Continuing Education for Digital Transformation in Primary Health Care: The Educa e-SUS PHC Iniciative

Abstract

This study presents the results achieved by the National Program for Continuing Education in Digital Health for Primary Health Care (PHC), delivered through a massive open online course (MOOC) platform. Collected data are used to monitor participants’ progress towards goal achievement for certification purposes and to evaluate course quality. Prolonged inactivity, defined as more than 90 days without progress, triggers an AI-generated motivational message tailored to the participant. Between November 2023 and November 2025, the program registered 236,309 enrollments by 84,408 participants, reaching 5,111 municipalities across all Brazilian states. A total of 15,292 (18.1%) people dropped out of their selected course, of whom 4,498 (11.7%) later returned to it. Content relevance and educational resources received high approval ratings: 57,259 (94.9%) and 56,230 (93.2%), respectively. The results demonstrate the broad reach of this educational strategy in supporting digital acceleration in PHC. It is expected that digital literacy focused on the effective use of e-SUS PHC software will enable digital systems to advance their role as catalysts of social transformation.

Key words:
Primary Health Care; Continuing Education; Digital Public Health; Distance Education

Resumo

O estudo apresenta os resultados alcançados pelo programa Oferta Nacional de Educação Permanente em Saúde Digital para a Atenção Primária à Saúde (APS), realizado em plataforma massiva online e aberta (MOOC). Dados coletados permitem monitorar a evolução do participante no cumprimento das metas, proceder à sua certificação e avaliar a qualidade dos cursos. A ausência de progresso por mais de 90 dias aciona uma mensagem personalizada motivacional, criada com apoio de inteligência artificial. Entre novembro de 2023 e novembro de 2025, foram contabilizadas 236.309 matrículas de 84.408 cursistas, alcançando 5.111 municípios de todos os estados brasileiros. 15.292 (18,1%) pessoas abandonaram o curso escolhido, 4.498 (11,7%) tendo retomado o mesmo. Relevância de conteúdo e recursos educacionais tiveram elevado índice de aprovação: 57.259 (94,9%) e 56.230 (93,2%). Os resultados demonstram o amplo alcance da estratégia formativa em apoio à aceleração digital na APS. Espera-se que com o letramento digital centrado na utilização eficiente dos softwares da Estratégia e-SUS APS os sistemas digitais avancem em seu papel catalisador da transformação social.

Palavras-chave:
Atenção Primária à Saúde; Educação Continuada; Saúde Pública Digital; Educação a Distância

Resumen

Este estudio presenta los resultados del programa Oferta Nacional de Educación Contínua en Salud Digital para la Atención Primaria de la Salud (APS), implementado en de una plataforma masiva, abierta y en línea (MOOC). Los datos recopilados permiten monitorear la evolución del participante en el cumplimiento de las metas de aprendizaje, a los efectos de su certificación y evaluar la calidad de los cursos. La inactividad durante más de 90 días activa el envío de un mensaje motivacional personalizado, generado mediante un sistema de inteligencia artificial. Entre noviembre de 2023 y noviembre de 2025, se registraron 236.309 inscripciones de 84.408 participantes, abarcando 5.111 municipios de todos los estados brasileños. 15.292 (18,1%) personas abandonaron el curso elegido, de las cuales 4.498 (11,7%) retomaron posteriormente el mismo. La relevancia del contenido y los recursos educativos obtuvieron elevados índices de aprobación: 57.259 (94,9%) y 56.230 (93,2%), respectivamente. Los resultados demuestran el amplio alcance de esta estrategia formativa como apoyo a la aceleración digital en la APS. Se espera que con la alfabetización digital, centrada en el uso eficiente de los softwares de la Estrategia e-SUS APS, los sistemas digitales avancen en su papel como catalizadores de la transformación social.

Palabras clave:
Atención Primaria de la Salud; Educación Contínua; Salud Pública Digital; Educación a Distancia

Introduction

Digital technology has directly improved health systems, leading to people’s better health and well-being¹. Digital revolution adds value while driving transformation across society and, in health care, it enables authorized access to information at care delivery points. Digital tools enhance care with decision support, reliable information, and self-care engagement². Brazil, aligned with the World Health Organization’s Digital Health strategy³, is recognized for advancing people-centered, inclusive, scalable digital solutions to seek digital transformation in its Unified Health System (SUS)^4,5.

A set of historically aligned public policies provided strategies and actions agreed upon by the Ministry of Health, states, and municipalities. These agreements made Brazilian Primary Health Care (PHC) information a successful example of information organization and management when combined with health data interoperability. The e-SUS APS Strategy was a historic milestone. It guided the restructuring of information at the national level and formalized an information management model. The Electronic Health Record, accessible through the e-SUS APS Electronic Medical Record, began in 2013 and has been adopted by most Brazilian municipalities⁶. The electronic medical record is free of charge and offered in modules. These are tailored to care delivery settings and the varying levels of digital maturity and infrastructure among the 47,847 health units that use it⁷. A set of mobile-device applications, synchronized with the e-SUS APS Electronic Medical Record through the internet, also facilitates communication among Family Health Team professionals by structuring activities that occur outside health units⁸. Access analytics from July 2025 show the following: the e-SUS Territory application recorded 133,175 active users and 460,027 downloads; the e-SUS Vaccination application had 58,562 active users and 511,581 downloads; the e-SUS Collective Activity application had 7,487 active users and 44,305 downloads; the e-SUS Home Care application had 726 active users and 7,631 downloads; and the e-SUS Management application had 5,911 active users and 32,921 downloads⁹. These digital resources aim to meet PHC demands. They incorporate new technologies, such as video calls and digital prescriptions, queue management to improve Family Health Teams’ problem-solving capacity, and georeferencing families to enhance territorial knowledge.

