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The contribution of distance education to health
promotion in Chile
Judith Salinas*, Carolina Muñoz, Andrea Albagli, Gloria Araya,
and Fernando Vio
Nutrición Pública, Universidad de Chile, INTA, Avda El Libano 5534, Macul, Santiago, Chile
*Corresponding author. E-mail: jsalinas@inta.uchile.cl
Summary
The objective of this paper is to present the distance education’s contribution to developing health
promotion in Chile, through evaluation of a postgraduate certificate program for professionals, and a
training course for nurse technicians working in primary healthcare, with an 8-month follow-up after
program completion. The program methodology was participatory, interactive and reflective, with
mentoring support, exercises, group work and discussions as well as content pertinent to the needs
of practice. The evaluation was quali-quantitative with an analysis of the student profile, the implemen-
tation process, outcomes at the end of the training and impacts on workplace changes. The results
showed a high rate of student approval (87 and 76%), good academic performance and a high level
of satisfaction with the methodology and knowledge delivered. The participants’final projects were
adapted to local work places realities and were implemented by 62.6% of technicians and 43% of pro-
fessionals, in addition to changes in work practices that favor health promotion. The level of fulfillment
of participants’expectations was very high and the most frequent barriers to implementing the final
project were lack of time and personnel, along with minimal support from management and low priori-
tization of health promotion. This study shows the effectiveness of a distance training model for profes-
sionals and technicians that can reach the most remote parts of the country, where there is no access to
presencial training, with an educational program centered on work activities and current health
challenges.
Key words: primary healthcare, health promotion programs, Chile, training, competencies
INTRODUCTION
The Pan American Health Organization (PAHO/WHO)
has encouraged an initiative to revitalize primary health-
care (PHC) with a focus on equity (PAHO, 2007,2010)
and developing the competencies of healthcare personnel
through the use of information and communication tech-
nologies (ICT) (Nebot et al., 2009;PAHO, 2010).
The subject of health promotion training has had a sig-
nificant progress during the last years, particularly into
academic fields and among the health services sector
(Arroyo, 2009). The Galway Consensus Statement on
domain of core competency in health promotion aimed
to consolidate a core suite of skills, knowledge and abil-
ities needed for effective health promotion practice and
how best they can be achieved (Barry et al., 2009).
There is an emerging literature on competencies re-
quired for health promotion practice in diverse social
and cultural settings. Having qualified human resources
doi: 10.1093/heapro/daw023
© The Author 2016. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com
Health Promotion International, 2017;32:913–921
Article
Advance Access Publication Date: 22 April 2016
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is essential to deliver quality health promotion actions,
and this includes qualifications both from undergraduate
and postgraduate studies, as well as technical and profes-
sional continuing education.
Models and programs from 14 countries of the Latin
America Region have been documented and disseminated in
a publication of Inter-American Consortium of Universities
and Training Centers of Health Education and Health
Promotion Personnel (CIUEPS), with the support of the
International Union for Health Promotion and Education
(UIPES) and Pan American Health Organization (PAHO/
WHO). Among countries with an academic history in the
subject is possible to mention México, Brazil, Cuba, Peru,
Colombia, Puerto Rico and Chile (Arroyo, 2010).
In Chile, the Health Ministry (Ministerio de Salud, or
MINSAL) has adopted the Comprehensive Health Care
Model with a Family and Community Approach; one of
its pillars is health promotion (MINSAL 2007,2014).
These change processes require new capacities that enable
providers to respond to the current healthcare needs of the
population. The socio-epidemiological realityof the country
is characterized by an advanced post-transition with popu-
lation aging, a predominance of cardiovascular diseases,
cancer and mental health problems. This situation is aggra-
vated by the lack of equity in healthcare (Vio et al.,2008).
Despite progress made by healthcare system reform and
the national health promotion plan (Salinas et al., 1999,
2007), adaptation of PHC to this socio-epidemiological
reality and formulation of government health promotion
policies, there are still many issues to be addressed in the
country.
In 2013, there were 54 652 primary healthcare workers
in Chile, with an average density of 35.95 basic profes-
sionals (physicians, nurses and midwives) for every 10 000
inhabitants, while for Latin America as a whole, the average
was 25 professionals for every 10000 inhabitants, accord-
ing to PAHO/WHO figures. The composition of this
workforce for Chile was as follows: 32% high-level nurse
technicians; 38%professionals (physicians, dentists, nurses,
midwives, nutritionists, social workers, psychologists and
others); 18% administrative assistants; and 12% service
assistants (Brahm, 2014).
