internet based learning and accessiblity in psycho-oncology

Department of Psychosocial Cancer Research

Internet based learning and accessibility in psycho-oncology

Mette Terp Høybye, MSc., PhD studentmetteh@cancer.dk

Christoffer Johansen, MD, PhD., DMSc

Department of Psychosocial Cancer ResearchInstitute of Cancer Epidemiology

Copenhagen, Denmark

Department of Psychosocial Cancer Research

Internet access

World: 1 billion internet usersA total of 16 % of global population has access

Some 50% of European population has access Romania: 2 %

Czech Republic: 47%Sweden: 75 %

USA and Canada: A total of 68% has access

Africa: <1% has accessSierre Leone: 0.03 %

(CIA World Factbook, 2005)

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Equity – the biggest challenge

High income countries:• 16% population• 7 % burden of disease• 89% health spending• 94 % internet hosts

Low income countries:• 84% population• 93 % burden of disease• 11% health spending• 6 % internet hosts

(WHO HINARI project, 2002)

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Access to technologyNew pathways of communication• GMS (Global System for Mobile Communication) and 3G –

1,6 billion users world wide (70% of the market)• Domination in Europe, Russia, Africa and the Middle East• Similar accessible mobile systems (cdmaOne) – Asia, North

and South America

• Access to internet through new mobile systems will widen traditional access

• Mobile access is less expensive to establish than traditional, cable based access

• Perspectives for use of the internet in remote, poor areas widen

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Searching for health information online

Americans51%

Europeans23%

(12-47%)

(Pew Internet & American Life Project, 2005;EUBAROMETER 58.0; European Opinion Research group, 2003)

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Spain14%

France15%

Italy23% Greece

12%

Germany24%

Denmark47%UK

29% Netherlands41%

Portugal14%

Finland 36%

Sweden39%

Austria31%

Belgium21%

Ireland23%

EU Average23 %

Luxembourg32%

New Member States23%

Internet use for health in the EU

(EUBAROMETER 58.0; European Opinion Research group, 2003)

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Language diversity

• English: dominant language of the internet – est. 45%– Internet users by language: English is dominant

• Information practically inaccessible to a large number of persons in non-English-speaking regions

• Proportion of English-language websites decreasing –as other web-populations grow

(Paolillo, Pimienta, Prado et al., UNESCO, 2005)

• Language as barrier to access – need for multilingual efforts - as the IPOS Core Curriculum

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How many cancer patients go on-line?

Estimated 39 % of peoplewith cancer in the developedworld use theinternet

Estimated 15-20 % of people with cancer use the internet “indirectly” through family and friends

(Eysenbach, 2003)

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Internet in clinical practiceSelf-report of symptoms among cancer patients

• Web-based patient reporting of toxicity symptoms during chemotherapy (Basch et al. 2005)

– Useful means to monitor toxicity symptoms• Information system – patient / provider (van Den Brink et al. 2005)

– Enabled early detection of health problems that required direct intervention

• Self-reporting improves patient satisfaction– Increase sense of empowerment– More control of own care

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• Ongoing randomised intervention study

• ”Internet based support in the rehabilitation of cancer patients”

• A multidisciplinary study – epidemiology and anthropology

• Department of Psychosocial Cancer Research, Copenhagen, Denmark

Internet intervention – Denmark

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Internet intervention – Denmark

• Including 1000 persons with cancer• 500 persons receive internet intervention

– Patient education on internet information– Internet self-support group

• Patient empowerment – Internet groups forming ways of action

• Strengthen the adjustment to cancer• Evaluate effect of internet communication on

health behaviour

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Internet based support

• Access to the internet offers a possibility to extend social support between cancer patients

• Randomised studies:– Participation in internet support groups

significantly reduces the prevalence of depression and perceived stress

– Increase information competence– Improve self-perceived health

(Gustafson et al. 2001; Winzelberg et al. 2003; Owen et al. 2005)

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Social inequality in use

• Data from non-randomised pilot phase– Aim: Identify social and psychological

characteristics, which determine the use of internet groups

• Based on 215 Danish cancer patients• Particular pursue to investigate who are not

inclined to enter internet based interventions

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Participants

• Inclusion: 1 July to 1 October 2003 and 1 January to 18 April 2004

• 230 cancer patients from public paid rehabilitation course at a national cancer rehabilitation centre in Denmark

• 15 participants did not return questionnaire• 215 eligible participants

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Participants

• 82% (n=176) participated in an introductory lecture

• Invitation for participation in one of 12 internet groups

• 1 August 2004 a total of 101 participants (47%) had actively used the internet group assigned to them, at least once

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Questionnaire

• Information on socio-demographic and psychological variables reported in self-administered questionnaire

• Baseline = 2 weeks prior to the intervention

• Analysis compared differences in baseline characteristics between internet group users (n=101) and non-users (n=114)

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42

43

15

58 (37-84)

Non-users; N=114

%

57Higher education (ISCED: 4-6)

35Youth education (ISCED: 3)

