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
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