Primary healthcare centers serve 76% of the total
population of the country through a national network
made up of 2125 outpatient service establishments; 45%
of these are family health centers (Centros de Salud
Familiar, or CESFAM) and 55% are rural health clinics
(Postas de Salud Rural, or PSR) (Gattini and Alvarez
Leiva, 2011).
A strong primary healthcare center must have multidis-
ciplinary health teams with the capacity to act in a com-
prehensive way in regard to health problems, develop
skills to interact with different community groups, and
facilitate social participation processes and intersectoral
action.
In this context, and considering how distance educa-
tion has helped improve public service (Barrios et al.,
2008;Umaña, 2013), the Institute of Nutrition and
Food Technology (Instituto de Nutrición y Tecnología
de los Alimentos, or INTA) at the University of Chile cre-
ated the Continuing Education Program in Health
Prevention and Promotion (Programa de Educación
Permanente en Prevención y Promoción de Salud, or
PROEPSA) to contribute developing the skills of PHC
teams. The program’s theoretical framework is built on a
conception of continuous education centered on practice-
based learning. The pedagogical approach is structured
on the students’work activities, emphasizing interaction
and reflection (Davini, 1995;Vasquez, 2007a,b;Medina
Ferrer, 2013). Technical and pedagogical management of
the program is based on a constructivist approach to educa-
tion, which is understood as a social process of ‘learning by
doing’(Schön, 1987;Freire, 2004;Tremblay et al.,2014).
The conception of health promotion as a discipline for
study and practice is considered a political and social pro-
cess that encompasses not only actions aimed at bringing
about change in individual behavior for a healthier life-
style, but also actions designed to modify social and envir-
onmental conditions, in order to mitigate their impact on
health.
PROEPSA supports a network of professionals and
technicians distributed over a wide geographic area who
exchange experiences and build practice-based knowledge
with an integral approach to health promotion that em-
phasizes the social determinants of health (Jackson et al.,
2013). It is worth noting that INTA has developed health
promotion training programs since 2002 for a variety of
recipients, with different durations and formats (Salinas
and Vio, 2011a,b;Salinas et al., 2014). The postgraduate
certificate program described in this paper is the 10th ver-
sion, while the training course is the 2nd version.
The objective of this article is to present the evaluation
of the distance education program for PHC workers;
the program consists of a postgraduate certificate for
professionals and a training course for high-level nurse
technicians. Participants in both programs were located
throughout the country and follow-up was conducted
8 months after completion. The expectation is that dis-
tance education will address the problem of unequal ac-
cess to personnel training for people in remote parts of
the country, strengthen healthcare teams by transforming
their practice and contribute to improving PHC and local
public policies from a health promotion and equity
perspective.
J. Salinas et al.
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METHODS
The study consisted of a quali-quantitative evaluation of a
training program for PHC workers. It includes an analysis
of the student profile, the implementation process, results
after completion of the training and the impact perceived
by graduates 8 months after the program ended.
The educational methodology promotes interaction
through study groups and supports individual learning
by each student at their own pace and according to their
own interests. To achieve this, the students are offered on-
going mentoring by 7 professors and 12 professional in-
structors, all of whom have experience with PCH and
health promotion.
Subjects
There were 162 professional participants in the certificate
program whose average age was 36 years and with
10 years of work experience on average in primary health-
care. In the group, 79% were women and 40% were from
rural districts. Social sciences and education professionals
(social workers, psychologists and educators) made up
38% of participants, while 62% represented the biomed-
ical area (nutritionists, midwives, nurses, physical thera-
pists, dentists and others). Everyone who participated
had a university degree representing at least 4 years of
study (Table 1).
In the training course, there were 172 technicians
whose average age was 37 years and with an average of
9.7 years of work experience. In the group, 89% were
women and 46% were from rural districts (Table 1).
High-level nurse technicians received on average 2 years
of training and work in all PHC programs (family health,
dental health, children’shealth,women’s health, adult
health, nutrition, social assistance, pharmacy and others).
These are the healthcare workers who are typically the first
to come into contact with patients and the community.