Alongside technological development, digital education is essential to ensure equitable technology use, promoting civic and culturally-adapted participation to prevent exclusion from Digital Health services¹⁰. As technology advances and is extremely useful, preparing users to adopt and use digital systems fully is critical to achieve its full potential. Promoting and facilitating digital health competencies for all professional users remains a global challenge. Digital literacy focusing on efficient, responsible, and ethical technology use enables digital systems to drive social transformation³. Digital Health, a multidisciplinary field, offers diverse perspectives on a single national information system. Over one million users interact with e-SUS APS Strategy software, fulfilling roles in technology maintenance, health surveillance, management, and healthcare. In these systems, users’ access profiles reflect their educational backgrounds and professional scopes. Digital Health training provides significant knowledge and addresses varied audiences: health professionals, DICT professionals, health unit managers, and other stakeholders¹¹. Each group needs ongoing, tailored guidance: Community Health Workers (ACS) operate outside health units; local and municipal technology managers oversee technology planning, implementation and monitoring; and PHC health professionals require educational modules aligned with their practice.

Massive open online courses (MOOCs) are a growing revolutionary approach to adult health education, with wide coverage autonomy for students, and a simultaneous access of a significant number of people¹². This distance learning modality aligns with the open-access education principles and offers a free, unrestricted self-education online environment¹³. In Brazil, continuing education is a public policy that seeks to improve and transform health practices, strengthening the SUS principles¹⁴. Its potential in training human resources is enormous and aligns with the promotion of the development of health workers and the digital acceleration process. This study presents the National Offer of Continuing Education in Digital Health for PHC, implemented in 2023, highlighting the technological innovations of the MOOC-based approach and its results.

Methods

The preparation of this article followed the international guidelines for publishing studies that evaluate Health Informatics applications, namely, the STAtement on the Reporting of Evaluation studies in Health Informatics (STARE-HI)¹⁵. The digital artifact presented is the MOOC teaching platform named Educa e-SUS APS.

Study context

This exploratory, observational, quantitative study presents the teaching platform, its technology, and the results from the first 20 months of the National Offer of Continuing Education in Digital Health. The project was developed by the Secretariat of Primary Health Care of the Ministry of Health (SAPS-MS) and the Federal University of Minas Gerais (UFMG), and was formalized through Decentralized Execution Term 31/2022. The aim is to provide digital literacy continuing education to PHC professionals and other interested parties, contextualized for e-SUS APS applications. Data are aggregate, sourced from the educational platform’s automated reports, and comply with the Brazilian General Data Protection Law (LGPD) for exclusive educational and public policy use. The privacy policy¹⁶ and terms of use¹⁷ are available on the platform¹⁸.

The Educa e-SUS APS open-access distance-learning environment

The Educa e-SUS APS MOOC platform was developed by a transdisciplinary team. Team members brought experience in teaching, research, and developing digital technology for health. The teaching environment is accessible online and uses free software, specifically the Learning Management System Moodle. Plugins were added to provide interactivity, learner progress monitoring, completion certificates, customized illustrations, and media resources. The platform also provides a responsive screen for mobile devices. In web design, PHC professional groups were represented by personas to promote an inclusive educational environment reflecting the diversity of Brazilian body types, with no age or gender discrimination.

A web interface, or landing page, was developed to give an overview of course offerings, guide users to targeted learning pathways, manage enrollments, and display real-time management indicators. Seven learning pathways were created to help the target audience identify their professional profile and locate content, illustrations, and exercises relevant to their practice. The pathways are Health Professionals, Oral Health Professionals, Digital Information and Communication Technology Professionals, People in Health Management, PHC Workers, PHC Technicians, and PHC Oral Health Technicians.

The Educa e-SUS APS MOOC is hosted on the data server of the UFMG School of Medicine and protected by sound information technology and digital security practices¹⁸. Access is through a GOV.BR account, a secure digital platform that provides citizens with a single protected login for federal government services, eliminating the need to manage an additional password.

On the access page, EDU, an intelligent conversational agent, provides comprehensive information about the courses offered, their duration, and enrollment and certification processes. Its training is based on a set of user questions and answers collected and updated over time, which were paraphrased so as to encompass different ways of formulating the same query, with distinct styles of (in)formality. This set was expanded by means of a generative language model with a sophisticated architecture for indexing and processing queries, offering accurate responses and efficient user routing. The approach provides colloquial-language responses and improves the user experience by integrating advanced Artificial Intelligence technologies¹⁹. Figure 1 illustrates the landing page with the learning pathways and access to EDU.

Figure 1
The Educa e-SUS APS platform.

Media resources in the format of podcasts and short instructional mini-videos used in the courses are produced with the support of free-version digital tools, Spreaker® and Capcut®. The media are stored on YouTube® with backup on UFMG data servers, which provide a permanent access link whose content can be periodically updated.

Educational premises and content definition

The content-development team is composed of experts from different academic units-Medicine, Nursing, Dentistry, Computer Science, and Languages-as well as SAPS-MS technical staff, as detailed on the Educa e-SUS APS MOOC Platform¹⁸ under Team. PHC professionals are invited to participate in course development according to their availability and the implementation schedule. Regular meetings involve faculty members, researchers, graduate students, and technical staff using an agile methodology²⁰. The continuous improvement and updating of content align with versioning of the e-SUS APS Strategy software applications and incorporate many of the learners’ suggestions collected through questionnaires during the final certification procedures of each course.

