Impact of Telehealth Training on Health Care Providers’ Knowledge in HIV/AIDS Care: A Mixed Methods Evaluation.

  • Hesborn Wao University of South Florida
  • Marilyn Aluoch University of South Florida
  • Sean McIntosh University of South Florida
  • Rahul Mhaskar University of South Florida
  • Joanne Orrick University of South Florida
  • Benjamin Djulbegovic University of South Florida
  • Jeffrey Beal University of South Florida
Keywords: Continuing education, eHealth, HIV/AIDS, telehealth, thematic analysis, meta-analysis, mixed methods, multilevel modelling


Healthcare providers (HCPs) serving HIV-infected patients in rural and underserved areas have limited access to continuing education. A telehealth training programme, Project Extension for Community Healthcare OUtcomes (ECHO), was implemented to enhance knowledge and skills of these HCPs in HIV care. A mixed methods approach including quantitative (multilevel modelling and meta-analysis) and qualitative (thematic analysis) components was used to evaluate the impact of ECHO on HCPs' knowledge. Over three years, 98 training sessions were conducted and 654 HCPs attended. ECHO was associated with an increase in knowledge. Change in HCP knowledge differed within the ECHO sessions, not across sessions. Four HCP-level factors (achievement of self-stated objective for attending the session, amount of time for the session, intention to make practice changes,and number of sessions attended) and one session-level factor (language used in the session) were associated with the change in knowledge. While increasing knowledge, skills and learning were frequently and intensely cited as objectives for attending ECHO, provider-based communication emerged as the key to converting the acquired knowledge into practice. Besides communication, most HCPs expressed intention to improve patient clinical management including linking, engaging, and retaining patients in care. Lack of time to focus on HIV/AIDS care, inadequate skills to convey medical information to patients, and patients' lack of insurance to pay for recommended care emerged as barriers to implementincontent learned. Implications for research are discussed.

Author Biographies

Hesborn Wao, University of South Florida
Assistant Professor of Research, Fepartment of Internal Medicine.
Marilyn Aluoch, University of South Florida
PhD Candidate, College of Nursing.
Sean McIntosh, University of South Florida
Florida/Caribbean AIDS Education Training Center, USF Center for HIV Education and Research.
Rahul Mhaskar, University of South Florida
Assistant Professor, Division of Evidence-based medicine, USF Health Program for Comparative Effectiveness Research, Morsani College of Medicine.
Joanne Orrick, University of South Florida
Associate Director, USF Center for HIV Education and Research Florida/Caribbean AIDS Education Training Center, USF Center for HIV Education and Research.
Benjamin Djulbegovic, University of South Florida
Distinguished Professor and Associate Dean for Comparative Effectiveness Research, Division of Evidence-Based Medicine.
Jeffrey Beal, University of South Florida
Professor, Clinical Director, Florida/Caribbean AIDS Education Training Center, USF Center for HIV Eduication and Redearch.


Prejean J, Song R, Hernandez A, et al. Estimated HIV incidence in the United States, 2006-2009. PLoS One 2011;6(8):e17502.

UNAIDS World AIDS Day report 2011. How to get to zero: Faster, smarter, better. 2011:1-52.

Adashi EY, Geiger HJ, Fine MD. Health care reform and primary care--the growing importance of the community health center. N Engl J Med 2010;362(22):2047-2050.

Cook NL, Hicks LS, O'Malley AJ, Keegan T, Guadagnoli E, Landon BE. Access to specialty care and medical services in community health centers. Health Affairs 2007;26(5):1459-1468.

Dreisbach S. Fact Sheet: HIV/AIDS in rural America: Challenges and promising strategies. Rural Center for AIDS/STD Prevention. 2010.

Arora S, Kalishman S, Dion D, et al. Partnering urban academic medical centers and rural primary care clinicians to provide complex chronic disease care. Health Aff 2011;30(6):1176-1184.

