Interactivity, Presence, and Targeted Patient Care: Mapping e-Health Intervention Effects Over Time for Cancer Patients with Depression.

This study examined the interplay of depression and different types of e-health interventions on breast cancer patients' perceived healthcare competence, emotional processing, and social well-being over time. The three e-health interventions--Internet Only as a control condition, CHESS (Comprehensive Health Enhancement Support System) Only, and CHESS with a Human Mentor, a cancer information specialist--provided varying degrees of interactivity and presence. A total of 328 women with breast cancer participated in one of the three interventions for a 6-month period. Women were further split into two groups based on reported levels of depression. For perceived healthcare competence and social well-being, results revealed significant interaction effects for intervention type by depression over time, such that breast cancer patients with higher levels of depression benefited most from the CHESS with Mentor intervention over the 6-month study period. For emotional processing, depressed cancer patients benefited more from the CHESS with Mentor than the other two interventions, regardless of time. These findings have (a) theoretical implications on how mental health factors can intersect with interactivity and presence to influence psychosocial outcomes, (b) conceptual implications for the role of human interaction within e-health systems, and (c) practical implications for the development of e-health interventions for cancer patients with depression.

How Cancer Patients Use and Benefit from an Interactive Cancer Communication System.

Despite the mounting evidence of efficacy of eHealth interventions, their mechanisms of action remain unknown. The current study analyzed patient log data as each patient engaged in an eHealth system called the Comprehensive Health Enhancement Support System (CHESS) and reports on how patients engage with different combinations of eHealth services over time. Newly diagnosed breast cancer patients (N = 443) were given access for 6 months to one of four different configurations of CHESS: (1) Information, (2) Information and Support, (3) Information, Support, and Coaching (Full CHESS), and (4) Full CHESS and Mentor. Besides a baseline survey, three follow-up posttests were administered. Action log data on how patients engaged with the CHESS were also collected and merged with surveys to examine how patients benefit during the cancer experience. The findings suggest that usage patterns were not competitive, implying that cancer patients' access to more complex tools generates more use with their time spreading out over the diverse services. Despite overall decline in usage rates, it was less severe in Full CHESS and Mentor condition, suggesting that communication functions drive long-term engagement with the system. Notably, the strongest relation between use and cancer information competence appeared late in the follow-up period.

Social support and responsiveness in online patient communities: impact on service quality perceptions.

BACKGROUND: Hospitals frequently evaluate their service quality based on the care and services provided to patients by their clinical and non-clinical staff.(1,2) However, such evaluations do not take into consideration the many interactions that patients have in online patient communities with the health-care organization (HCO) as well as with peer patients. Patients' interactions in these online communities could impact their perceptions regarding the HCO's service quality. PURPOSES: The objective of this pilot study was to evaluate the impact of social support and responsiveness that patients experience in an HCO's online community on patients' perceptions regarding the HCO's service quality. METHOD: The study data are collected from CHESS, a health-care programme (Comprehensive Health Enhancement Support System) run by the Centre for Health Enhancement System Studies at the University of Wisconsin-Madison. FINDINGS: Findings show that the social support and the responsiveness received from peer patients in the online patient communities will impact patients' perceptions regarding the service quality of the HCO even when the organizational members themselves do not participate in the online discussions. PRACTICE IMPLICATIONS: The results indicate that interactions in such HCO-provided online patient communities should not be ignored as they could translate into patients' perceptions regarding HCOs' service quality. Ways to improve responsiveness and social support in an HCO's online patient community are discussed.

The role of the family environment and computer-mediated social support on breast cancer patients' coping strategies.

Despite the importance of family environment and computer-mediated social support (CMSS) for women with breast cancer, little is known about the interplay of these sources of care and assistance on patients' coping strategies. To understand this relation, the authors examined the effect of family environment as a predictor of the use of CMSS groups as well as a moderator of the relation between group participation and forms of coping. Data were collected from 111 patients in CMSS groups in the Comprehensive Health Enhancement Support System "Living with Breast Cancer" intervention. Results indicate that family environment plays a crucial role in (a) predicting breast cancer patient's participation in CMSS groups and (b) moderating the effects of use of CMSS groups on breast cancer patients' coping strategies such as problem-focused coping and emotion-focused coping.

The Development of an eHealth tool suite for prostate cancer patients and their partners.