The technicians had significantly less experience with
distance education than the professionals. For 85% of
the technicians, this was their first experience with dis-
tance education, compared with 31% of the professionals
(Table 1).
Intervention
The certificate program included 268 h and was offered
over 8 months, from 25 June 2012 to 1 April 2013, with
15 learning units and a final project (Figure 1).
The training course was 120 h long and was offered
over 4 months, from 1 August to 30 November 2013,
with six learning units and a final project (Figure 1).
The pedagogical model was one of networked learning
with a collaborative, active and participatory method-
ology that promotes open exchange of ideas, reflection
and group analysis to build knowledge. Figure 2outlines
its objectives, content and resources.
Evaluation
The evaluation process included:
•Evaluation of learningthrough individual and group ex-
ercises, participation in discussion groups, knowledge
tests and preparation of a final project. These activities
were graded on a scale from 1 to 7; the minimum
passing score was 4.
•Evaluation of the program, through surveys at the
beginning and end of the program and follow-up; the
variables are presented in Table 2. In addition, the cer-
tificate program students completed a mid-term survey,
given its longer duration. The course included a test of
knowledge at the beginning and end. Program manage-
ment included continuous monitoring of the activities
and use of the Moodle platform, version 2.6.3.
Table 1: Profile of participants and academic results
Postgraduate
certificate for
professionals N: 162
Training course
for technicians
N: 172
Gender*
Female 79% 89%
Male 21% 11%
Age (average in years) 36 37
Work experience in PHC
(average in years)
10 9.7
Previous experience with distance education**
With experience 69% 15%
No experience 31% 85%
District
Urban 60% 54%
Rural 40% 46%
Passed 87% 76%
Final grade
Average± SD 5.4 ± 1.2 5.3 ± 1.6
Range 1.2–6.9 3.0–7.0
Final project topic
Diet-physical activity 67 51
Tobacco and alcohol 10 19
Mental and sexual
health, others
23 30
Training program for PHC professionals and technicians in health promotion.
Chile 2013.
SD, standard deviation.
*χ
2
test = 6.4749, p< 0.011.
**χ
2
test = 73.9451, p< 0.000.
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Statistical analysis
A descriptive analysis was developed of the variables for
all of the training subjects according to indicators of the
profile, performance and evaluation of the students. The
number of cases and proportions were used for general re-
sults, as well as the median, standard deviation, minimum
and maximum when appropriate. The χ
2
test was calcu-
lated to compare groups, using STATA 10.1 for Windows.
RESULTS
Academic performance
Table 1shows the pass rates, with higher values for profes-
sionals than technicians (87 and 76%, respectively), but
these differences are not significant. The reasons for failure
were poor performance or deferment. The average final
grades were 5.4 and 5.3, respectively.
In both groups, the most common topics for the final
projects were healthy eating and physical activity (67%
of professionals and 51% of technicians), followed by to-
bacco, alcohol, promotion of mental and sexual health
and other specific areas, mainly in relation to children.
In terms of methodological spaces, the technicians focused
on educational work in their health centers while profes-
sionals valued work with educational establishments and
at the community level in their districts.
Final survey
According to the results of the final survey at the end of the
training, both groups positively evaluated the usefulness
of the content and the educational methodology (referring
to the academic activities, educational materials and inter-
action). This survey had a rate response of 92.9% in both
cases. The teaching activities that consisted of individual
exercises and group discussions and exercises were as-
sessed as positive (close to 90%), as were all the education-
al materials (guides, classes, readings and others). The
interaction receiving the highest marks was working
Fig. 1: PHC training program syllabus. Chile 2013.
J. Salinas et al.
916
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with mentors (95%), followed by 90% who said they had
positive interactions with professors and 78% with their
peers.
As for fulfillment of objectives and expectations,
knowledge acquisition and overall satisfaction with the
program, 95% evaluated these positively.
Regarding the open-ended questions, in both groups, it
was found that the main barrier to participation in teach-
ing and learning processes was lack of time and lack of
support from superiors. In fact, only 20% said they were
given time to study during work hours.
Follow-up survey
The follow-up survey applied 8 months after the end
of each training program (January and August 2014,
respectively) had a high rate response, reaching 67% in
both cases.
The contribution to improving health promotion in
primary healthcare through implementation of interven-
tions developed in the final project showed excellent re-
sults, with more than 50% of the projects later
implemented in practice. This occurred to a greater extent
among technicians than professionals (62.6 versus 43%
who said they had fully or partially implemented the
final project).
