Internet based learning and
            accessibility in psycho-oncology

                          Mette Terp Høybye, MSc...
Internet access

                     World: 1 billion internet users
                     A total of 16 % of global popul...
Equity – the biggest challenge




    High income countries:                   Low income countries:
    • 16% population...
Access to technology
    New pathways of communication
    • GMS (Global System for Mobile Communication) and 3G –
      1...
Searching for health information online




                                                     Europeans
         Americ...
Internet use for health in the EU

      EU Average                                                         Finland
      ...
Language diversity

  • English: dominant language of the internet – est. 45%
     – Internet users by language: English i...
How many cancer patients
                        go on-line?

    Estimated                                Estimated
    3...
Internet in clinical practice
 Self-report of symptoms among cancer patients

 • Web-based patient reporting of toxicity s...
Internet intervention – Denmark
    • Ongoing randomised intervention study

    • ”Internet based support in the rehabili...
Internet intervention – Denmark

    • Including 1000 persons with cancer
    • 500 persons receive internet intervention
...
Internet based support
    • Access to the internet offers a possibility to
      extend social support between cancer
   ...
Social inequality in use

    • Data from non-randomised pilot phase
      – Aim: Identify social and psychological
      ...
Participants
 • Inclusion: 1 July to 1 October 2003 and 1 January
   to 18 April 2004

 • 230 cancer patients from public ...
Participants

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

• Invitation for participation in one of 12 interne...
Questionnaire

     • Information on socio-demographic and
       psychological variables reported in self-
       adminis...
Age and Education
                                                                          p-value
                      ...
Gender

                                                               p-value
                                Internet-us...
Marital Status

                                                                   p-value
                               ...
Household Income

                                                                     p-value
                           ...
Employment Status
                                                                     p-value
                           ...
Psychological Measures

                                             Users       Non-users
                      Subscale ...
Psychological Measures
                                                 Users        Non-users
                           ...
Conclusion - Barriers
• Socio-economic gap – users / non-users
   – Issue of social position
   – Mainly determined by eco...
But how is the internet used by health
                      professionals?

                                             ...
E-learning – health professionals

• General objectives for introducing e-learning:
  – Web-based learning = effective lea...
Assessments of e-learning

 • Review of effect of internet-based continuing medical
   education on physician performance ...
Assessments of e-learning
 • Internet-based programmes are just as effective in
   imparting knowledge as traditional form...
Barriers – e-learning for professionals

    • Requirement for change

    • Access to computer / internet

    • Cost of ...
Possible solutions – e-learning for
                        professionals
 • Clear strategies – and standardisations

 • I...
E-learning in psycho-oncology

 • Challenges
       – Access to information communication technology (ICT)
       – Lingui...
Initiatives for e-learning and e-health
    • IPOS/ ESO Core Curriculum
    • WHO – HINARI program (Health InterNetwork Ac...
Opportunity – enhancing quality

                                                        ”Without computers
              ...
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Internet based learning and accessiblity in psycho-oncology

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Internet based learning and accessiblity in psycho-oncology

  1. 1. 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
  2. 2. 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
  3. 3. 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)
  4. 4. 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 Department of Psychosocial Cancer Research
  5. 5. Searching for health information online Europeans Americans 23% 51% (12-47%) Department of Psychosocial Cancer Research (Pew Internet & American Life Project, 2005; EUBAROMETER 58.0; European Opinion Research group, 2003)
  6. 6. 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) Department of Psychosocial Cancer Research
  7. 7. 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 Department of Psychosocial Cancer Research
  8. 8. 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) Department of Psychosocial Cancer Research
  9. 9. 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 Department of Psychosocial Cancer Research
  10. 10. 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
  11. 11. 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 Department of Psychosocial Cancer Research
  12. 12. 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) Department of Psychosocial Cancer Research
  13. 13. 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 Department of Psychosocial Cancer Research
  14. 14. 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 Department of Psychosocial Cancer Research
  15. 15. 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 Department of Psychosocial Cancer Research
  16. 16. 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) Department of Psychosocial Cancer Research
  17. 17. 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) Department of Psychosocial Cancer Research
  18. 18. Gender p-value Internet-users; Non-users; N=101 N=114 % % Gender 0.27 Women 90 85 Men 10 15 Department of Psychosocial Cancer Research
  19. 19. 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 Department of Psychosocial Cancer Research
  20. 20. 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 Department of Psychosocial Cancer Research
  21. 21. 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 Department of Psychosocial Cancer Research
  22. 22. 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. Department of Psychosocial Cancer Research
  23. 23. 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 Department of Psychosocial Cancer Research p value adjusted for age, education, gender, household income, marital status and employment status *
  24. 24. 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 Department of Psychosocial Cancer Research
  25. 25. But how is the internet used by health professionals? – Access – Barriers – Solutions Department of Psychosocial Cancer Research
  26. 26. 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 ) Department of Psychosocial Cancer Research
  27. 27. 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) Department of Psychosocial Cancer Research
  28. 28. 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) Department of Psychosocial Cancer Research
  29. 29. 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) Department of Psychosocial Cancer Research
  30. 30. 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) Department of Psychosocial Cancer Research
  31. 31. 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 Department of Psychosocial Cancer Research
  32. 32. 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 Department of Psychosocial Cancer Research
  33. 33. 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 Department of Psychosocial Cancer Research

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