The Digital Health competencies to be developed in the courses follow values aligned with the principles of qualification in Public Health to promote the capacity for communication in digital environments, professionalism, and collaborative work skills supported by digital resources. A set of competencies was defined based on the review by Jimenez et al.²¹, and subsequently discussed jointly by the academic teams and SAPS-MS, leading to the identification of knowledge gaps that were summarized in Chart 1.

Chart 1
Knowledge gaps to be explored in the context of digital literacy in Primary Health Care (PHC).

Themes	Needs
Digital literacy	To appropriate digital literacy concepts in a contextualized way within the e-SUS APS environment, aligned with public health policies. To understand and value the context of health informatics, information systems, and information security. To become aware of the potential of remote care and mobile applications in improving the quality of care. To implement practices to ensure data quality in work routines, with the appropriate use of terminology and standards, and paying attention to clear and appropriate free writing.
Communication	To utilize best practices in communication through digital technologies in relationships with those being cared for and among professionals. To know how to listen, record information using accessible and non-discriminatory language to avoid communication risks in both digital and face-to-face environments.
Digital environment	To work ethically using the digital resources specific to the e-SUS APS Strategy, including software, computers, tablets, and the internet. To understand the principles of the Brazilian General Data Protection Law (LGPD), the resources available to provide digital security in healthcare, and to adopt safe practices.
Collaborative and team work	To recognize the importance of the different knowledge areas involved in Digital Health practices. Conduct productive and responsible interaction between the family health team and eMulti x in a virtual environment. To share citizen care between the eSF and eMulti teams and discuss clinical cases and care plans using digital resources from the e-SUS APS electronic health record.
PHC principles and values	To value digital technology as a means to action, based on a comprehensive view of the needs of individuals, social groups, and the territory. To respect ethical values, the autonomy of individuals, and individual stances regarding the use of digital technologies.
Data management and analysis	To plan, organize, and manage health resources using the features and functionalities of the e-SUS APS digital environment. To critically analyze management reports and use them to support evidence-based decision-making.

• eMulti: Multidisciplinary team. eSF: Family Health Team. SUS: Brazilian Unified Health System.
• Source: Authors.

Offerings and target audience

Each National Offer of a course is opened after a curation process supported by 14 Brazilian municipalities that act in the pilot validation of the software applications of the e-SUS APS Strategy, as defined by agreements among the Ministry of Health, states, and municipalities. The pilot evaluation process for each course provides suggestions for adjustments and improvements in content, illustrations, media resources, and practical exercises, which are refined before broad national rollout. The first National Offer took occurred in November 2023, followed by progressive opening by pathways aligned with PHC professional profiles, presented in Chart 2. The pathways consist of freely chosen, non-sequential courses. A completion certificate is issued for each course.

Chart 2
Training pathways of the Educa e-SUS APS platform, duration and target audience, by opening date.

Name of training pathway	Target audience	Courses	Duration (hours)
Health Professionals (11/2023)	Doctors, nurses and eMulti	- Overview of digital health in PHC - Health records in PHC - e-SUS APS system	80
Oral Health Professionals (11/2023)	Dental surgeons from eSF and CEOs	- Overview of digital health in PHC - Health records in PHC - e-SUS APS system	80
PHC Health Technicians (04/2024)	Nursing Technicians and Assistants	- Overview of digital health in PHC - e-SUS APS system for Health Technicians	40
PHC Oral Health Technicians (04/2024)	Dental Technicians and Assistants from the eSF and CEOs	- Overview of digital health in PHC	20
DICT Professionals (06/2024)	Information technology professionals who implement and maintain the e-SUS APS system	- Accelerating Digital Health in PHC - Registration in PHC and Digital Security - e-SUS APS system for DICT professionals TDIC (under preparation)	125
People in Health Management (06/2024)	Health Unit Managers and People in PHC Management	- Accelerating Digital Health in PHC - Registration in PHC and Digital Security - e-SUS APS system for People in Health Management	80
PHC Health Workers (06/2025)	Community Health Workers	- e-SUS APS system for Health Workers - Accelerating Digital in PHC	40

• PHC: Primary Health Care. CEO: Specialized Dental Centers. eMulti: Multidisciplinary team. eSF: Family Health team. SUS: Brazilian Unified Health System. DICT: Digital Information and Communication Technologies.
• Source: Authors.

The courses are publicized through the official media channels of the university and SAPS-MS. Other opportunities for dissemination and course engagement incentive have included meetings with municipal managers and congresses of scientific societies and of Digital Health.

Under the direct influence of the UFMG School of Medicine’s involvement in managing the Educa e-SUS APS MOOC platform, a mandatory course was created in 2023 for medical students: Introduction to Primary Health Care II, offered in the third semester of the degree program, with 60 hours per semester. The syllabus involves Digital Health theory and practice for students in informatics laboratories, based on courses from the Health Professionals learning pathway and access to the e-SUS APS electronic medical record in training mode. In addition, it includes student participation in extension activities in PHC units²².

Learner assessment and monitoring strategies

Automated routines for individual learner monitoring were developed based on learners’ progress in performing tasks in the Moodle teaching environment. The stored data are used to signal the learner’s trajectory throughout the planned duration, enabling the issuance of the completion certificate. In addition, some routines signal the lack of progress when 90 days elapse without any learner activity.

