Knowledge of professional healthcare providers about sickle cell disease: Impact of a distance education course


hematol transfus cell ther. 2 0 1 9;4  1(1):62–68

w w w . r b h h . o r g

Hematology, Transfusion and Cell Therapy

Original article

Knowledge  of  professional  healthcare  providers
about sickle  cell  disease:  Impact  of a distance
education course

Katy Karoline Santos Diniz ∗, Adriana Silvina Pagano,
Ana  Paula Pinheiro Chagas Fernandes, Ilka Afonso Reis,
Leonardo Gonçalves Pinheiro Júnior, Heloísa de Carvalho Torres

Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil

a  r  t  i  c  l  e  i  n  f  o

Article history:

Received 9 March 2018

Accepted 20 June 2018

Available online 20 July 2018

Keywords:

Sickle cell disease

Healthcare provider

Knowledge

Health education

a  b  s  t  r  a  c  t

Objective: To assess the impact of the distance education course “Sickle Cell Disease: Primary

Health Care Line” on knowledge acquisition of professional healthcare providers.

Methods: A cross-sectional study was conducted with a quantitative approach at the Edu-

cational and Support Center for Hemoglobinopathies (Cehmob-MG), state of Minas Gerais,

Brazil, in 2016. One hundred and fifty-three out of 300 professional healthcare providers

were  invited to participate in the proposed distance course. Of the participating professional

healthcare providers, 72 (47%) successfully concluded the course (Group A), whereas 81 (53%)

did not complete their course assignments and did not meet the minimum requirements

for regular attendance (Group B). Knowledge acquisition was assessed with the Knowl-

edge of Sickle Cell Disease Instrument, DFConhecimento, applied using the web  tool eSurv.

Univariate analysis by Poisson regression was employed to assess the influence of sociode-

mographic variables on the DFConhecimento score and to select variables to compose the

initial multivariate regression model (p-value < 0.20). The analysis was performed in the

statistical programming environment R.

Results: The average score was 9.76 for Group A and 6.54 for Group B. The two  groups were

considered statistically different (p-value < 0.05) for all items with the proportion of correct

items being greater in Group A. Professional healthcare providers who concluded the course

had a significantly higher DFConhecimento score (45%) when compared to those who did

not  successfully conclude the course.

Conclusion: Participation in a distance education course on sickle cell disease had a posi-

tive  impact on the acquisition of knowledge about the disease by professional healthcare

providers.
o Bra
©  2018 Associaçã
by  Elsevier Editora Lt

∗ Corresponding author.
E-mail address: katykarolinesd@gmail.com (K.K. Diniz).

https://doi.org/10.1016/j.htct.2018.06.004
2531-1379/© 2018 Associação Brasileira de Hematologia, Hemoterapia
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hematol transfus cell

ntroduction

onsidered a public health problem, sickle cell disease is a
ereditary condition of great importance globally and in Brazil.

t predominantly affects the Black population and presents
linical manifestations within the first years of life with reper-
ussions on morbidity and mortality.1,2 Despite technological
nd scientific advances to improve the prognosis of sickle cell
isease, its management persists as a challenge for profes-
ional healthcare providers, since it involves complex aspects
f diagnosis, treatment and prevention of complications.3–5

Studies point to insufficient knowledge of professional
ealthcare providers about important aspects of the quality of

ife of people with sickle cell disease, such as growth and devel-
pmental consultations, immunization, school performance,
se of folic acid, prophylactic antibiotic therapy, complications
ue to vaso-occlusion, transfusions, prevalence of iron over-

oad, strokes in children and screening of stroke risk using
ranscranial Doppler ultrasonography.2,6–9 In order to improve
he quality of care provided to people with sickle cell dis-
ase and to reduce morbidity and mortality rates, there is a
lear need to develop educational interventions to increase
nowledge of professional healthcare providers about sickle
ell disease.3,10–12

To that end, a distance education course entitled “Sickle
ell Disease: Primary Health Care Line” has been offered by

he Educational and Support Center for Hemoglobinopathies
CEHMOB-MG) of the state of Minas Gerais since 2010. The
urpose of the course is to build competence of profession-
ls and to improve the quality of care for people with sickle
ell disease.2,3

Distance education is considered an important tool in
he dissemination of up-to-date knowledge and information,
specially in emerging countries. Its educational resources
llow interaction, shared experience, improvement of knowl-
dge in different health areas and can affect a large number of
rofessionals in different regions of the country. In addition,
tudies have demonstrated the effectiveness of this approach
y educational interventions targeting professional health-
are providers.13–16 Despite the relevance of distance courses,
o studies were found in the literature that investigate the

mpact of distance education on the management of sickle
ell disease.