Hecht FM, Wilson IB, Wu AW, Cook RL, Turner BJ. Optimizing care for persons with HIV infection. Society of General Internal Medicine AIDS Task Force. Ann Intern Med 1999;131(2):136-143.

Tilleczek K, Pong R, Caty S. Innovations and issues in the delivery of continuing education to nurse practitioners in rural and northern communities. Can J Nurs Res 2005;37(1):146-162.

Curran VR, Fleet L, Kirby F. Factors influencing rural health care professionals' access to continuing professional education. Aust J Rural Health 2006;14(2):51-55.

Arora S, Kalishman S, Thornton K, et al. Expanding access to hepatitis C virus treatment—Extension for Community Healthcare Outcomes (ECHO) project: Disruptive innovation in specialty care. Hepatology 2010;52(3):1124-1133.

Arora S, Thornton K, Murata G, et al. Outcomes of treatment for hepatitis c virus infection by primary care providers. New Engl J Med 2011;364(23):2199-2207.

Arora S, Thornton K, Jenkusky SM, Parish B, Scaletti JV. Project ECHO: linking university specialists with rural and prison-based clinicians to improve care for people with chronic hepatitis C in New Mexico. Public Health Rep 2007;122 Suppl 2:74-77.

Pilcher J, Bradley DA. Best practices for learning with technology. J Nurses Prof Dev 2013;29(3):133-137.

Bandura A. Self efficacy: The exercise of control. New York: W. H. Freeman and Co.; 1997.

Bandura A. Social foundations of thought and action: A social cognitive theory. Englewood Cliff, NJ: Prentice-Hall; 1986.

Vygotsky L. Mind in society: The development of higher psychological processes. Cambridge, MA: Harvard University Press; 1978.

Lave JW, Wenger E. Situated learning: Legitimate peripheral participation. New York: Cambridge University Press; 1991.

Leech NL, Onwuegbuzie AJ. A typology of mixed methods research designs. Qual Quant 2009;43(2):265-275.

Kirkpatrick DL, Kirkpatrick, J. D. Evaluating training programs: The four levels. 3rd ed. San Francisco: Berrett-Koehler Publishers, Inc; 2005.

Raudenbush SW, Bryk, A. S. Hierarchical linear models: Applications and data analysis. 2 ed. Thousand Oaks, CA: Sage; 2002.

Bashook PG, Linsk NL, Jacob BA, et al. Outcomes of AIDS Education and Training Center HIV/AIDS skill-building workshops on provider practices. AIDS Educ Prev 2010;22(1):49-60.

Cook PF, Friedman R, Lord A, Bradley-Springer LA. Outcomes of multimodal training for healthcare professionals at an AIDS education and training center. Eval Health Prof 2009;32(1):3-22.

Huba GJ, Panter AT, Melchior LA, et al. Do characteristics of HIV/AIDS education and training affect perceived training quality? Lessons from the evaluation of seven projects. AIDS Educ Prev 2000;12(5):455-476.

Davis D, O'Brien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA 1999;282(9):867-874.

Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance - a systematic review of the effect of continuing medical-education strategies. JAMA 1995;274(9):700-705.

Singer JD. Using SAS PROC MIXED to fit multilevel models, hierarchical models, and individual growth models. J Educ Behav Stat 1998;23(4):323-355.

Akaike, H. Information theory as an extension of the maximum likelihood principle. In B. N. Petrov, and F. Csaki, (Eds.) Second International Symposium on Information Theory. Akademiai Kiado, Budapest; 1973:267-281.

Wao HO, Dedrick RF, Ferron JM. Quantitizing text: using theme frequency and theme intensity to describe factors influencing time-to-doctorate. Qual Quant 2011;45(4):923-934.

Miles MB, Huberman A M. Qualitative data analysis: A sourcebook of new methods. Beverly Hills, CA: Sage; 1994.

Chung MH, Severynen AO, Hals MP, Harrington RD, Spach DH, Kim HN. Offering an American graduate medical HIV course to health care workers in resource-limited settings via the Internet. PLoS One 2012;7(12).