BACKGROUND: eHealth resources for people facing health crises must balance the expert knowledge and perspective of developers and clinicians against the very different needs and perspectives of prospective users. This formative study explores the information and support needs of posttreatment prostate cancer patients and their partners as a way to improve an existing eHealth information and support system called CHESS (Comprehensive Health Enhancement Support System). METHODS: Focus groups with patient survivors and their partners were used to identify information gaps and information-seeking milestones. RESULTS: Both patients and partners expressed a need for assistance in decision making, connecting with experienced patients, and making sexual adjustments. Female partners of patients are more active in searching for cancer information. All partners have information and support needs distinct from those of the patient. CONCLUSIONS: Findings were used to develop a series of interactive tools and navigational features for the CHESS prostate cancer computer-mediated system.

Factors Associated with Use of Interactive Cancer Communication System: An Application of the Comprehensive Model of Information Seeking.

In order to provide insights about cancer patients' online information seeking behaviors, the present study analyzes individuals' transaction log data and reports on how demographics, disease-related factors, and psychosocial needs predict patterns of service use within a particular Interactive Cancer Communication System (ICCS). Study sample included 294 recently diagnosed breast cancer patients. Data included pretest survey scores of demographic, disease-related, and psychosocial factors and automatically collected ICCS use data over the 4-month intervention. Statistical analyses correlated pre-test survey scores with subsequent, specific types of ICCS service usage. Patterns of online cancer information seeking differed according to the patients' characteristics, suggesting that lower income, less educated women and those lacking in information-seeking competence use the computer and online services to the same or a greater degree if those services are made available to them. Results of this study can inform more effective resource development for future eHealth applications.

Health information, credibility, homophily, and influence via the Internet: Web sites versus discussion groups.

Despite concerns about online health information and efforts to improve its credibility, how users evaluate and utilize such information presented in Web sites and online discussion groups may involve different evaluative mechanisms. This study examined credibility and homophily as two underlying mechanisms for social influence with regard to online health information. An original experiment detected that homophily grounded credibility perceptions and drove the persuasive process in both Web sites and online discussion groups. The more homophilous an online health information stimulus was perceived as being, the more likely people were to adopt the advice offered in that particular piece of information.

Expressing positive emotions within online support groups by women with breast cancer.

Based upon Fredrickson's Broaden-and-Build Theory of Positive Emotions, this study examined the role of expressing positive emotions in online support groups for women with breast cancer. Underserved women with breast cancer in rural Wisconsin and Detroit, Michigan were recruited from 2001 to 2003, and they were given access to online support groups. Both pretest and four-month posttest surveys were conducted with a sample of 231 women. Messages from 96 active participants were analyzed using a computerized text analysis program. Psychological benefits that occurred following the expression of positive emotions were greater among those who expressed more negative emotions.

Randomized clinical trial of an Internet-based versus brief office intervention for adolescent smoking cessation.

OBJECTIVE: Evaluation of novel treatment delivery methods, such as the Internet are notably absent from the adolescent smoking treatment literature. METHODS: Adolescent smokers ages 11-18 years were randomized to a clinic-based, brief office intervention (BOI; N=69) consisting of four individual counseling sessions; or to Stomp Out Smokes (SOS), an Internet, home-based intervention (N=70). Adolescents in SOS had access to the SOS site for 24 weeks. RESULTS: The 30-day, point-prevalence smoking abstinence rates for BOI and SOS were 12% versus 6% at week 24 and 13% versus 6% at week 36, with no significant treatment differences. Among participants who continued to smoke, SOS was associated with a significantly greater reduction in average number of days smoked than BOI (P=0.006). The BOI was found to be feasible with high session attendance rates. SOS participants accessed the site a mean+/-S.D. of 6.8+/-7.1 days. SOS use dropped to less than one-third of participants by week 3. CONCLUSION: Additional research is needed to tap the potential capabilities of the Internet for adolescent smoking cessation using proactive, personalized, patient-education components. PRACTICE IMPLICATIONS: Augmenting the SOS type of intervention with more structured, personal and proactive patient-education components delivered in-person or by telephone or electronic mail is recommended.

Attributes of interactive online health information systems.

The development of online communication systems related to prevention, decision making, and coping with cancer has outpaced theoretical attention to the attributes that appeal to system users and that create effective interactions. This essay reviews a number of sociotechnical attributes related to online discussion systems and tutorials, including interactivity, presence, homophily, social distance, anonymity/privacy, and interaction management. These attributes are derived from different theoretical perspectives which have led to clinical trials and other empirical studies demonstrating effectiveness or attraction to end users. The effects of a subset of these attributes are connected to learning, social influence, and coping, as illustrated in evaluations of an interactive smoking prevention site and a cancer advice/support discussion system.