To minimize course dropout, the MOOC environment incorporated the use of Artificial Intelligence in re-engagement strategies, which include identifying learners who started a course and completed at least the first class but then stopped accessing it for 90 days; extracting individualized data on platform use, identifying the tasks performed and the point at which the course was abandoned; and using Large Language Models (LLMs) to customize a re-engagement message. For this purpose, we developed prompt engineering that requires the learner’s first name, the position declared in PHC, the point in the training pathway at which the learner stopped, and the indication of the next content items not yet viewed. The customized encouragement message is then automatically sent to the learner’s registered personal email address²³.

In the learner assessment process, a set of mandatory tasks must be performed throughout the pathway. These tasks are developed based on a survey of the responsibilities or tasks that must be performed in PHC settings with the support of digital technology. These activities may be simple or complex, but characteristically, they must be performed safely, following the recommendations of Entrustable Professional Activities²⁴. The practical activities seek to verify the learner’s ability to address events from routine professional practice as well as unexpected events involving the use of the e-SUS APS Strategy software applications. Structured with advanced Moodle plugin resources, the practical activities of the courses provide the experience of learning by acting in situations that simulate workplace practices. They apply fundamental digital literacy concepts in the digital environment and show and make learners aware of the importance of technology-mediated interactions in professional, social, and cultural people-centered contexts. The mini-videos offer interactivity through a question that appears during playback.

Evaluation metrics and methods of analysis

At the end of each course, learners complete a questionnaire evaluating the teaching resources made available on the Educa e-SUS APS MOOC platform and the relevance of the content to professional practice. The complete de-identified database resulting from the first 20 months of the project was used to demonstrate the performance of the National Offer of Continuing Education Educa e-SUS APS by accounting for access entries, enrollments, completion certificates issued, municipality of origin, and pathway attended, which are also publicly available on the Educa e-SUS APS MOOC Platform¹⁸ under Educa in Numbers. The means of access to the courses and the performance of the distance-learning strategies used are also verified through specific questionnaire items.

People who access the educational environment are defined as learners when they register on the platform and complete at least one activity, and they may enroll in several courses. Enrollments comprise the total number of people enrolled in the courses, regardless of whether they are performing the activities or not. The average time users spend in a course on the platform is obtained by summing the average durations of stay in each access, as calculated by Google Analytics. Course completion is calculated using certificates issued as the numerator and the number of learners as the denominator, whereas the dropout rate is calculated as the ratio between the number of learners who have not accessed a course for more than 90 days and the total number of learners. Quantitative variables were described in terms of medians and interquartile ranges, and qualitative variables were presented as absolute and relative frequencies.

Results

Reach of the National Offer of Continuing Education Educa e-SUS APS

Between November 2023 and November 2025, 236,309 enrollments from 84,408 learners were recorded, reaching 5,111 municipalities across all Brazilian states. A total of 60,887 completion certificates were issued, and the dissemination of content through the Educa e-SUS APS platform is shown in Figure 2 as a geographic distribution, in which color intensity represents the density of people enrolled in a course, adjusted for the population of the state.

Figure 2
Distribution of enrollments on the Educa e-SUS APS platform, by state.

Among the PHC professional groups enrolled in the courses, the most frequent were ACS (n=12,835, 28%), nurses (n=4,061, 8.9%), and doctors (n=3,576, 7.8%). Among people without a professional connection with PHC, 5,219 (29.3%) sought the courses as complementary training. Also, most of the 5,111 municipalities reached (96.5%) have populations below 20,000 inhabitants.

The learner profile by municipal population size is shown in Table 1. In most learning pathways, learners were younger than 40 years, except in pathway 5, dedicated to ACS. Regarding schooling level, notably, Pathway 1, dedicated to higher education health professionals, attracted 7,065 (29.0%) individuals with completed secondary education, many of whom were undergraduate students.

Table 1
Educa e-SUS APS platform student profile.

	Age group (years)			Schooling (complete)			Municipality (inhabitants)
	18-40 n (%)	41-60 n (%)	> 60 n (%)	Up to High School	Higher Education	Post graduate	< 50,000	50,000 to 500,000	>500,000
Pathway 1	16,286 (66.8)	7,627 (31.2)	477 (2.0)	7,065 (29.0)	16,310 (66.9)	1,015 (4.2)	10,385 (42.6)	8,506 (34.9)	5,499 (22.5)
Pathway 2	3,194 (65.3)	1,577 (32.2)	119 (2.5)	1,217 (24.9)	3,412 (69.8)	261 (5.3)	2,228 (45.6)	2,068 (42.3)	594 (12.1)
Pathway 3	969 (61.3)	589 (37.3)	23 (1.4)	799 (50.5)	728 (46.0)	54 (3.4)	852 (53.9)	488 (30.9)	218 (15.2)
Pathway 4	895 (56.4)	655 (41.2)	38 (2.4)	381 (24.0)	1,091 (68.7)	116 (7.3)	734 (46.2)	586 (36.9)	268 (16.9)
Pathway 5	4,689 (44.8)	5,363 (51.2)	416 (4.0)	7,598 (72.6)	2,826 (27.0)	44 (0.4)	5,007 (47.8)	3,987 (38.1)	1,473 (14.1)
Pathway 6	1,318 (57.3)	930 (40.5)	51 (2.2)	1,882 (81.9)	406 (17.7)	11 (0.5)	1,289 (56.1)	792 (34.4)	218 (9.5)
Pathway 7	585 (52.8)	500 (45.1)	24 (2.2)	906 (81.7)	199 (17.9)	4 (0.4)	470 (42.4)	438 (39.5)	201 (18.1)

• Pathway 1: Health Professionals. Pathway 2: Oral Health Professionals. Pathway 3: Digital Information and Communication Technology Professionals. Pathway 4: People in Health Management. Pathway 5: PHC Health Workers. Pathway 6: PHC Health Technicians. Pathway 7: PHC Oral Health Technicians.
• Source: Authors.

