Internet based learning and
accessibility in psycho-oncology
Mette Terp Høybye, MSc., PhD student
metteh@cancer.dk
Christoffer Johansen, MD, PhD., DMSc
Department of Psychosocial Cancer Research
Institute of Cancer Epidemiology
Copenhagen, Denmark
Department of Psychosocial Cancer Research

Internet access
World: 1 billion internet users
A total of 16 % of global population has access
Some 50% of European population has access
Romania: 2 %
Czech Republic: 47%
Sweden: 75 %
Africa: <1% has access
USA and
Sierre Leone: 0.03 %
Canada:
A total of 68%
has access (CIA World Factbook, 2005)
Department of Psychosocial Cancer Research

Equity – the biggest challenge
High income countries: Low income countries:
• 16% population • 84% population
• 7 % burden of disease • 93 % burden of disease
• 89% health spending • 11% health spending
• 94 % internet hosts • 6 % internet hosts
Department of Psychosocial Cancer Research
(WHO HINARI project, 2002)

Access to technology
New 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
Europeans
Americans 23%
51% (12-47%)
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(Pew Internet & American Life Project, 2005;
EUBAROMETER 58.0; European Opinion Research group, 2003)

Internet use for health in the EU
EU Average Finland
36%
23 %
Sweden
39%
Denmark
47%
Ireland UK
23% Netherlands
29%
41%
New Member
Belgium Germany
21% 24%
States
Austria
31%
France 23%
15%
Luxembourg Italy
32% 23%
Spain Greece
Portugal
14% 12%
14%
(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 Estimated
39 % of people 15-20 % of people
with cancer in with cancer use the
the developed internet “indirectly”
world use the through family and
internet friends
(Eysenbach, 2003)
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Internet in clinical practice
Self-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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Internet intervention – Denmark
• 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
Department of Psychosocial Cancer Research

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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Age and Education
p-value
Internet users; Non-users;
N=101 N=114
% %
Mean age – years (range) 50 (35-85) 58 (37-84) 0.74
Education 0.06
15
8
Basic education (ISCED: 1-2)
35 43
Youth education (ISCED: 3)
57 42
Higher education (ISCED: 4-6)
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Gender
p-value
Internet-users; Non-users;
N=101 N=114
% %
Gender 0.27
Women 90 85
Men 10 15
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Marital Status
p-value
Users; Non-users;
N=101 N=114
% %
Marital status 0.0005
Married or co-habiting 78 50
Divorced 12 25
Single 6 14
Widowed 3 11
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Household Income
p-value
Internet Non-users;
users;
N=101 N=114
%
%
<.0001
Household income
9 39
Low (0 - 40,000 $)
44 38
Medium (41,000 - 90,000 $)
High (≥ 91,000 $) 29 6
19 18
Do not wish to answer
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Employment Status
p-value
Users; Non-users;
N=114
N=101
%
%
Employment status < 0.001
Working 83 46
Pensioner 4 34
Sick leave 3 4
Unemployed 3 6
Other * 5 10
*Persons outside the labor market for reasons other than unemployment or
illness - e.g. housewife, student, maternity leave
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Psychological Measures
Users Non-users
Subscale /
Scale Crude Adjusted*
median median
item
(SD) (SD)
EORTCa n = 100 n = 111
Quality of life 75 (20.0) 75 (20.3) 0.7598 0.1656
POMSb n = 99 n =103
Total mood
16 (22.8) 15 (22.8) 0.5292 0.4275
disturbance
The European Organization for Research and Treatment of Cancer QLQ-C30 (Aronson et al., 1993)
a
Profile of Mood States scale (McNair and Lorr, 1971)
b
* p value adjusted for age, education, gender, household income, marital status and employment status.
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Psychological Measures
Users Non-users
Subscale /
Scale median median Crude Adjusted*
item
(SD) (SD)
Mini
n = 94 n = 98
MACc
Helplessness-
12 (4.2) 14 (4.3) 0.0978 0.4842
hopelessness
Anxious
20 (5) 20 (5.2) 0.6876 0.4786
preoccupation
Cognitive
9 (2.3) 10 (2.1) 0.0009 0.0282
avoidance
Fatalism 13 (2.2) 14 (2.3) 0.0088 0.1743
Fighting spirit 12 (2.1) 11 (2.2) 0.7321 0.7833
Mental Adjustment to Cancer scale (Watson et al., 1994)
c
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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
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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
Change knowledge
CHANGE ?
Internet-based
learning
Practice
(Wutoh et al., 2004)
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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,
New and old record-keeping systems side by
Orissa, India
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
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