Implementing an evidence-based breast cancer support and communication tool to newly diagnosed patients as standard care in two institutions.

While many women turn to the Internet to obtain health information, it is unlikely that unstructured Internet use provides optimal benefit to women newly diagnosed with breast cancer, due to uneven quality, conflicting claims, redundancy, and search engine idiosyncrasies, which may make finding information and assessing its accuracy and applicability difficult. To answer the need for information and support, the Comprehensive Health Enhancement Support System (CHESS) was developed to provide access to integrated information for decision-making, behavior change, and emotional support, and has been validated in randomized trials. This observational study of real-world implementation focuses on the process of integrating CHESS into standard care in two Denver healthcare systems. Results from this study provide guidance for implementation of other web-based patient information and support programs in large healthcare organizations.

Barriers to information access, perceived health competence, and psychosocial health outcomes: test of a mediation model in a breast cancer sample.

This study examined the relationship between breast cancer patients' experience of barriers to accessing health information and their psychosocial health outcomes and explored the extent to which this relationship was mediated by patient perceptions of competence in dealing with health-related issues. Study sample consisted of 225 women surveyed within 6 months of diagnosis. Regression analyses suggested that patients who reported greater difficulty in accessing needed information experienced lower emotional (P=0.05), functional (P<0.05), and social/family (P<0.05) well-being as well as lower perceptions of health competence (P<0.001). Also, patient perceptions of health competence mediated the relationship between barriers to accessing information and patient outcomes (emotional well-being, P<0.05; functional well-being. P<0.01; social/family well-being, P=0.01). Breast cancer patients often report dissatisfaction with the extent to which their information needs are addressed by their health care providers. Our findings underscore the need for designing and implementing interventions that would aid providers in better meeting the information needs of their patients.

Cultural differences in use of an electronic discussion group.

This article describes how 121 women newly diagnosed with breast cancer used a computer mediated discussion group to cope with their diagnosis. These data are part of a larger data set from a randomized clinical trial assessing the impact of a computer-based system called CHESS (the Comprehensive Health Enhancement Support System) on health outcomes. The larger study found significant improvement in health outcomes for those in the experimental group (those receiving CHESS), especially for women of color. Since discussion group is by far the most heavily used service of CHESS, one might conclude that these benefits (both overall and greater for women of color) should be attributed to amount of discussion group use. This study looks at how women of color and Caucasian women used the CHESS discussion group over the period of the study. Content analysis of messages in the discussion group showed that women of color used the discussion group differently from Caucasian women-they used it less frequently but their messages were more focused on breast cancer, suggesting they used discussion group more instrumentally.

CHESS: 10 years of research and development in consumer health informatics for broad populations, including the underserved.

This paper reviews the research and development around a consumer health informatics system CHESS (The Comprehensive Health Enhancement Support System) developed and tested by the Center for Health Systems Research and Analysis at the University of Wisconsin. The review places particular emphasis on what has been found with regard to the acceptance and use of such systems by high risk and underserved groups.

Optimizing eHealth breast cancer interventions: which types of eHealth services are effective?

Little is known about the effective elements of Interactive Cancer Communication Systems (ICCSs). A randomized trial explored which types of services of a multifaceted ICCS benefited patients and the nature of the benefit. Women with breast cancer (N=450) were randomized to different types of ICCS services or to a control condition that provided internet access. The Comprehensive Health Enhancement Support System (CHESS), served as the ICCS. ICCS services providing information and support, but not coaching such as cognitive behavior therapy, produced significant benefits in health information competence and emotional processing. Provision of Information and Support ICCS services significantly benefited women with breast cancer. More complex and interactive services designed to train the user had negligible effects.

Interactivity and Presence of Three eHealth Interventions.

A number of researchers have identified interactivity and presence as potentially important attributes of e-Health applications, because they are believed to influence users to interact with systems in ways that increase commitment, learning, and other desirable responses. This paper reports on the development of brief scales to assess the two concepts, and on use of them with participants in six conditions of a large-scale trial of interventions for breast cancer patients. Overall, the Internet scored very low on both measures. Versions of an integrated system of services (CHESS) scored higher, particularly as conditions added features to different versions of the system. Interventions involving a human Cancer Information Mentor scored highest, though even the Mentor was perceived as more interactive and having more presence when combined with the integrated eHealth system.

