Cultural feasibility and sustainability of Internet-based specialist access in rural Ecuador

1. Cultural feasibility and sustainability of Internet-based specialist access in rural Ecuador Paul Heinzelmann, MD Joseph Kvedar, MD May 5, 2004

2. TECHNICAL BARRIERS ECONONOMIC BARRIERS SUSTAINABILITY CULTURAL BARRIERS

3. CULTURAL BARRIERS withina social setting: culturally acceptable Individual Institutional Societal Ecuador Adoption Diffusion

4. CULTURAL BARRIERS withina social setting: culturally acceptable Individual Institutional Societal Ecuador Adoption Diffusion US Individual Institutional Societal betweensocial settings: culturally competent

5. “Cultural competence is a set of congruent behaviors, attitudes and policies that come together in a system, agency, or among professionals and enable that system, agency, or those professionals to work effectively in cross-cultural situations.” Objective: Understand stakeholders Patients Providers Individual Institutional Societal

6. Societal TARGET REGION

7. Hospital PVM

8. Action Research Plan Act Observe Reflect

9. Individual Institutional Patients • Self-administered survey • 13 questions • n = 59 • (male=38.5%, • female=61.5%) • Web-based surveyFocus group • 26 questions Hospital director • N = 10 Hospital Lab Director • (male = 100%) NGO Director Physicians Hospital Administrators

10. Individual Patients Majority “Agreed” or “Strongly agreed” 90% would allow their doctor to use         88% would be comfortable with telemedicine 83% useful to the community 83% improve hospital and clinic operations 72% improve the way doctors treat patients 66% equal to or adequate to in-person exam · ·

11. Individual Physicians • All “Agree” or “Strongly Agree” • Useful for the physicians • Valuable learning opportunities • Comfortable using Internet for consults • 90% Comfortable receiving consults in English • 80% Could improve health of patients • 80% Could be safe and private • 80% Prefer it to the option of transferring patients • 77% Could lower healthcare costs • 70% Could add more work for them

12. Institutional Hospital Administrators Patients • Decreased costs associated with transfer to Quito Physicians • Increased confidence in diagnosis and treatment • Continuing education opportunities • Decreased professional isolation Hospital • Increased hospital revenue by decreasing transfer of patients to Quito facilities

13. Internet-based specialist consultation appears to be culturally feasible in this setting. Individual • All physicians have internet experience • Potential for early adoption • Concerns about extra work • Opinion leaders at the hospital are engaged in the process and have identified potential relative advantages of telemedicine. Institutional

14. Next Plan….a trial

15. Conclusions • Action Researchis a practical means to introduce telemedicine and evaluate cultural influences. • Develop “culturally acceptable” & “culturally competent” programs. • Promote adoption and diffusion • Overcoming cultural barriers is important to achieve sustainability • Sustainable programs are needed to demonstrate a positive impact in the developing world.

16. “Now it is up to all of us to build an information society from trade to telemedicine, from education to environmental protection. We have in our hands, on our desktops and in the skies above, the ability to improve the standards of living for millions upon millions of people.” United Nations - Secretary General Kofi Annan Dec. 2003

17. Muchas Gracias Special Thanks to: Andean Health & Development - Ecuador Carey Noland, Ph.D – Northeastern University Nancy Lugn, JD, MBA – Partners Telemedicine Carola Roeder – Partners Telemedicine

18. Individual Physicians

19. References: • 1. Developing Health Technology Assessment in Latin America and the Caribbean. Program on Organization and Management of Health Systems and Services, Division of Health Systems and Services Development, Pan American Health Organization, 1998.  • Wooton, R. “Telemedicine and developing countries – successful implementation will require a shared approach.” Journal of Telemed and telecare 2001;7 (suppl1):S1:1-6 • Grigsby, J., Rigby, M., Heimstra, A., House, M., Olsson, S., Whitten, P. “Chapter 7. The Diffusion of Telemedicine.” Telemedicine Journal and e-Health 2002, 8:1:79-94. • Robinson, DF, Savage, GT, Campbell, KS “Organizational learning, diffusion of innovation, and international collaboration in telemedicine.” Health Care Management Review, 2003, 28(1), 68-78. • Cross TL, Bazron BJ, Dennis KW, Isaacs MR (1999). Toward a Culturally Competent System of care, Volume 1. National Institute of Mental Health, Child and Adolescent Service System Program (CASSP) Technical Assistance Center, Georgetown University Child Development Center. • Lustig, MW, Koester, J. Intercultural Competence: Interpersonal communication across cultures. Allyn and Bacon 2003 • 7. Finch, TL, May, CR, Mair, FS, Mort, M, Gask, L. “Integrating service development with evaluation in telehealthcare: an ethnographic study.” British Medical Journal 2003;327, 1-5 (BMJ online downloaded 2/15/04) • 8. Meyer J. “Using qualitative methods in health related action research.” British Medical Journal 2000;320:178-181 (15 January) • 9. Rogers, E. Diffusion of Innovations. 4th ed. New York: The Free Press, 1995. • 10. Gilmore, T., Krantz, J., Ramirez, R. “Action based modes of inquiry and the host- • researcher relationship.” Consultation 5.3 (Fall 1986): 161 • 11. Profile of the health services system of Ecuador. PAHO Program on organization • and management of health systems and services. Nov. 2001.

20. Experience Enquire Examine Active participation Interviews Medical charts Active observation Focus Groups Journals Passive observation Questionnaires Field notes Attitude scales (Likert) Audio & Video tapes Standardized tests Methods: Action Research

21. Population below poverty line: Top Ten Country % below poverty 1. Zambia 86% (1993 est.) 2. Chad 80% (2001 est.) 3. Haiti 80% (1998 est.) 4. Liberia 80% 5. Moldova 80% (2001 est.) 6. Tajikistan 80% (2001 est.) 7. Bolivia 70% (1999 est.) 8. Burundi 70% (2001 est.) 9. Ecuador 70% (2001 est.) 10. Madagascar 70% (1994 est.) Definition: National estimates of the percentage of the population lying below the poverty line are based on surveys of sub-groups, with the results weighted by the number of people in each group. Definitions of poverty vary considerably among nations. For example, rich nations generally employ more generous standards of poverty than poor nations. Source: CIA World Factbook 2002

22. Health expenditures (% of GDP): Ecuador 2.4 US 13.0 2001*** Physicians per 1000: Ecuador 1.7 US 2.8 1998**** 2000**** Mortality (per 1000 live births) Infant Mortality Ecuador 32.00 US 6.75 2003*** 2003*** Under-5 Mortality Ecuador 45.4 US 8.7 2001* 2001**** *= Population, Health and Nutrition Information Project: Ecuador, 9/02 **= Profile of the Health Services System of Ecuador. PAHO, 11/01 ***= CIA Factbook web site accessed 9/12/03 ****=World Bank web site accessed 9/22/03

23. Age Leading causes of Mortality Infants: Acute Respiratory infections 1-5 years: Acute Respiratory infections 5-14 years: Accidents & violence 20-59: Cardiovascular disease Malignant tumors Accidents & violence (Source: PAHO 1996) Tuberculosis

24. Tropical & Communicable Disease Incidence (Source: PAHO 1996) Diarrheal disease: 193,352 Dengue fever: 12,796 Malaria: 12,011 TB: 7,938 Gonorrhea: 7,703 Cutaneous leishmaniasis: 1,655 Cysticercosis: 336 AIDS/HIV: 186 Leprosy: 151 Chagas disease: 500,000(estimated prevalence)