The usefulness of the content, measured in terms of
its applicability and increased reflexibity and self-efficacy
in their work, was high for both groups. As shown in
Figure 3, more than 80% of the participants said the train-
ing increased their ability to think critically about practice
and their self-efficacy in their work; this was higher among
technicians (96.4 and 98.4%). Meanwhile, the applicabil-
ity of the content was valued significantly more by profes-
sionals than technicians (78.5 versus 46.9%).
Regarding changes in work practices, 30% of the pro-
fessionals reported that training had some effect, such
as being given new responsibilities, improved salaries or
receiving a mark of merit. Referring to changesin their du-
ties, the professionals said the following: according to
52%, the training stimulated their community work;
43% made some improvement to a program; 42% incor-
porated health promotion activities into their annual
healthcare programs; 38% created new projects or pushed
for new administrative measures; and 32% started pro-
cesses to systematize or evaluate their health promotion
experiences.
Fig. 2: Pedagogical model of training program for PHC professionals and technicians. Chile 2013.
Contribution of distance education to health promotion 917
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The technicians identified important changes in their
work practices: 57% said they now frequently offer infor-
mal education when working with patients; 53% provide
advice on healthy living; 20% conduct group educational
activities at the health center; 21% work in the commu-
nity; 17% participate in design and planning educational
or community health activities; and 8% participate in edu-
cational or community activities in other sectors.
Fulfillment of expectations remained high, similar to
the survey at the end of the training, with figures over
90% for both groups. Finally, 98% of the technicians
and 95% of the professionals would recommend the
program to other people.
The most frequently cited barriers to implementing the
program content and the final project in participants’
workplaces were: lack of time and personnel, management
with low levels of confidence in team capacities, low pri-
oritization of health promotion, lack of financial resources
and administrative red tapes.
DISCUSSION
The PHC training program was implemented with two
groups of similar size (162 and 172 students, respectively)
and similar characteristics in terms of age, years of work
experience and regional distribution throughout the coun-
try. The participants were from all parts of the country,
including rural, isolated and remote districts. Although
the technicians had significantly less experience with
distance education, they participated very actively in the
educational process, and like the professionals, they per-
formed well academically and reported similar effects on
their work performance, strengthening their skills in
health promotion (Suárez Conejero et al., 2013). An ad-
vance orientation regarding the use of the platform and
ICT provided by PROEPSA contributed to this result.
The program participants were workers with the great-
est time of service, closeness to patients, community lead-
ership and potential to constitute a critical mass that
can make the changes needed to revitalize PHC through
effective implementation of health promotion; this does
not usually occur with physicians and management
personnel.
Table 2: Program evaluation variables and instruments
Variables Start End Follow-up
Demographic information
Age x
Gender x
Employment information
Professional or technical training x
Place of work, type of PHC
establishment
x
Years of work experience x
Workplace region and district x
Previous experience in distance
education
x
Educational methodology
Academic activities (discussions,
individual and group exercises,
tests, final project)
x
Educational materials x
Interaction with mentors,
professors and peers (quantity
and contribution to learning)
x
Barriers to participation in training
program
x
Assigned work hours for studying x
Fulfillment of objectives x
Fulfillment of expectations x x
Knowledge acquisition x x
Overall satisfaction with the training
program
xx
Usefulness of content
Applicability x x
Reflexivity on work practices x x
Self-efficacy x x
Implementation of theoretical,
methodological and practical
content
x
Barriers to implementing content x
Implementation of final project x
Barriers to implementing final project x
Changes in work practices
Engaging in health promotion
activities
x
Personal effects x
Recommendation of the training
program
x
Training program for PHC professionals and technicians in health promotion.
Chile 2013.
Fig. 3: Usefulness of training program content. Follow-up survey
of PHC professionals and technicians (N Professionals: 108,
N Technicians: 115). *χ
2
test = 19.8455, p< 0.000 (comparison
between professionals and technicians of applicability variable).
J. Salinas et al.
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The evaluation model provides a systematic vision of
the teaching and learning process and the impact in
terms of skills development and workplace practice,
both when the training ended and with follow-up some
time later.