The most frequent means of access to the Educa e-SUS APS MOOC platform was a personal computer (n=24,629, 41.1%), followed by mobile devices (n=23,251, 38.8%).

Perceived quality of the courses

The characteristics of the seven pathways, according to automated monitoring of the trajectories of the 60,887 learners who received completion certificates, are shown in Table 2. The number of people who abandoned the courses was 15,292 (18.1%).

Table 2
Quality of Educa e-SUS APS courses, by date of opening of the training pathway.

Training Pathway Opening name and date	Students	Completion certificate	Retention (min) 1	Dropout2	Content Relevance3	Educational Resources4
Total	84,371	60,351	60.3	15,292 (18.1%)	57,259 (94.9%)	56,230 (93.2%)
Health Professionals (11/2023)	46,163	33,790	61.7	8,802 (19.1%)	31,668 (93.7%)	30,945 (91.6%)
Oral Health Professionals (11/2023)	10,064	7,566	50.0	1,776 (17.6%)	7,211 (95.3%)	7,063 (93.3%)
PHC Health Technicians (04/2024)	4,751	3,490	50.0	730 (15.4%)	3,354 (96.1%)	3,335 (95.6%)
PHC Oral Health Technicians (04/2024)	1,588	1,190	66.0	278 (17.5%)	1,151(96.7%)	1,125(94.5%)
DICT Professionals (06/2024)	3,037	1,720	59	879 (28.9%)	1,642 (95.5%)	1,607 (93.4%)
People in Health Management (06/2024)	3,337	1,714	79.7	922 (27.6%)	1,673 (97.6%)	1,636 (95.4%)
PHC Health Workers (06/2025)	15,461	10,884	55.5	1,905 (12.3%)	10,560 (97.0%)	10,519 (96.6%)

• ¹Average time spent by students on the pathway platform. Average pathway course duration; ² Students without access for more than 90 days/Total number of students; ³ Extremely useful or very useful. Sum of pathway courses/Total number of graduates; ⁴ Extremely suitable or very suitable. Sum of pathway courses/Total number of graduates.
• Source: Authors.

Engagement and dissemination strategies

The intelligent conversational agent EDU had 7,899 interactions with visitors, of which 1,195 (15.1%) were converted to human support. The most frequent questions were related to how to enroll, how to generate a certificate, and inquiries about the courses, such as which courses exist, when a specific course starts, and how long a course can be accessed.

Regarding the automated strategy to mitigate course abandonment using text generated by artificial intelligence, 38,335 emails were sent to learners who had stopped using the Educa e-SUS APS MOOC platform for 90 days or more. This system recovered 4,498 (11.7%) learners, who returned to interact with the digital teaching environment.

A set of six e-books was published to broaden open access to the content of the courses in the Health Professionals pathways^11,25,26, Oral Health Professionals²⁷, Digital Information and Communication Technology Professionals, and People in Health Management^28,29. They are available in the Virtual Health Library and can be used even outside the MOOC environment. They are richly illustrated and include links to digital media such as podcasts and instructional mini-videos.

Discussion

The teaching-learning model adopted on the Educa e-SUS APS MOOC platform has sought to strengthen competencies that improve professional performance while also providing an opportunity for reflection and the adoption of good practices in the digital environment that supports PHC. The results obtained reveal the innovative nature of the initiative, which contributes to advancing knowledge about Digital Health in the country and highlights the importance of MOOC platforms in disseminating digital literacy. The digital literacy deficit among health professionals is a reality in national and international settings. A study with domain experts from 14 European countries highlighted the lack of training opportunities that promote the digital competencies of health professionals, where 39.6% reported the lack of formal training, although 95.8% of respondents reported using digital solutions in daily practice³⁰. In Brazil, the annual TIC-Saúde sample survey has highlighted advances in the adoption of digital technologies while also pointing to challenges in the training of health professionals. Only 23% of doctors reported some type of informatics training in 2024³¹. In a country as vast and heterogeneous in resources as Brazil, the Educa e-SUS APS continuing education offer’s largest audience is smaller municipalities, by which we can infer that opportunities for digital literacy among health professionals are fewer than in more populous municipalities. In addition, the online teaching environment has been used by undergraduate students who will enter the labor market with digital literacy.

Within the Brazilian SUS, there is an underlying premise that involves stakeholders from everyday work, which is pedagogical in itself, values prior knowledge, and provides a permanent school that strengthens the health system³². We interpreted the broad reach of open and accessible distance continuing education as the result of content developed and validated with the support of the target audience and of the combined use of educational resources recognized for stimulating adult learning³³, such as flexible access, self-direction, and meaningful content with motivational design. We should underscore to highlight that interest in the courses, assessed by the number of municipalities reached, exceeded the locations that use the e-SUS APS electronic medical record, which is also evidenced by the 5,219 learners who sought complementary training in Digital Health. Regarding international experiences, a study conducted in Portugal highlights the importance of using digital tools in national health-promotion strategies, emphasizing investment in a digital repository of resources and content made available to health professionals and citizens³⁴. Notably, we aligned with this same premise by offering permanent reference material that gathers the contents and access to the media used in the learning pathways of the Educa e-SUS APS MOOC platform in the Ministry of Health’s Virtual Health Library^11,25-29.