This study aims to evaluate the impact of the distance
ducation course “Sickle Cell Disease: Primary Health Care
ine” on knowledge acquisition by professional healthcare
roviders.

ethods

his is a cross-sectional study with a quantitative approach
arried out from April to June 2016 at the Educational and Sup-
ort Center for Hemoglobinopathies (Cehmob-MG) in the state
f Minas Gerais.
The distance education course “Sickle Cell Disease: Primary
ealth Care Line” aims at promoting an educational strategy

o improve knowledge within a virtual learning environment.
he course workload is 95 h over three months with follow-up
. 2 0 1 9;4  1(1):62–68 63

sessions managed by tutors with expertise in sickle cell dis-
ease. The course content is divided into modules dealing with
topics related to health surveillance actions targeting children,
adolescents and adults, management of acute events, sickle
cell behavior and other hemoglobinopathies (Table 1). Con-
tent is developed through student engagement in case study
analysis, discussion forums and group activities with debate
and reflection on the provision of professional care, leading to
knowledge construction and proposals to improve the quality
of care for people with sickle cell disease.

To recruit participants, local and regional authorities
are contacted and alerted as to the relevance of build-
ing professional competence to deal with the disease. As a
result, authorities delegate healthcare providers working with
sickle cell disease (physicians, nurses, dentists, social assis-
tants, psychologists, physical therapists, physical educators,
dieticians and others) to take part in the course. Other profes-
sionals wishing to participate in the course are also welcome.

During the period from 2010 to 2016, 2446 professionals
were selected to participate in the Cehmob distance education
course. Of these, 1171 (48%) successfully concluded the course
obtaining a minimum score of 70% for course work and atten-
dance. The remaining 1275 (52%) did not obtain the minimum
score or dropped out of the course.

The present study used a database of all professional
healthcare providers for the selection of prospective partici-
pants. In April 2016, an invitation to participate in this study
with a brief explanation of the research, and an informed
consent form was sent by email to 300 randomly selected pro-
fessionals among those enrolled in the course. As the study
aimed to assess participants who successfully concluded the
course as well as those who did not, 150 professionals were
randomly selected from each group.

Of the invitees, 153 (51%) accepted to participate in this
study; 72 (47%) had successfully concluded the course (hence-
forth referred to as Group A) and 81 (53%) had not met  the
minimum requirements for course completion (Group B).

Participants were requested to answer a questionnaire
applied using the web tool e-Surv. This questionnaire
comprised three sections: (1) sociodemographic data: sex,
education, city of residence, and professional category; (2)
details of professional performance: type of health service
in which the participant worked and the number of years
working in healthcare services; and (3) the DFConhecimento
instrument (Attachment 1). Thirteen multiple-choice ques-
tions were included about the disease covering: 1. Newborn
screening program; 2. Sickle cell disease; 3. Sickle cell anemia
genotype; 4. Sickle cell trait; 5. Clinical manifestations; 6. Acute
events; 7. Conditions favoring red blood cell hemolysis; 8. Signs
of sickle cell disease; 9. Medications; 10. Prophylaxis; 11. Ado-
lescence; 12. Pregnancy; and 13. Prevention of leg ulcers.

The DFConhecimento instrument was constructed and val-
idated by the study authors from May 2015 to April 2016 at
the Universidade Federal de Minas Gerais (UFMG). Instrument
content validation was carried out by 11 experts in instrument
validation and in sickle cell disease that made up a panel of

experts. The instrument presented an average content validity
index of 0.88. Regarding the reliability analysis, the instrument
presented satisfactory indexes. Cronbach’s alpha presented
a value of 0.818, indicating a high internal consistency. The



64  hematol transfus cell ther. 2 0 1 9;4  1(1):62–68

Table 1 – Modules, units and aims of the distance course “Sickle Cell Disease: Primary Health Care Line”.