Mediating processes of two communication interventions for breast cancer patients.

OBJECTIVE: Test whether three mediating processes of Self-Determination Theory are involved in intervention effects on quality of life for breast cancer patients. METHODS: A randomized clinical trial recruited newly diagnosed breast cancer patients for 6 months of (1) Internet training and access, (2) access to an integrated eHealth system for breast cancer (CHESS), (3) a series of phone conversations with a Human Cancer Information Mentor, or (4) both (2) and (3). RESULTS: This paper reports results after the initial 6 weeks of intervention, at which point patients in the combined condition had higher quality of life scores than those in the other three conditions. All three Self-Determination Theory constructs (autonomy, competence, and relatedness) mediated that effect as hypothesized. In addition, the single-intervention groups were superior to the Internet-only group on relatedness, though perhaps this was too soon for that to carry through to quality of life as well. CONCLUSIONS: The SDT constructs do mediate these interventions' effects. PRACTICE IMPLICATIONS: Intervention design can profitably focus on enhancing autonomy, competence and relatedness.

Unraveling Uses and Effects of an Interactive Health Communication System.

By developing a number of measures distinguishing amount, type of content, and when and how that content is used, the current study revealed effective patterns of use that are associated with quality of life benefits during an eHealth intervention. Results generally suggest that the benefits depend on how a patient uses the system, far more than on sheer amount of exposure or even what type of content is chosen. The next generation of eHealth system should focus on providing new and varying content over time, but even more on encouraging intensity of use and long-term commitment to the system.

Internet-Based Interactive Support for Cancer Patients: Are Integrated Systems Better?

To compare the benefits of the Internet generally versus a focused system of services, 257 breast cancer patients were randomly assigned to a control group, access to the Internet with links to high-quality breast cancer sites, or access to an eHealth system (Comprehensive Health Enhancement Support System, CHESS) that integrated information, support, and decision and analysis tools. The intervention lasted 5 months, and self-report data on quality of life, health-care competence, and social support were collected at pretest and at 2-, 4-, and 9-month posttests. CHESS subjects logged on more overall than Internet subjects and accessed more health resources, but the latter used non health-related sites more. Subjects with access to the Internet alone experienced no better outcomes than controls at any of the 3 time points, compared to pretest levels. Subjects with CHESS experienced greater social support during the intervention period and had higher scores on all 3 outcomes at 9 months, 4 months after the intervention ended. CHESS subjects also scored higher than those with Internet access during the intervention period but not significantly after the intervention ended. Thus, CHESS (with one simple interface and integrated information, communication, and skills services) helped newly diagnosed breast cancer patients even after computers were removed. In contrast, patients received little benefit from Internet access, despite having links to a variety of high-quality sites.

Changes in readiness to quit and self-efficacy among adolescents receiving a brief office intervention for smoking cessation.

PURPOSE: To examine changes in readiness to quit and self-efficacy among adolescents who received a clinic-based, brief office intervention (BOI) for smoking cessation. METHODS: This study utilized a prospective, pre-post- treatment design. Participants were adolescent smokers (34 females, 35 males) with a mean +/- SD age of 15.8 +/- 1.4 years; 86% were Caucasian, who were randomly assigned to receive the BOI as part of a larger clinical trial. They were recruited from three cities in the Midwest and Northeastern part of the United States. After the baseline assessment, the BOI was designed for adolescents to receive four weekly individual sessions with a research counselor lasting between 10 and 40 min each. The BOI includes motivational interviewing and cognitive-behavioral techniques. Readiness to quit was assessed at each treatment session using the stages of change algorithm. The validated Adolescent Smoking Self-Efficacy Scale (SES) was used to assess self-efficacy at baseline (week 0) prior to the intervention and at post-treatment (week 4). The SES items comprise three factors or subscales: opportunities to smoke, emotional stress, and friends' influence. RESULTS: The percentage of adolescents who made improvement on readiness to quit from the baseline treatment session was statistically significant (p < .001) for each of the three subsequent treatment sessions. Self-efficacy scores increased significantly (p < .004) from baseline to post-treatment for all three subscales. CONCLUSIONS: Adolescents receiving a BOI progressed in their readiness and self-efficacy to quit. Understanding the change process among adolescent smokers during treatment could influence the design of future stop smoking interventions.