health literacy is defined by the Institute of Medicine as ‘the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions’ (31). Teleconferences may serve as lowcost mechanisms to empower individuals and health professionals to obtain and understand health information that ultimately will be used in their health-related decision making. In order to continue to expand the work of health educators, it is essential for public health and health education students to develop a solid knowledge base of health-related topics around the world. In addition, they need to be exposed to different cultures in order to develop an understanding and appreciation for cultural diversity. International sharing, via teleconferences, helps enrich global understanding and promotes international collaboration (26). Traditionally, students have gained international experience and knowledge about other cultures through study abroad programs. Although this type of experience is unmatched, these opportunities are limited to those who have the available time and economic means. Internet-linked conferences or teleconferences can be an effective way for students to have a similar experience at a lower cost. Virtual travel via teleconferences can be an effective substitute for physical travel when time and money are in short supply (32). Although teleconferences have multiple benefits, it is also important to recognize their disadvantages. Limitations of this technology include difficulties in coordinating technology compatibility among the geographical sites, time differences across countries, apprehension about appearing on videocamera, interruptions due to technical failures or problems with Internet connections, and concerns about how much learning is actually retained in the absence of a personal and face-to-face interaction (26). In addition, even though international teleconferences
have lower costs as compared to traditional educational methods, they involve other costs such as technological equipment and translation services. Teleconferences would be most effective for countries that have similar time zones, to reduce limitations such as low participation and lack of attendance due to significant time differences. In addition, teleconferences are recommended for exchange of knowledge or information, more than for discussion of complex issues, since there is a natural apprehension to discuss complex situations on videocamera (26). Although the experiences using teleconference systems described in this article are specifically related to the academic environment and involved students, faculty, and community members from the participating countries, this educational methodology is also appropriate for mid-career professionals not in school (23). Teleconferences could be used as a cost-effective mechanism to provide continuing education for mid-career health care workers. It is important to recognize the need to combine teleconference systems with other health education methods, such as classroom instruction and online education. Although teleconferences are costeffective educational mechanisms, they can never replace the one-to-one teacher-student interaction. Teleconferences can be used to supplement classroom and online education. Teleconferences serve as the medium to unite countries despite the geographical distances and to facilitate collaborations and networking across nations. Teleconferences are an example of effective technology-based health education and health promotion programs. Conflict of interest None declared.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
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