This survey showed that most of the students were satisfied with the qualification offered by the UNA-SUS network. More satisfaction was reported in terms of the course's contributions to professional practice, the quality of the materials made available, and for having stirred interest in the area of family health.
In general, the graduate course in family health has been considered satisfactory by participants in Brazil. A study conducted in Rio de Janeiro that surveyed 102 graduates of a professional master's course in family health via an online questionnaire in 2014 found that 77% of respondents considered this educational process to have made a positive contribution to their professional practice . This finding is corroborated by an online survey conducted in northeastern Brazil with 225 graduates of a master's program in family health, in which most students assigned high scores to the skills they acquired, emphasizing that graduate studies contributed to their professional activity from the perspective of integrated health care . The lato sensu specialization in family health appears to make the same contribution for professionals in terms of improving practices. According to Sturmer et al. , the professionals involved in the UNA-SUS family health specialization courses are recent entrants into the primary care system who pursue this qualification in order to refine their work through continuing education.
Considering Brazil's expansive size and the significant variations in training among higher-level health professionals despite the existence of National Curriculum Guidelines, online specialization courses make it possible for workers in remote regions where there are few or no face-to-face educational offerings to access professional training opportunities. Distance specialization breaks away from the face-to-face relationship between teachers and students and develops other forms of interaction, generating interactivity with the virtual learning environment and developing new cooperative links between students in the same class . This strengthens the students’ role in taking responsibility for their own learning, through autonomy and self-management.
The development of new technologies allows new resources to be incorporated into online courses for effective learning that is significant for various types of learners, and is reflected in the student's perception of the course and what they learned. This article describes the UNA-SUS network's specialization courses in family health that were offered to physicians, dental surgeons and nurses from primary health care and reached 61.635 enrollments between 2013 and 2017. The respondent profile is in line with other educational offerings from the UNA-SUS network, in which most students are female, white, Brazilian, and aged 40 years or less [4, 12, 17].
Different quality indicators are used to evaluate distance learning courses; one such indicator that is recognized worldwide is student retention [18, 19]. Dissatisfaction with the teacher, trouble with internet access, complexity of the activities, difficulty assimilating into the culture inherent to distance education, failures in course planning, mistaken student expectations, and inadequate technology or inability to use technology correctly have been indicated as the main reasons for student withdrawal or absences, and direct impact the retention rate . For this reason, student perceptions were verified via a questionnaire sent by email using the Survey Monkey Platform.
Students who expressed greater satisfaction with the course also recorded higher scores on the questions related to the level of difficulty in assessments and understanding of the content. Among those who were unsatisfied, most were younger than 40 years of age, were physicians, and failed the course. Similarly, physicians, nurses, and dentists from the city of Amparo, São Paulo who participated in a UNA-SUS/UNIFESP family health specialization course reported great satisfaction when asked about the learning process in this teaching modality, notably the ability to share what they learned with their work teams and to share knowledge and experiences with their classmates .
A similar study that used the COOLES instrument to evaluate perceptions among graduates about their educational experience found the highest satisfaction scores were given for the course stirring interest in the area, the quality of the materials, and course’s relation to professional practice. Furthermore, better perception of course material quality was positively associated with greater interest in relation to the knowledge area among the students . This is important, because simply providing materials in the virtual learning environment does not guarantee learning; they must be stimulating, and develop critical thinking and reflection on the part of the student about what they have observed in the territory where they work . The materials produced for use in online courses should be appropriately scaled in terms of content and language, and use various resources in order to allow students to be autonomous and manage themselves, since they are the main mediators in the learning process [24, 25].
A successful learning experience can result in satisfied students, and student learning outcomes are a good predictor of student satisfaction in online education .
Using forums in online courses dates back to the original Roman forums that were the center of power where political, economic, religious, and administrative issues were resolved, providing interactions and information among the people. Use of this strategy in online courses is consequently intended to generate debate and exchange experiences, contributing to personal and professional growth and civic development among students and teachers . Discussion forums are asynchronous tools that allow participants to reflect, organize their ideas, and express their viewpoints, and participation is continuously encouraged to foment the collective construction of knowledge .