Another relevant element was the development of a digital environment with a pleasant and motivating visual design. Digital technology has changed the very way knowledge is disseminated, especially in distance learning and learning itself. Internet users read quickly the information presented in an online interface and are less willing to engage in in-depth reading, behaviors studied in the field of human-computer interaction³⁵, and considered from the moment the courses were developed. Visual hierarchy in interfaces considers human perception as favorable to receiving information based on visual codes expressed in the definition of typography, the choice of colors and bolding, and the visual arrangement between text and complementary elements such as images, boxes, captions, and infographics²⁹. In this regard, we created customized illustrations aligned with PHC-specific scenarios and personas, infographics, podcasts, and mini-videos, as well as more objective texts with color highlights, preferably presenting examples that translate concepts into practice. The e-SUS APS electronic medical record interface itself is used on many occasions throughout the learning pathways, giving meaning to the content presented. The media and design resources highlight the essential elements of digital health literacy and were created to arouse learners’ interest in solving problems from their daily professional routine, such as data quality, digital security, and interoperability between systems.

Encouraging learners to remain in the environment was promising, reaching an average of 60.6 minutes per access and 81.9% retention (18.1% dropout), a high value compared with the 10% retention found in other well-established professional MOOC platforms³⁶. Although MOOCs are considered by many to be a revolution in education, they face numerous challenges besides and low persistence: technological barriers, learners’ time management for study, lack of direct interaction with the tutor, and ergonomic issues associated with platform usability³⁷. Evidence demonstrating learning over time and its impacts in the professional environment remains scarce¹³, which is also a limitation of the analysis conducted in our study.

The use of Artificial Intelligence resources in MOOCs has emerged as an alternative for promoting greater interaction between the educational environment and its users, especially approaches involving natural language processing such as LLMs³⁸. Technology has changed the way people interact in MOOCs, especially when systems are trained to communicate in natural language, as with intelligent conversational agents³⁹. The results of the virtual assistant EDU in guiding visitors on the Educa e-SUS APS MOOC platform are striking because of its ability to generate a response without direct human support in 85.8% of interactions. In a very large target audience, with courses permanently open and enrollments increasing, a language-model-enhanced front line has the advantage of promptly answering the simplest questions, reserving only unsatisfactory responses for human support. A current limitation of the virtual assistant EDU is that it was not trained on the courses’ knowledge base; therefore, it is not capable of answering conceptual or practical questions related to the e-SUS APS environment. Involving a major transdisciplinary effort, a conversational agent with greater intelligence capabilities to support questions related to the software applications of the e-SUS APS Strategy is under development⁴⁰.

The use of machine-learning models to predict dropout in MOOCs has been reported in the scientific literature³⁹. However, the strategy of developing personalized messages with the support of LLMs to mitigate dropout rates remains a little-explored topic. Longer follow-up of the MOOC platform and more in-depth investigation of the causes of dropout will still be necessary, as these are often associated with limited access to digital technologies, insufficient time in the work environment, and lack of motivation, among other factors⁴¹.

Our results show the broad reach of this training strategy, structured to support digital acceleration in PHC through a partnership between academia and government, with direct support from managers of the municipalities involved in the curation process. The reach of PHC professionals in most of Brazilian municipalities, already within the first 24 months after the national opening of the courses, reveals how MOOC environments can contribute to large-scale professional development in the health sector.