The explosive development of distance teaching pro-
grams, its growing use and effectiveness in healthcare
(D’Agostino et al., 2014) has unfortunately not been sub-
ject to systematic evaluation or subsequent follow-up to
measure its contribution to policy development and imple-
mentation of the changes it seeks to bring about. Very few
public health evaluations have been reported, with an even
smaller group relating to health promotion. Some worth
mentioning are the evaluation of a distance learning pro-
gram on environmental health in Cuba (Olite and
Mercedes, 2004) and two mixed programs that combine
online and in-person learning: PAHO’s International
Health Program (Auer and Guerrero, 2011) and the health
promotion program in Mexico (Magaña et al., 2010;
Alcalde et al., 2013). The Mexican program is the only
health promotion training program that has been assessed,
and it included: a master’s degree in public health with a
specialization in health promotion, a 160 h health promo-
tion leadership certificate and short, 50 h courses for
health promoters. The results were positive and demon-
strated that healthcare personnel in states where training
was provided acquired a comprehensive perspective of
health promotion, which then translated into better
management.
The academic results of the certificate and the course
were similar, with average final grades of 5.4 and 5.3
and approval rates of 87 and 76%, respectively. The ap-
proval rate is higher than that reported by other authors
(Sigulem et al., 2001).
The positive evaluation of the pedagogical, interactive,
participatory and practically applicable activities, consist-
ent with the nature of health promotion, favored knowl-
edge acquisition and practice improvement.
The most important results of the training program were
observed in the follow-up evaluation of the usefulness and
implementation of the theoretical content, methodologies
and practices, as well as the high number of workers who
implemented the final project. This is a commendable
effort, since participation in the program is voluntary and
does not have the formal support of supervisors, a situation
that is similar to what is observed in medical training
programs (Montero and Valdés, 2008).
The final projects were consistent with local realities
and contributed to national priorities. The technicians de-
veloped a larger number of educational interventions,
which may be influenced by the emphasis of the individual
perspective of nurses on health promotion (Kemprainen
et al., 2013) and also by the greater recognition of their
assistance work. Meanwhile, the professionals oriented
their work largely toward the educational sector or local
government, probably influenced by the fact that they
had greater training in health promotion, the continuity
in Chile of the healthy schools strategy (Salinas and Vio,
2011a,b) and the community work component contained
in district health promotion plans since 1998 (Salinas
et al., 2007).
The notable increase in self-efficacy and reflexivity on
their work practices in both groups is consistent with the
conceptualization of the health promotion programwith a
social determinant of health approach applied to the local
reality and with the incentive of working in teams and net-
works through the methodology used.
The greatest applicability of the content for the techni-
cians may be influenced by the strengthening of their com-
munity leadership roles in small towns and carrying out
educational work at their own health centers. Meanwhile,
for the professionals, the challenge of intersectoral action
implies greater time, political will and working with other
sectors.
The barriers to implementing content and the final pro-
ject are similar to those observed in previous studies and to
what was reported in Mexico (Alcalde et al., 2013;Ramos
et al., 2014). These barriers reflect inadequate understand-
ing of health promotion by management, the low value
given to team work and the lack of public policies that
guarantee continuity of actions and improved health out-
comes, from an equity perspective (Etienne, 2013).
This study demonstrates the contribution of distance
education to development of health promotion and the
effectiveness of an interactive training model with profes-
sionals and technicians, which is able to reach the most
remote parts of the country where people do not have
access to in-person training (Guri-Rosenblit, 2005). In
addition, it confirms the positive effect at the local level
of a methodology based on learning by doing, with a
practice-centered approach (Vasquez, 2007a,b).
What is needed currently is an effective distance learn-
ing system, which should evolve from a concept centered
on information delivery (information-centric) or the use
of new communication technologies (technology-centric)
(Vasquez, 2007a,b) to a practical learning system that
assists but does not interfere with the work of PHC
teams. It should address the needs related to everyday
activities, with content that is pertinent and adequate
in terms of quality and quantity. The development of
health promotion requires integrated, interdisciplinary
and reflective healthcare teams, capable of leading change
in healthcare systems, which is what this ongoing, inclu-
sive training initiative is designed to do.
Contribution of distance education to health promotion 919
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Finally, it should be mentioned that the changes and
social transformations that health promotion seeks to
achieve go hand in hand with changes in educational para-
digms and a new healthcare model with a biopsychosocial
and equity-based approach.
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