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

TECHNICAL BARRIERS SUSTAINABILITY ECONONOMIC BARRIERS CULTURAL BARRIERS TECHNICAL BARRIERS SUSTAINABILITY ECONONOMIC BARRIERS CULTURAL BARRIERS

CULTURAL BARRIERS within a social setting: culturally acceptable Individual Institutional Adoption Societal Ecuador Diffusion CULTURAL BARRIERS within a social setting: culturally acceptable Individual Institutional Adoption Societal Ecuador Diffusion

CULTURAL BARRIERS within a social setting: culturally acceptable Individual Institutional Adoption Individual Societal Ecuador CULTURAL BARRIERS within a social setting: culturally acceptable Individual Institutional Adoption Individual Societal Ecuador Diffusion Institutional Societal US between social settings: culturally competent

“Cultural competence is a set of congruent behaviors, attitudes and policies that come together “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

Societal TARGET REGION Societal TARGET REGION

Hospital PVM Hospital PVM

 Plan Act Observe Reflect Plan Act Observe Reflect

Individual Institutional Self-administered survey 13 questions n = 59 (male=38. 5%, female=61. 5%) Web-based Individual Institutional Self-administered survey 13 questions n = 59 (male=38. 5%, female=61. 5%) Web-based survey 26 questions N = 10 (male = 100%) Focus group Hospital director Hospital Lab Director NGO Director

Individual Majority “Agreed” or “Strongly agreed” 90% would allow their doctor to use 88% Individual 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 ·

Individual All “Agree” or “Strongly Agree” • Useful for the physicians • Valuable learning Individual 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

Institutional n n n Patients Decreased costs associated with transfer to Quito Physicians Increased Institutional n n n 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

Internet-based specialist consultation appears to be culturally feasible in this setting. Individual • All 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 Institutional • Opinion leaders at the hospital are engaged in the process and have identified potential relative advantages of telemedicine.

 Next Plan…. a trial Next Plan…. a trial

Conclusions Action Research is a practical means to introduce Action Research telemedicine and evaluate Conclusions Action Research is a practical means to introduce Action Research 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.

“Now it is up to all of us to build an information society from “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

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

Individual Individual

References: 1. Developing Health Technology Assessment in Latin America and the Caribbean. Program on 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. 2. Wooton, R. “Telemedicine and developing countries – successful implementation will require a shared approach. ” Journal of Telemed and telecare 2001; 7 (suppl 1): S 1: 1 -6 3. 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. 4. 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. 5. 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. 6. 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. 4 th 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.

Methods: Action Research Experience Enquire Examine Active participation Interviews Medical charts Active observation Focus Methods: Action Research 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

Population below poverty line: Top Ten Country % below poverty 1. 2. 3. 4. Population below poverty line: Top Ten Country % below poverty 1. 2. 3. 4. 5. 6. 7. 8. Zambia Chad Haiti Liberia Moldova Tajikistan Bolivia Burundi 86% (1993 est. ) 80% (2001 est. ) 80% (1998 est. ) 80% (2001 est. ) 70% (1999 est. ) 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

Health expenditures (% of GDP): Ecuador 2. 4 US 13. 0 2001*** Physicians per Health expenditures (% of GDP): Ecuador 2. 4 US 13. 0 2001*** Physicians per 1000: Ecuador US 1998**** 1. 7 2. 8 2000**** Mortality (per 1000 live births) 2003*** Infant Mortality Ecuador 32. 00 2003*** US Under-5 Mortality 6. 75 Ecuador 45. 4 US 8. 7 *= 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 2001****

Age Leading causes of Mortality Infants: Acute Respiratory infections 1 -5 years: Acute Respiratory 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

Tropical & Communicable Disease Incidence (Source: PAHO 1996) Diarrheal disease: 193, 352 Dengue fever: 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)