Prospective Trial of a Video Educational by adriana vargas

ORIGINAL ARTICLE

Prospective Trial of a Video Educational Tool for Radiation Oncology Patients Carol A. Hahn, MD,* Laura J. Fish, MPH,† Renee H. Dunn, PhD,‡ and Edward C. Halperin, MD*

Objectives: Prospective assessment of the informational needs of radiation oncology patients and efficacy of an educational video in meeting them. Methods: Subjects completed baseline self-administered questionnaires and subsequently viewed the patient education video. Posttesting was performed after initiation of therapy and subjects rated their satisfaction with the video, its relevance, and their emotional response. Analyses were performed with respect to patient and disease characteristics. Results: Fifty-three subjects were enrolled and completed both before and after video measures. The mean age of participants was 58 years (range, 33 to 83). Pretreatment, ⬎90% of patients reported specific information needs. One hundred percent of patients watched the video and 77% rated it as highly relevant. High levels of satisfaction (⬎90%) were reported with video information describing radiation and simulation. Older subjects (58 years and older) found video information significantly more relevant than those younger (55% versus 27%, P ⫽ 0.04) and rated greater satisfaction with side effect information (78% versus 41%, P ⫽ 0.006). Subjects with breast cancer exhibited a trend towards feeling better informed by the video. Conclusions: Radiation oncology patients reported informational needs unmet by standard educational measures. High levels of satisfaction were reported with video education. It promoted better understanding of radiotherapy. Older patients found the video to be significantly more relevant and informative. Key Words: patient education, radiation therapy, video education (Am J Clin Oncol 2005;28: 609 – 612)

pproximately half of all cancer patients receive radiotherapy as a part of their cancer management. Radiotherapy produces physical side effects and can have severe psychologic consequences, which may be exacerbated by uncertainty. The need for information among radiation therapy patients is high.1–3

From the *Departments of Radiation Oncology, †Cancer Prevention, Detection and Control Research Program, and the ‡Brain Tumor Center at Duke, Duke University Medical Center, Durham, NC. Reprints: Carol A. Hahn, MD, Department of Radiation Oncology, Duke University Medical Center, Box 3085, Durham, NC 27710. E-mail: hahn@radonc.duke.edu. Copyright © 2005 by Lippincott Williams & Wilkins ISSN: 0277-3732/05/2806-0609 DOI: 10.1097/01.coc.0000182417.94669.a0

The initial radiation oncology consultation facilitates the assessment of the patient in terms of their oncologic history and physical examination, explanation of therapeutic options and treatment recommendations. It also begins the process of patient education regarding therapeutic radiation: what it is, how it is delivered, and the reason for its use in their cancer therapy. Unfortunately, however, patients often have inadequate information, comprehension, and retention.4 Standard education as part of a routine clinical consultation typically involves patient counseling and providing written materials. Published studies have described the efficacy of different forms of patient education.5–12 Educational videos improve patient recall of information about particular types of therapy.9,10,13 Videos also help reduce patient anxiety when approaching unfamiliar situations.9,11,13 This study sought to prospectively evaluate the educational needs of patients seen in initial consultation in the Department of Radiation Oncology of the Duke University Health System and ascertain the extent to which a patient education video met these needs.

MATERIALS AND METHODS All new adult cancer patients seen at 5 clinical sites of the Duke University Health System’s Department of Radiation Oncology were eligible to participate in the study. Enrollment followed completion of a new patient consultation and after obtaining informed consent. After enrolling in the study, subjects completed pretesting with a baseline self-administered 5 question questionnaire concerning specific informational needs. Subjects were asked to rate the importance of information on: possible side effects of radiation therapy, side effects to report to their doctor or nurse, prevention of side effects, what will happen during radiation therapy, and how they will feel during radiation therapy. Responses were rated on a Liekert 1 to 5 scale, with 1 ⫽ not at all important to 5 ⫽ extremely important. Subjects were subsequently provided with both standard written educational materials and the patient educational video. The script for the video, “Your Treatment with Radiation Therapy,” was written by faculty members of the Department of Radiation Oncology at Duke University Medical Center and produced by the Instructional Television Division of Duke Educational Media Services. It was filmed within Duke’s Department of Radiation Oncology and featured members of the physician and dosimetry staff. The video was the winner of the First Place Silver Telly Award in 2001 in the non-network television and video competition.

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The video was 20 minutes long. Subjects had the option to watch the video in the clinic or borrow a copy for home viewing. Subjects were given discretion to view alone or with others. After initiation of radiation therapy, patients completed post-testing via self-administered questionnaire or telephone interview. Subjects were questioned on how much of the video was viewed and whether they viewed alone or with others. If viewed with others, the relationship of the other viewer(s) to the subject was recorded. Subjects rated relevance of the video and specific components of it on a 1 to 5 Liekert scale, with 1 ⫽ not at all relevant and 5 ⫽ completely relevant. The patients’ thoughts while viewing the video were collected via a modified thought listing technique, an open response method for acquiring and categorizing an individual’s thoughts, feelings, ideas, and expectations.14 Content analysis of the thoughts patients had after viewing the video was performed to learn how patients interpret and process the information contained in the video. Patients rated if the video made them feel informed, scared, prepared, in control, and safe on a 1 to 7 Liekert scale. Satisfaction with video information regarding how radiation is performed, how radiation is tailor-made for each patient, the description of the simulation visit, and possible side effects were rated on a 1 to 5 Liekert scale, with 1 ⫽ not at all satisfied and 5 ⫽ completely satisfied. Analyses were performed with respect to patient and disease characteristics to identify those populations best served by the video. This study is a portion of a larger scale prospective randomized trial evaluating the impact of the video on the anxiety of radiation oncology patients. The randomized study is ongoing and will be reported separately.