Module Unit Aim

Getting familiar Course introduction To get familiar with the virtual learning environment and tools
1. Monitoring children with

sickle cell disease
Active search, prophylaxis,
immunization

Understanding risks of sickle cell disease and the need to
identify the disease in primary healthcare for planning
monitoring by all professional healthcare providers

2. Managing acute events Acute splenic sequestration,
infection, pain crisis, stroke,
cholecystitis, acute chest
syndrome

Learning about acute events and establishing protocols for
dealing with them at basic healthcare units and referral

3. Monitoring adolescents
and adults with sickle cell
disease

Pregnancy, puberty Understanding special needs of adolescents and adults with
sickle cell disease. Identifying risks in pregnancy

4. Caring for patients with
sickle cell disease and
other

Hb  AS—sickle cell trait; Hb
CC—hemoglobin C

Acquiring advanced knowledge about sickle cell disease and
other hemoglobinopathies to plan guidelines for instruction
and follow up
hemoglobinopathies
5. Discussing healthcare

promotion strategies
End  of course assignment 

intraclass correlation coefficient between the test and retest
presented a value of 0.67 [95% confidence interval (95% CI):
0.55–0.76], indicating that the temporal reproducibility is
acceptable. The instrument presents dimensions composed
of items compatible with themes indicated as priorities for
knowledge on sickle cell disease by the health professional
(diagnosis, treatment and prevention of complications).17

The DFConhecimento instrument scores were calculated
with 1 being assigned for correct answers and 0 for incorrect
answers (range: 0–13). The qualitative variables—sex, educa-
tion, training category, number of years working in healthcare
services, type of health service and previous experience assist-
ing patients with sickle cell disease—are summarized using
absolute and relative frequencies. The scores obtained with
the instrument are summarized as mean, median, standard
deviation (SD) and interquartile range. The Fisher exact or
chi-square tests were used to analyze the homogeneity of
groups in relation to sex, education, professional category,
professional performance and number of years working in
healthcare services. A level of significance of 5% or more  (p-
value > 0.05) indicated evidence of homogeneity.18

The chi-square test with a level of significance of 5%
was adopted to compare the proportions of correct answers
between Group A and Group B. The qualitative variables are
presented using absolute and relative frequencies.18

The Poisson regression model was used to study the influ-
ence of factors—having completed the course, sex, academic
training, training category, number of years working in health-
care, type of healthcare service and previous experience
assisting patients with sickle cell disease.19 Univariate analy-
sis allowed the selection of factors that potentially influenced
the knowledge score with a level of significance equal to 25%
being considered at this selection stage. Using the selected
variables, univariate analysis employing a generalized linear
Poisson model was employed to verify the direct influence of
distance education on the scores of the professionals and con-
firmed whether other characteristic variables of the sample

had a significant influence on their knowledge. Thus, mul-
tivariate Poisson regression models were fit with backward
elimination being used to select the variables of the final
model. A significance level of 5% was adopted for backward
Exercise on planning educational actions about sickle cell
disease as a joint task by a team of family healthcare providers

elimination.17 All analyses were performed using the statisti-
cal software R (R core team).

The project was approved by the Research Ethics Commit-
tee Involving Human Beings of the Universidade Federal de
Minas Gerais (decision No. 1.717.975). The agreement of the
subjects to participate in the study was recorded by means of
the informed consent form available in the initial menu  of the
electronic questionnaire on the website e-Surv.

Results

Of the participants of the study, 127 (83%) were female, 82
(54%) only studied to degree level, 88 (58%) were nurses, 52
(34%) had worked in healthcare services for more  than nine
years, 118 (77%) had previously provided care to sickle cell
disease patients and 134 (90%) work in municipalities in the
State of Minas Gerais (Table 2). The groups under study were
considered homogeneous in all analyzed variables.