Flys T, Gonzalez R, Sued O, et al. A novel educational strategy targeting health care workers in underserved communities in Central America to integrate HIV into primary medical care. PLoS One 2012;7(10).

Ng ML, Bridges S, Law SP, Whitehill T. Designing, implementing and evaluating an online problem-based learning (PBL) environment - A pilot study. Clin Linguist Phonet 2014;28(1-2):117-130.

Laws MB, Lee Y, Rogers WH, et al. Provider-patient communication about adherence to anti-retroviral regimens differs by patient race and ethnicity. Aids Behav 2014;18(7):1279-1287.

Murphy DA, Roberts KJ, Martin DJ, Marelich W, Hoffman D. Barriers to antiretroviral adherence among HIV-infected adults. AIDS Patient Care STDS 2000;14(1):47-58.

Ddumba-Nyanzi I, Kaawa-Mafigiri D, Johannessen H. Barriers to communication between HIV care providers (HCPs) and women living with HIV about child bearing: A qualitative study. Patient Educ Couns 2016:99(5):754-759.

Bharath-Kumar U, Becker-Benton A, Lettenmaier C, Fehringer J, Bertrand JT. Communication and the antiretroviral treatment rollout: beyond the medical model. Aids Educ Prev 2009;21(5):447-459.

Ajzen I. The theory of planned behaviour: reactions and reflections. Psychol Health 2011;26(9):1113-1127.

Davis D, Davis N. Selecting educational interventions for knowledge translation. CMAJ 2010;182(2):E89-93.

Scott JD, Unruh KT, Catlin MC, et al. Project ECHO: a model for complex, chronic care in the Pacific Northwest region of the United States. J Telem Telecare 2012;18(8):481-484.

Arora S, Kalishman S, Dion D, et al. Partnering urban academic medical centers and rural primary care clinicians to provide complex chronic disease care. Health Aff 2011;30(6):1176-1184.

Bagayoko C-O, Gagnon M-P, Traore D, et al. E-Health, another mechanism to recruit and retain healthcare professionals in remote areas: lessons learned from EQUI-ResHuS project in Mali. BMC Med Inform Decis Mak 2014;14:120.

Gagnon M-P, Pollender H, Trepanier A, Duplaa E, Ly BA. Supporting health professionals through information and communication technologies: a systematic review of the effects of information and communication technologies on recruitment and retention. Telemed J E Health 2011;17(4):269-274.

Ulett KB, Willig JH, Lin H-Y, et al. The therapeutic implications of timely linkage and early retention in HIV care. AIDS Patient Care STDS 2009;23(1):41-49.

Mugavero MJ. Improving engagement in HIV care: what can we do? Top HIV Med 2008;16(5):156-161.

Zhang Y, Dou Z, Sun K, et al. Association between missed early visits and mortality among patients of china national free antiretroviral treatment cohort. J Acquir Immune Defic Syndr 2012;60(1):59-67.

Mugavero MJ, Lin H-Y, Willig JH, et al. Missed visits and mortality among patients establishing initial outpatient HIV treatment. Clin Infect Dis 2009;48(2):248-256.

Mayer KH. Introduction: Linkage, engagement, and retention in HIV care: essential for optimal individual- and community-level outcomes in the era of highly active antiretroviral therapy. Clin Infect Dis 2011;52 Suppl 2:S205-207.

Schwarz N, Oyserman D. Asking questions about behavior: Cognition, communication, and questionnaire construction. Am J Eval 2001;22(2):127-160.

How to Cite
Wao, H., Aluoch, M., McIntosh, S., Mhaskar, R., Orrick, J., Djulbegovic, B., & Beal, J. (2016). Impact of Telehealth Training on Health Care Providers’ Knowledge in HIV/AIDS Care: A Mixed Methods Evaluation. Journal of the International Society for Telemedicine and EHealth, 4, e14 (1-17). Retrieved from
Original Research