RESULTS Fifty-three patients were enrolled to the study and completed both before and after video measures. Mean age of participants was 58 years of age (range, 33 to 83 years) with 58% of patients 58 years or older; 82% of patients were white and 18% were black, and 85% of participants were female. Diagnoses included: 70% breast cancer, 10% lung cancer, 6% prostate cancer, 4% lymphoma, and 10% other; 51% of patients were enrolled at a single urban center in the Duke Health System and 31% were enrolled at rural sites. Before treatment, all patients expressed a strong need for information. More than 90% of patients reported specific needs pertaining to simulation and radiation side effects rating at a level of 4 to 5 importance of information on possible side effects, side effects to report to their doctor or nurse, prevention of side effects, how they would feel after radiation, and the simulation visit. One hundred percent of patients reported watching the video and 98% watched it in its entirety. Sixty-five percent of patients watched the video with another, most frequently a spouse (62%). Seventy-seven percent of patients felt the video was highly relevant to them personally, with scores of 4 to 5. With scores ⱖ4 on the 1 to 7 scale, patients reported

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that the video made them feel: prepared (94%), safe (94%), informed (88%), in control (79%), and not scared (66%). Patients indicated high levels of satisfaction, ie, scores 4 to 5, with video information about: how radiation is tailormade specifically for each patient (96%), description of radiation (92%), simulation (92%), and side effects (63%). Forty-six patients (87%) provided feedback describing their thoughts about the video. Thirty-two of these patients (70%) listed details about the radiotherapy process and technology that helped them better understand the process of planning or therapy. Eighteen patients (39%) recalled side effects as a topic covered by the video and, of these, 11 expressed a desire for greater or more specific information on side effects. Sixteen patients (35%) recalled information about differing types of radiation and, of these, 6 patients would have liked to see information in the video specifically about their type of cancer and its treatment. Subjects 58 years of age and older reported video information to be highly relevant (score 4 to 5 on 1 to 5 scale) significantly more often than younger subjects (55% versus 27%, P ⫽ 0.04; Fig. 1). They also rated greater satisfaction with information about side effects with scores ⱖ3 on 1 to 5 scale (78% versus 41%, P ⫽ 0.006; Fig. 2). Breast cancer patients reported a trend towards feeling better informed after watching the video (ⱖ4 on 1 to 7 scale) than patients with other diagnoses (69% versus 43%, P ⫽ 0.09; Fig. 3). There were no significant differences in patient reactions to the video by race or gender.

CONCLUSIONS Radiation oncology patients have informational needs that are unmet by standard patient educational methods. The use of video education has been shown in a number of medical settings to improve patient recall of information.9,10,13 In the oncology setting these needs are more acute because of the low degree of retention of information from

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FIGURE 2. Percent satisfied with video information on side effects by age.

the initial consultation visit accompanied by the high degree of anxiety and distress associated with both the diagnosis of cancer and complexity of treatment.4,12,15 Radiotherapy is technically complex and generally unfamiliar to most patients. Health professionals may also overestimate a patient’s ability to understand both the content and the language used in consultation.4 The ability of physicians to communicate necessary information in a empathetic manner also varies.15 The use of video technology provides

information in a format that is generally familiar to patients. It also ensures that information is delivered in a uniform fashion. High levels of satisfaction were expressed by patients who viewed the video. The majority of patients better understood the processes of radiotherapy simulation and treatment after viewing the video. The video made patients feel safer, better informed, and more in control. These results in terms of satisfaction with the educational video are similar to those of Dunn et al.16 They, however, found no significant impact on outcome variables when looking at testing before and after use of the educational tool. Older patients found the video to be highly relevant significantly more often than younger patients. They also felt the video to be more informative about side effects. This may be related to the film’s relatively serious tone and jacket and tie-clad sober-looking narrator. Various strategies have been used in creating educational videotapes. Some have used familiar television and film personalities as narrators.9,11 Our video was filmed in house and featured members of the physician and support staff at Duke. Although for some patients it may be comforting and familiar to see their own care team presenting information, different formats may be preferable to others. Breast cancer patients demonstrated a trend towards feeling better informed than those with other diagnoses after viewing the video. Studies specifically assessing needs of patients with breast cancer demonstrate patients’ ongoing need for information in all areas.1,17 Our study group had a large percentage of breast cancer patients. This may have influenced the results in terms of overall acceptance of the video. Evaluation of particular educational needs of patient subgroups demonstrate that some will prefer minimal education and only necessary information.3,13 These patients would likely steer away from such a study as ours and for patients declining study participation, a frequent reason for was patient perception of information overload. Tailoring of videos to individual diagnoses and patient subgroups should be further investigated. Baseline determination of patient educational needs should drive interventions to improve their educational experience to reduce uncertainty. Further research should evaluate the impact of educational methods on patient anxiety in attempts to best address the needs of patients, promote patient satisfaction, and positively impact their psychosocial well-being while we strive to cure their underlying malignancy. REFERENCES

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