References

• ¹ Singh V, Singh A. Digital Health Revolution: Enhancing Well-Being Through Technology. In: Nadda V, Tyagi PK, Vieira RM, Tyagi P. Implementing Sustainable Development Goals in the Service Sector [Internet]. 2023 [cited 2025 jul 23]. p. 213-219. Available from: https://services.igi-global.com/resolvedoi/resolve.aspx?doi=10.4018/979-8-3693-2065-5.ch016
  » https://services.igi-global.com/resolvedoi/resolve.aspx?doi=10.4018/979-8-3693-2065-5.ch016
• ² Powell J, Arvanitis TN. Welcome to the Digital Health revolution. Digit Health [Internet]. 2015 [cited 2025 jul 23]. Available from: https://journals.sagepub.com/doi/10.1177/2055207614561571
  » https://journals.sagepub.com/doi/10.1177/2055207614561571
• ³ World Health Organization (WHO). Global strategy on digital health 2020-2025 [Internet]. 2021 [cited 2023 abr 8]. Available from: https://apps.who.int/iris/handle/10665/344249
  » https://apps.who.int/iris/handle/10665/344249
• ⁴ Brasil. Ministério da Saúde (MS). Secretaria-Executiva. Departamento de Informática do SUS. Estratégia de Saúde Digital para o Brasil 2020-2028. [Internet]. 2020 [acessado 2023 abr 8]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/estrategia_saude_digital_Brasil.pdf
  » https://bvsms.saude.gov.br/bvs/publicacoes/estrategia_saude_digital_Brasil.pdf
• ⁵ Brasil. Portaria GM/MS no 3.232, de 1o de março de 2024. Altera a Portaria de Consolidação GM/MS nº 5, de 28 de setembro de 2017, para instituir o Programa SUS Digital. Diário Oficial da União 2024; 4 mar.
• ⁶ Celuppi IC, Mohr ETB, Felisberto M, Rodrigues TS, Hammes JF, Cunha CL, Wazlawick RS, Dalmarco EM. Dez anos do Prontuário Eletrônico do Cidadão e-SUS APS: em busca de um Sistema Único de Saúde eletrônico. Rev Saude Publica 2024; 58(1):23.
• ⁷ Brasil. Ministério da Saúde (MS). Secretaria de Atenção Primária do Ministério da Saúde. Sistema de Informação em Atenção Primária à Saúde - Siaps [Internet]. 2025 [acessado 2025 abr 8]. Disponível em: https://sisaps.saude.gov.br/sistemas/siaps/.
  » https://sisaps.saude.gov.br/sistemas/siaps
• ⁸ Brasil. PEC e-SUS APS [Internet]. 2024 [acessado 2025 abr 8]. Disponível em: https://sisaps.saude.gov.br/esus/.
  » https://sisaps.saude.gov.br/esus
• ⁹ Brasil. Ministério da Saúde (MS). Número de usuários dos aplicativos e-SUS APS [Internet]. [acessado 2025 jul 28]. Disponível em: https://play.google.com/.
  » https://play.google.com
• ¹⁰ Shaw RJ. Access to Technology and Digital Literacy as Determinants of Health and Health Care. Creat Nurs 2023; 29(3):258-263.
• ¹¹ Reis ZSN. Panorama da Saúde Digital na APS: Educação permanente para enfermeiros, médicos da equipe de saúde da família, cirurgiões-dentistas e equipes multiprofissionais. Belo Horizonte: Biblioteca J. Baeta Vianna; 2023. (Educa e-SUS APS).
• ¹² Liyanagunawardena TR, Williams SA. Massive Open Online Courses on Health and Medicine: Review. J Med Internet Res 2014; 16(8):e191.
• ¹³ Burd EL, Smith SP, Reisman S. Exploring Business Models for MOOCs in Higher Education. Innov High Educ 2015; 40(1):37-49.
• ¹⁴ Brasil. Portaria GM-MS no 1.996, de 20 de agosto de 2007. Dispõe sobre as diretrizes para a implementação da Política Nacional de Educação Permanente em Saúde. Diário Oficial da União; 2007.
• ¹⁵ Talmon J, Ammenwerth E, Brender J, Dekeizer N, Nykanen P, Rigby M. STARE-HI-Statement on reporting of evaluation studies in Health Informatics. Int J Med Inf 2009; 78(1):1-9.
• ¹⁶ Universidade Federal de Minas Gerais (UFMG). Política de Privacidade da Oferta Educa e-SUS APS [Internet]. 2025 [acessado 2025 nov 26]. Disponível em: https://educaesusaps.medicina.ufmg.br/termos.php
  » https://educaesusaps.medicina.ufmg.br/termos.php
• ¹⁷ Universidade Federal de Minas Gerais (UFMG). Termos de Uso da Oferta Educa e-SUS APS [Internet]. 2025 [acessado 2025 nov 26]. Disponível em: https://educaesusaps.medicina.ufmg.br/politicas.php
  » https://educaesusaps.medicina.ufmg.br/politicas.php
• ¹⁸ Universidade Federal de Minas Gerais (UFMG). Plataforma MOOC Educa e-SUS APS [Internet]. [acessado 2025 nov 26]. Disponível em: https://educaesusaps.medicina.ufmg.br/.
  » https://educaesusaps.medicina.ufmg.br
• ¹⁹ Sociedade Brasileira de Informática em Saúde, Gumiel YB, Oliveira IJR, Pagano A, Reis ZSN. Leveraging large language models to enhance a question-answering system for a Massive Open Online Course (MOOC) In: Anais Estendidos do XX Congresso Brasileiro de Informática em Saúde - CBIS24 [Internet]. 2024 [cited 2025 jul 25]. Available from: https://zenodo.org/doi/10.5281/zenodo.14175656
  » https://zenodo.org/doi/10.5281/zenodo.14175656
• ²⁰ Srivastava A, Bhardwaj S, Saraswat S. SCRUM model for agile methodology. In: 2017 International Conference on Computing, Communication and Automation (ICCCA) [Internet]. 2017 [cited 2024 dez 7]. p. 864-869. Available from: http://ieeexplore.ieee.org/document/8229928/.
  » http://ieeexplore.ieee.org/document/8229928
• ²¹ Jimenez G, Spinazze P, Matchar D, Koh Choon Huat G, Van Der Kleij RMJJ, Chavannes NH, Car J. Digital health competencies for primary healthcare professionals: A scoping review. Int J Med Inf 2020; 143:104260.
• ²² Brasil. Curso de Medicina, versões curriculares [Internet]. 2024 [acessado 2025 jul 28]. Disponível em: https://www.medicina.ufmg.br/cegrad/wp-content/uploads/sites/102/2024/09/Versao-Curricular-2024-2.pdf