Table 3 shows the descriptive statistics of the knowledge
scores according to the situation of the professionals in rela-
tion to concluding the course. It can be observed that Group
A had higher mean and median scores than Group B. Scores
ranged from a minimum of 0 to a maximum of 13 points. The
mean score was 9.76 (SD: 2.62) for Group A and 6.54 (SD: 3.22)
for Group B.

Table 4 presents a comparison of proportions of correct
answers between Group A and Group B. There was a significant
difference (p-value < 0.05) for all the questions with the propor-
tion of correct answers being significantly higher among those
who completed the course.

The mean percentage of correct answers of subjects in
Group A (75.0 ± 2.6%) was higher than the results of Group B
(50.6 ± 3.2%).

In the univariate analysis (Table 5), the following variables
were selected: Group (A and B), academic training, health
service type and previous experience assisting sickle cell dis-

ease patients; variables were considered possible significant
influences when p-values were <0.25. A significant difference
regarding the knowledge score (p-value < 0.001) was observed
between Group A (average score was 49% higher) and Group



hematol transfus cell ther. 2 0 1 9;4  1(1):62–68 65

Table 2 – Sociodemographic characterization of the professionals who answered the DFConhecimento instrument
stratified depending on course completion.

Sociodemographic characteristic n  (%) p

Group A Group B Total

Sex
Female 59  (82) 68 (84) 127 (83) 0.909a

Male 13 (18) 13 (16) 23 (17)
Education

Degree 13 (18) 29 (36) 42 (27) 0.141b

Specialization 40 (56) 42 (52) 82 (54)
Master’s degree 10 (14) 8 (10) 18 (12)
Doctorate degree 6 (8) 2 (2) 8 (5)

Professional category
Nursing 40 (56) 48 (59) 88 (58) 0.765a

Others* 32 (44) 33 (41) 65 (42)
Number of years working in healthcare services

Up to 4 years 14 (19) 30 (37) 44 (29) 0.110a

From 5 to 8 20 (28) 19 (23) 39 (25)
9 years or more 29 (40) 23 (28) 52 (34)
None 9 (13) 9 (11) 18 (12)

Type of health service
Primary healthcare 32 (44) 41 (53) 74 (48) 0.706a

Others** 40 (56) 40 (57) 79 (52)
Previous experience assisting patients with sickle cell disease

No 13 (18) 22 (27) 35 (23) 0.252a

Yes 59 (82) 59 (73) 118 (77)

a Chi-square test.
b Fisher’s exact test.
∗ Others: biomedicine (2); physical education (1); pharmacy (7); physiotherapy (2); health management (3); manager (1); medicine (12); nutrition

(8); odontology (4); pedagogy (1); psychology (5); social work (18); occupational therapy (1).
∗∗ Others: Technical references and projects of the state and municipal health departments (27); hospital (15); educational institution (10);

emergency care unit (7); blood center (7); laboratory (3); social work department (5); social control (1); does not work in the health area (4).

Table 3 – Descriptive analysis of scores.

Scores Mean SD Min. 1st quartile Median 3rd quartile Max.

Total 8.1 3.1 0 6 8 11 13
Group A 9.8 2.6 0 8 10 12 13
Group B 6.5 3.2 0 4 6 9 13

SD, standard deviation; Min., minimum; Max., maximum.

Table 4 – Proportions of correct answers of professionals who answered the questionnaire and completed the course
(Group A) and those that did not (Group B).

Questions Total  (n = 153) Group A (n = 72) Group B (n = 81) pa

n (%) n (%) n (%)

Q1 118 (77.1) 62 (86.1) 56 (69.1) 0.013
Q2 131 (85.6) 67 (93.1) 64 (79) 0.013
Q3 123 (80.4) 65 (90.3) 58 (71.6) 0.004
Q4 115 (75.2) 65 (90.3) 50 (61.7) 0.000
Q5 59 (38.6) 38 (52.8) 21 (25.9) 0.001
Q6 105 (68.6) 64 (88.9) 41 (50.6) 0.000
Q7 73 (47.7) 47 (65.3) 26 (32.1) 0.000
Q8 61 (39.9) 35 (48.6) 26 (32.1) 0.037
Q9 59 (38.6) 37 (51.4) 22 (27.2) 0.002
Q10 82 (53.6) 46 (63.9) 36 (44.4) 0.016
Q11 104 (68) 63 (87.5) 41 (50.6) 0.000
Q12 92 (60.1) 54 (75) 38 (46.9) 0.000
Q13 111 (72.5) 60 (83.3) 51 (63) 0.005
Mean 95 (62.1) 54 (75) 41 (50.6) 0.000

a Chi-square test.