In the present study, among the respondents who successfully completed the course, most expressed less satisfaction with the forums and their potential association with learning, suggesting that improvements are needed when this course is offered again in the future. In a study on the use of forums that applied a questionnaire to 132 teachers of various distance education courses at the Federal University of Rio Grande do Norte (UFRN), 52.6% stated that forums were employed to discuss the subjects addressed in the classes to promote learning through class interaction. A total of 31.6% used forums only to answer questions when they arose, and only 10% used them with specific, delineated and planned learning objectives . In this same study, 78.9% of the teachers considered forum interactions irregular, demonstrating the need for activities to transform and restructure forums into a tool to achieve learning objectives. The same percentage of teachers considered forums a motivating environment for student participation.
Along similar lines, a survey of thirty-four students in a distance course on scientific methodology found that forums were not particularly effective for interactive practices and the exchange of information and experiences, presenting only isolated individual contributions from students, with little or (in some cases) no interaction between them . A qualitative case study type survey was conducted with students in a distance course on education because there was little interaction in the forums, with participation occurring notably in the final days or hours of an activity, and because there were many complaints about lack of learning in the course. To improve student participation and satisfaction, some strategies were implemented, such as developing and disseminating learning objectives related to the forum, recommending previous readings, encouraging participation by a scoring system, requiring minimum participation in the forum, rapid feedback, suitable teacher preparation on the content, teacher assistance and empathy. With these strategies, participation doubled in comparison to the previous time the course was offered. Furthermore, the teachers observed an improvement in post quality and in student involvement and participation .
In order for forums to be an effective collaborative learning strategy in online courses, some important points need to be considered. Teacher feedback in response to students should generate new contributions on the topic, creating new challenges for students to continue participating in the forum. For this to happen, teachers require certain technical, pedagogical, and affective skills to generate student engagement .
In this study, we observed that nearly 60% of the students who reported less satisfaction were from the group that failed the course. Few studies on student satisfaction about online training are available, particularly those addressing failure. In one previous study comparing in-classroom students with those taking a course online, the students taking the online course were less satisfied, mostly because the use of the technology was new for them and they lacked the discipline and skills needed for distance learning . However, this study was conducted over twenty years ago, when much less was known about the use of technology in educational strategies, there was much less connectivity, usability, and user competence, and the software available was less reliable. Even so, this is still the reality in some Brazilian scenarios. Another study that investigated determining factors for obtaining learning results from the point of view of undergraduate students in South Korea and India found that interaction, student motivation, course structure, and instructor knowledge and facilitation positively influenced satisfaction with online courses .
Although less than 2% of the respondent sample failed the course, this lower satisfaction is expected. This has been previously observed in a study evaluating student perceptions of distance courses offered by the Getulio Vargas Foundation, in which students who failed responded to all items on the questionnaire with lower scores compared to students who passed . In a study including students who passed and failed a lato sensu graduate course offered by the Brazilian National Public Administration Training Program (PNAP) to train public managers within Brazil, 17% of the individuals who did not successfully complete the course indicated that difficulties with the course were the reason for evasion. However, in this study, the main reason was the lack of time (38%) . In another study on perceptions of an online logistics course, 58.3% of students responded that distance courses are more difficult than face-to-face courses. This response may be justified by the fact that 61.5% of the respondents stated they had already failed a distance class during their program, and 65% of these students reported that a lack of mastery of technological resources was one of the reasons that led to failure in distance learning .
Lack of interest or motivation is one of the main barriers to growth in education using web technologies, as well as one of the reasons for dropout rates for online courses . In this study, the authors investigated differences in demographics, enrollment, academics, and individual learning characteristics among students who successfully completed or did not complete online courses at a college in the American Midwest, as well as why students did not complete their courses. The results did not show statistically significant differences in age, gender, ethnicity, financial support for studying, student grade-point average, or enrollment time; differences found were in academic aptitude among the students who concluded the course, and that they enrolled in more online courses than students who did not successfully conclude the course, and were more literate in web technologies. Thus, regardless of sociodemographic factors, the more a student becomes a user of online courses the greater his or chance of completing the course.
One limitation of this study was the low return of the questionnaires, although the expected sample was attained. It is extremely important to understand student perceptions of educational offerings, and online questionnaires offer an effective tool for online courses. Still, one differential of this study is its national scale, which revealed interesting perceptions about lato sensu specialization courses in the field of family health which are offered by the UNA-SUS network. These in turn can be used to improve its educational processes, and may even have the potential to minimize failures or even dropout rates. Other qualitative studies are recommended to obtain more detail about the perceptions of students linked to the UNA-SUS network.