  » https://www.medicina.ufmg.br/cegrad/wp-content/uploads/sites/102/2024/09/Versao-Curricular-2024-2.pdf
• ²³ Lebeis GM, Oliveira, Juliana Lara, Oliveira IJR, Reis ZSN. Avaliação do uso de IA em estratégia de recuperação de cursistas não concluintes em MOOC: Educa e-SUS APS [Internet]. 2024 [acessado 2025 jul 25]. Disponível em: https://repositorio.ufmg.br/bitstream/1843/78914/1/AnaisSimposio2024.pdf#page=46
  » https://repositorio.ufmg.br/bitstream/1843/78914/1/AnaisSimposio2024.pdf#page=46
• ²⁴ Cate OT. Guia Atualizado sobre Atividades Profissionais Confiáveis (APCs). Rev Bras Educ Med 2019; 43(1 Supl. 1):712-720.
• ²⁵ Reis ZSN, editor. Registro de Saúde na APS: Educação permanente para enfermeiros, médicos da equipe de saúde da família, cirurgiões-dentistas e equipes multiprofissionais. Belo Horizonte: Biblioteca J. Baeta Vianna; 2024. (Educa e-SUS APS; vol. 1).
• ²⁶ Reis ZSN. O sistema E-SUS APS para profissionais de saúde: educação permanente para enfermeiros, médicos da equipe de saúde da família e equipes multiprofissionais. Belo Horizonte: Biblioteca J. Baeta Vianna; 2024. (Educa e-SUS APS).
• ²⁷ Reis ZSN. O sistema E-SUS APS para profissionais de saúde bucal: educação permanente para cirurgiões-dentistas da equipe de saúde bucal e centros de especialidades odontológicas. Belo Horizonte: Biblioteca J. Baeta Vianna; 2024. (Série Educa E-SUS APS).
• ²⁸ Reis ZSN, Reis GS, Pagano AS, Oliveira IJR, Aguiar RALP. Qualidade de dados e segurança digital na APS: Educação permanente para pessoas na gestão da atenção primária à saúde, gerentes de unidades de saúde e profissionais de tecnologia digital de informação e comunicação. Belo Horizonte: Biblioteca J. Baeta Vianna; 2025.
• ²⁹ Reis ZSN, Pagano AS, Oliveira IJR, Aguiar RALP. Aceleração para Saúde Digital na APS: educação permanente para gestores de saúde e profissionais de tecnologias digitais da informação e comunicação da APS. Belo Horizonte: Biblioteca J. Baeta Vianna; 2024.
• ³⁰ Protogiros D, Tsitsi T, Cloconi C, Nicolaidou I, Kyriacou E, Couespel N, Moreno-Alonso D, Carrión C, Claveria A, Charalambous A. Mapping and Assessing Existing Digital Skills Training Programs for Health Care Professionals and Health Managers in Europe: Expert-Based Survey for Investigating the Landscape, Accessibility, and Effectiveness of Training Initiatives. J Med Internet Res 2025; 27:e71657.
• ³¹ Núcleo de Informação e Coordenação do Ponto BR, Barbosa AF, Velloso P. Survey on the use of information and communication technologies in Brazilian healthcare facilities: ICT in Health 2024. São Paulo: Núcleo de Informação e Coordenação do Ponto BR; 2025.
• ³² Higashijima MNS, Slomp Junior H, Ferla AA, Feuerwerker LCM, Merhy EE, Ceccim RB, Vasconcelos J, Carli AD, Santos MLMD. Princípios e características da Educação Permanente em Saúde: resgate e resistência em favor de um SUS potente e em defesa da vida. Cien Saude Colet 2025; 30(Supl. 1):e05902023.
• ³³ Stubbé HE, Theunissen NCM. Self-directed adult learning in a ubiquitous learning environment: A meta-review. Proc Spec Track Technol Support Self-Organised Learn 2008; 5-28.
• ³⁴ Costa AS, Arriaga M, Mendes RV, Miranda D, Barbosa P, Sakellarides C, Peralta A, Lopes NA, Roque C, Ribeiro S. A Strategy for the Promotion of Health Literacy in Portugal, Centered around the Life-Course Approach: The Importance of Digital Tools. Port J Public Health 2019; 37(1):50-54.
• ³⁵ Dias JM. Estratégias de avaliação para o desenvolvimento de MOOC - Massive Open Online Course. Rev Meta Aval 2021; 13(38):101.
• ³⁶ Greene JA, Oswald CA, Pomerantz J. Predictors of Retention and Achievement in a Massive Open Online Course. Am Educ Res J 2015; 52(5):925-955.
• ³⁷ Cheng C, Papadakos J, Umakanthan B, Fazelzad R, Martimianakis MAT, Ugas M, Giuliani ME. On the advantages and disadvantages of virtual continuing medical education: a scoping review. Can Med Educ J 2023; 14(3):41-74.
• ³⁸ Li C, Xing W. Natural Language Generation Using Deep Learning to Support MOOC Learners. Int J Artif Intell Educ 2021; 31(2):186-214.
• ³⁹ Mzwri K, Turcsányi-Szabó M. Chatbot Development using APIs and Integration into the MOOC. Cent-Eur J New Technol Res Educ Pract 2023; 5(1):18-30.
• ⁴⁰ Asevedo RA, Isaias JRO, Polidoro JAP, Magalhães GR, Andrade CMV, Viterbo JP, Pagano AS, Gonçalves MA, Reis ZSN. Desenvolvimento de uma taxonomia de suporte para um Faq-Chatbot inteligente de suporte ao usuário do sistema e-SUS APS [Internet]. 2025 [acessado 2025 jul 30]. Disponível em: https://portal.bridge.ufsc.br/wp-content/uploads/2025/07/16.pdf
  » https://portal.bridge.ufsc.br/wp-content/uploads/2025/07/16.pdf
• ⁴¹ Goopio J, Cheung C. The MOOC dropout phenomenon and retention strategies. J Teach Travel Tour 2021; 21(2):177-197.

• Funding
  Decentralized Execution Agreement 31/2022 between the Primary Care Secretariat of the Ministry of Health and the UFMG Faculty of Medicine.
• Data availability statement
  The data sources adopted in the research are indicated in the article’s body.

• Chief editors:
  Maria Cecília de Souza Minayo, Romeu Gomes, Antônio Augusto Moura da Silva, Vania de Matos Fonseca

Data availability

The data sources adopted in the research are indicated in the article’s body.

Publication Dates

• Publication in this collection
  29 June 2026
• Date of issue
  May 2026

History

• Received
  07 Aug 2025
• Accepted
  18 Dec 2025
• Published
  20 Dec 2025