66  hematol transfus cell ther. 2 0 1 9;4  1(1):62–68

Table 5 – Univariate analysis using the Poisson regression model.

Variable  ̌ EP(ˇ)  Exp(ˇ)  95% CI p

Group A  0.40 0.06 1.49 1.32–1.69 <0.001
B – – –

Sex Female – – –
Male 0.10 0.09 0.91 0.76–1.09 0.291

Education Degree – –
Specialization 0.16 0.08 1.17 1.00–1.37 0.047
Master’s degree 0.28 0.11 1.32 1.06–1.64 0.015
Doctorate degree 0.44 0.14 1.55 1.17–2.04 0.003

Training category Nursing – –
Other 0.02 0.07 1.02 0.89–1.17 0.764

Number of years working in
healthcare

None – –
Up to 4 years 0.07 0.12 1.07 0.84–1.36 0.593
From 5 to 8 years 0.12 0.12 1.13 0.89–1.44 0.321
9 years or more 0.25 0.12 1.29 1.02–1.62 0.033

Type of health service Primary healthcare – –
Other 0.08 0.07 1.09 0.95–1.24 0.227

Previous experience assisting
patients with sickle cell disease

No  – –
Yes 0.15 0.08 1.16 0.99–1.37 0.075
95% CI: 95% confidence interval.

B. There was a significant difference (p-value < 0.005) between
training levels. On average, compared to participants with just
a degree, those with a specialization presented 17% higher
scores; with a master’s degree or taking a master’s degree
had scores 32% higher; while those with a doctorate degree
had scores 55% higher. There was a significant difference (p-
value = 0.033) in the number of years working in healthcare,
since the knowledge score for professionals who had worked
nine years or more  was on average 29% higher than the score
of those who had never worked in healthcare. There was no
significant difference between mean scores when compar-
ing variables such as gender, professional category, type of
healthcare service and whether they had dealt with sickle cell
disease patients previously.

Table 6 presents the results of the Poisson regression model
adjusted using the variables: group, academic training, health
service type and previous assistance to patients with sickle
cell disease (initial multivariate model). The final multivariate
model was reached after step-by-step elimination of non-
significant variables (p-value > 0.05) from the initial model
(Table 6). The analysis of the final model shows that Group A
maintained a significant difference, presenting on average 45%
(95% CI: 28–64%) higher scores than Group B, even when this
comparison is adjusted by the level of training. There was also
a significant difference (p-value = 0.029) in the means of the
knowledge score of professionals with different levels of aca-
demic training; those with a doctoral degree had, on average,
34% (95% CI: 3–73%) higher scores when compared to profes-
sionals just with graduation. For the levels of specialization
and master’s degree, no statistically significant differences
were observed in the score in relation to the level of gradu-
ation.
Discussion

The characteristics of the sample studied related to the vari-
ables of gender, professional category and specialization were
similar to those observed in other studies with professional
healthcare providers. In those, most of the professionals
were female, with a nursing background and some level of
specialization.16,20 A favorable aspect of this study, observed
in the characterization of the sample, is related to the graduate
and higher education groups, which were considered homo-
geneous in all the variables analyzed.

In the individual evaluation of the items of the DFCon-
hecimento instrument, the proportion of correct answers for
the whole instrument were on average 75% higher among the
participants in Group A. This average was higher than that
observed in a study carried out in the United States (65%) that
investigated knowledge about sickle cell disease among physi-
cians and nurses of emergency services who participated in a
workshop that included ten lectures given by specialists in
the area. The participants answered an electronic question-
naire of multiple-choice questions prepared by the authors of
the study before the beginning of the lectures and after the
event.7

