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 [email protected]

Christoffer Johansen, MD, PhD., DMSc

Department of Psychosocial Cancer ResearchInstitute of Cancer Epidemiology

Copenhagen, Denmark


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)


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)


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


Searching for health information online

Americans51%

Europeans23%

(12-47%)

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


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)


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


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)


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


• 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


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


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)


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


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


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


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)


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


Gender

15

85

Non-users; N=114

%

p-valueInternet-users; N=101

%

10Men

90Women

0.27Gender


11

142550

Non-users; N=114

%

6Single

3Widowed

12Divorced78Married or co-habiting

0.0005Marital status

p-valueUsers; N=101

%

Marital Status


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


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


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.


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


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


But how is the internet used by health professionals?

– Access

– Barriers

– Solutions


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 )


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)


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 ?


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)


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)


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


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


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

Health & Medicine

Internet based learning and accessiblity in psycho-oncology