8 Basic education (ISCED: 1-2)

0.06Education

0.7450 (35-85)Mean age – years (range)

p-valueInternet users; N=101

%

Age and Education

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Gender

15

85

Non-users; N=114

%

p-valueInternet-users; N=101

%

10Men

90Women

0.27Gender

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11

142550

Non-users; N=114

%

6Single

3Widowed

12Divorced78Married or co-habiting

0.0005Marital status

p-valueUsers; N=101

%

Marital Status

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186

3839

Non-users;

N=114 %

29High (≥ 91,000 $)

19Do not wish to answer

44Medium (41,000 - 90,000 $)

9Low (0 - 40,000 $)

<.0001Household income

p-valueInternet users; N=101

%

Household Income

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10

6

43446

Non-users; N=114

%

3Sick leave

< 0.001Employment status83Working4Pensioner

3Unemployed

5 Other *

p-valueUsers; N=101

%

*Persons outside the labor market for reasons other than unemployment or illness - e.g. housewife, student, maternity leave

Employment Status

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Psychological Measures

0.42750.529215 (22.8)16 (22.8)Total mood disturbance

n =103n = 99POMSb

0.16560.759875 (20.3)75 (20.0)Quality of lifen = 111n = 100EORTCa

Adjusted*CrudeNon-users

median (SD)

Usersmedian

(SD)

Subscale / itemScale

a The European Organization for Research and Treatment of Cancer QLQ-C30 (Aronson et al., 1993)b Profile of Mood States scale (McNair and Lorr, 1971)* p value adjusted for age, education, gender, household income, marital status and employment status.

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Psychological Measures

0.78330.732111 (2.2)12 (2.1)Fighting spirit0.17430.008814 (2.3)13 (2.2)Fatalism

0.02820.000910 (2.1)9 (2.3)Cognitive avoidance

0.47860.687620 (5.2)20 (5)Anxious preoccupation

0.48420.097814 (4.3)12 (4.2)Helplessness-hopelessness

n = 98n = 94Mini MACc

Adjusted*CrudeNon-users

median (SD)

Usersmedian

(SD)

Subscale / itemScale

c Mental Adjustment to Cancer scale (Watson et al., 1994)

* p value adjusted for age, education, gender, household income, marital status and employment status

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Conclusion - Barriers

• Socio-economic gap – users / non-users – Issue of social position– Mainly determined by economic resources and active

participation in the work market – Related specifically to access

• Barriers to address – mainly social

• Internet technology does not support groups of underserved cancer patients unless we make a specific effort to include this group

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But how is the internet used by health professionals?

– Access

– Barriers

– Solutions

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E-learning – health professionals

• General objectives for introducing e-learning:– Web-based learning = effective learning– Convenient and cost-effective (for all)

• In recent years e-learning introduced in different professional settings:– Teaching component of undergraduate medical

curriculum– Continuing education (medicine + nursing)– Training of health professionals in rural settings

(Wutoh et al., 2004; Clarke et al., 2005; Li et al., 2005; Atack & Rakin, 2002; Brudo & Walsh, 2002 )

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Assessments of e-learning

• Review of effect of internet-based continuing medical education on physician performance and health care outcomes

– 16 eligible randomised studies – 9 studies found positive changes in participant

knowledge or change in practices over traditional formats

– 7 studies found no change(Wutoh et al., 2004)

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Assessments of e-learning

• Internet-based programmes are just as effective in imparting knowledge as traditional formats

• Relation of changes in knowledge to changes in practice – results limited

Internet-based learning

(Wutoh et al., 2004)Practice

Change knowledgeCHANGE ?

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Barriers – e-learning for professionals

• Requirement for change

• Access to computer / internet

• Cost of producing e-learning resources

• Poorly designed packages / inadequate technology

• Lack of skills – computer literacy

• Computer anxiety(Childs et al., 2005)

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Possible solutions – e-learning for professionals

• Clear strategies – and standardisations

• Integration of e-learning into a core curriculum

• Blended teaching (web-based + in-person)

• User friendly packages

• Access to technology + computer/ internet skills training

• Dedicated work time for e-learning - acknowledgement(Childs et al., 2005)

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E-learning in psycho-oncology

• Challenges– Access to information communication technology (ICT)– Linguistic diversity– Environments for information and communication

• Opportunities– Policy to enhance quality– Partnership and best practice

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Initiatives for e-learning and e-health

• IPOS/ ESO Core Curriculum• WHO – HINARI program (Health InterNetwork Access to

Research Initiative )– Free / low cost access to over 3421 journal titles

available to health institutions in 113 countries– HINARI India pilot project (http://www.hin.org.in/)

• ESO – ’The New York Statement’: Using ICT and the internet to optimise cancer control– Increased focus of internet as resource in cancer control– Spin off local and global initiatives in research and

practice

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Opportunity – enhancing quality

”Without computers and the internet, we are fighting 21st century health problems with 19th century tools”Tuberculosis field officer, Orissa, India

New and old record-keeping systems side by side at a PHC, Orissa

(Photo kindly lend by WHO HINARI India project )

E-learning initiatives in training healthcare professional –possible impact on quality of treatment and care