The results of DFConhecimento, verified by the descrip-
tive analysis of the scores and by the generalized linear
Poisson model, showed that members of Group A had signif-
icantly more  knowledge about the disease after the course
compared to Group B. A similar result was obtained in a
randomized study carried out in the northern part of the
State of Minas Gerais, aimed at assessing an educational
program about sickle cell disease that targeted commu-
nity healthcare agents and nursing assistants working in
primary healthcare. Participants in the study showed knowl-
edge acquisition by improvements in their performance
during the assessment (p-value < 0.001).21 Studies verified
a significant positive impact on knowledge of professional
healthcare providers after being submitted to an interven-
tion in other health domains using the method of distance

14–16
education.
The positive impact of the distance education course

about sickle cell disease on the professionals who  completed
the study suggests that this educational strategy can be



hematol transfus cell ther. 2 0 1 9;4  1(1):62–68 67

Table 6 – Results of multivariate analysis (adjustment of the generalized linear Poisson model).

Variables Initial model Final model

 ̌ EP(ˇ)  Exp(ˇ)  95% CI p  ̌ EP(ˇ)  Exp(ˇ) 95% CI p

Group A  0.37 0.06 1.44 1.27–1.64 <0.001 0.37 0.06 1.45 1.28–1.64 <0.001
B – – – – – – – – – –

Education Degree – – – – – – – – – –
Specialization 0.08 0.08 1.09 0.94–1.26 0.280 0.11 0.07 1.12 0.96–1.29 0.143
Master’s degree 0.15 0.11 1.16 0.94–1.44 0.179 0.20 0.10 1.22 1.00–1.50 0.056
Doctorate degree 0.20 0.14 1.22 0.92–1.61 0.161 0.29 0.13 1.34 1.03–1.74 0.029

Number of years working in
healthcare

None – – – – – – – – – –
Up to 4 years 0.16 0.12 1.17 0.93–1.48 0.173 – – – – –
From 5 to 8 years 0.13 0.12 1.14 0.90–1.45 0.280 – – – – –
9 years or more 0.21 0.12 1.24 0.99–1.56 0.068 – – – – –

Type of health service Primary healthcare – – – – – – – – – –
Other 0.08 0.07 1.08 0.94–1.24 0.259 – – – – –

Previous experience assisting
patients with sickle cell disease

No  – – – – –
Yes 0.07 0.08 1.07 0.92–1.25 0.390 – – – – –

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95% CI: 95% confidence interval.

ntroduced in the context of all professional healthcare
roviders working in the healthcare network. Thus, it is

mportant that this strategy includes content related to
nowledge deficits of professional healthcare providers as
escribed in the literature: content that addresses patho-
hysiological complications, transfusion, prevalence of iron
verload, stroke in children, clinical manifestations as well
s the management of sickle cell disease.2,7,9,10,12

The results obtained from the professionals in this study
nd reported in the literature show that a deficit of knowl-
dge about sickle cell disease exists and persists despite the
echnical-scientific advances and the availability of guidelines
ith recommendations for professional practice. However, the
ositive impact on the knowledge about sickle cell disease
f professionals after participating in educational interven-
ions was confirmed in recent studies with North American,
razilian and Mexican professionals with different educa-
ional levels using qualitative and quantitative methods of
nowledge assessment.2,10,22–24

This study fills a gap highlighted in a previous study, which
ecommended including physicians and nurses in educational
rograms on sickle cell disease.21 Because this educational

ntervention seeks to improve the knowledge of profession-
ls in respect to sickle cell disease using technology, its strong
oint is the viability of reproducing this study with more
articipants and with geographical expansion to represent a
reater proportion of professionals.15,16,25

onclusion

istance learning courses have a positive impact on the
nowledge acquired by professional health providers about
ickle cell disease. It is essential to include professionals
ho  assist sickle cell disease patients in similar educational

ctions.
onflicts  of  interest

he authors declare no conflicts of interest.
Appendix  A.  Supplementary  data

Supplementary data associated with this article can be found,
in the online version, at doi:10.1016/j.htct.2018.06.004.

 e  f  e  r  e  n  c  e  s

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	Knowledge of professional healthcare providers about sickle cell disease: Impact of a distance education course
	Introduction
	Methods
	Results
	Discussion
	Conclusion
	Conflicts of interest
	Appendix A Supplementary data
	References