In sum, the self-management experiences of COPD patients in these focus groups were limited to taking prescribed medications and reducing movement and activity. Patients reported widespread confidence with regards to managing and using prescribed medications to treat COPD symptoms, and they also perceived that getting plenty of rest could reduce their shortness of breath. However, the focus group participants did not realize the importance of practicing other COPD self-management skills and behaviors. By and large, patients reported a lack of knowledge and skill development related to alternative rehabilitative activities such as controlled breathing and coughing, stress reduction, smoking cessation, nutrition, and paced walking/activity. Furthermore, the focus group participants expressed an interest in learning more about these and other novel topics, which have universally been identified as staples within COPD self-management regimens [10
]. It should be noted here that the social characteristics of this particular community may limit the generalizability of these particular educational needs. However, the findings from this study may generalize to communities which possess similar shared characteristics. In this primarily rural community, it can be surmised that needs identified from these focus groups can potentially be applied to other COPD patient populations represented by relatively equal proportions of African American and Caucasians who are living at or below regional poverty lines with a low socioeconomic status.
Given the learning needs identified earlier, the low educational levels of many of the patients in the sample, and the variability in terms of patient time spent coping with COPD, careful attention was paid to developing the DVD instructional tool based on patient feedback obtained during this exploratory study. It was imperative to only include segments that were comprehensible, to the point and clear. Segments which contained relatively novel COPD self-management education (determined based on input from patients) were selected for inclusion, while segments deemed irrelevant were not included. The edited DVD was not intended to bombard patients with an excess of information that they could not remember and use; rather, it was developed in hopes of keeping patients' interest by only including information that they would find to be applicable to their disease self-management efforts.
For example, there were no segments included on medication management, because most patients felt comfortable using their medications, and these segments tended to describe specific prescription medication terminology, which may have confused patients who did not explicitly remember the names of the medications that they were currently taking. Given that the majority of patients in the focus groups had been diagnosed for many years (Mean = 6 years; SD = 4.43 years), they professed being familiar with the medications they used regularly to management their disease. Had the focus groups or patient sample been composed of those more recently diagnosed with COPD, however, it would have been prudent to include information on prescription management and adherence to help assist patients in adapting to their new disease status. After taking into account input from the Medical Director of the clinic where the patients were treated, the DVD clips were edited and placed on an original disc.presents the content areas included on the edited DVD and the running time for each segment.
Final segments included on DVD (edited).
The total run time for the entire edited DVD was approximately 34 minutes and 18 seconds. It was used in a study [57
] to determine optimal self-management education strategies for COPD patients. Patients provided with a DVD reported watching the targeted segments multiple times (Mean = 2.58, SD = 1.81), perhaps because of the control they had over the implementation of the DVD player used to transmit the self-management education. Moreover, using DVD technology as the technological modality for this intervention gave COPD patients the greatest opportunity for empowerment over persistent shortness of breath which characterizes their disease. Patients could view the educational material in the convenience of their own home, using a technology they were familiar with, at their own discretion. Given the geographic and socioeconomic characteristics of this sample of COPD patients, the overarching instructional strategy supported limited interpersonal interaction with patients. Thus, a distance education
method served as the primary means of instruction. For the purpose of this project, distance education can be defined best by Moore [58
] as, “all arrangements for providing instruction through…electronic communications to people engaged in planned learning in a place or time different from that of the instructor or instructors” (p. xv).
In future dissemination studies using the targeted DVD within the distance learning milieu, various other telecommunications vehicles may be integrated into self-management education for rural patients with COPD. For example, the multimedia content reformatted for this project (i.e., to coincide with patient self-management education needs) has been posted on the internet by way of YouTube broadcasting using the feed managed by the proprietor of RVision Corporation: http://www.youtube.com/watch?v=pte_GGQb1_4
. The authors posit that these types of interactive, media sharing URLs will allow COPD patients to contribute both video and text-based responses, comments and concerns as regards the self-management tutorials streamed over the internet. An added benefit of using the YouTube application is that patients subscribing to the feed will be afforded the opportunity to view related videos within the preexisting library of all health education segments produced by RVision Corporation. For the multitude of COPD patients that suffer from other, comorbid chronic conditions, the access to these libraries could prove to be an extremely valuable resource. RVision Corporation educational content for various diseases and disorders (including COPD) is commercially available and distributed by Health Ix via their website: http://www.healthix.com/
. Each video clip posted for telemedical purposes could be dispensed using a unique host URL link.
This integration of video-based education in an open access web environment (e.g., YouTube) can provide a forum for patients to share their experiences attempting to cope with disease-related issues within a virtually networked community. For rural patients who have difficulty commuting to a common, localized site for health services and support, this portal containing instructional multimedia material is ideal. This converged approach to congregating patients and providers in a user environment amenable to patient/provider feedback can enable the site administrator to continually meet patient needs for self-management education. In addition, the administrator has the luxury of managing and optimizing a single network to transmit both audio-visual education and patient feedback asynchronously over the internet on a common system. This technologically-mediated strategy would reduce rural patients' need to travel and deliver the educational content directly to patients at their place of residence in the same vein as the DVD, but with the added networking capacity.
Access to this host URL could also be granted to certified medical personnel of rural health clinics to better assimilate the DVD content with tailored medical advice provided both through audio-visual and text-based responses. Special attention must be paid to ensuring that patient confidentiality is not breached when sharing medical information within a public domain forum on the internet. An encrypted web portal with VOIP software applications (e.g., Skype, Google Talk, Cisco IP Communicator, etc.) enabling two-way voice communication over the internet could assuage concerns regarding the unauthorized transmission of patient health information.
At this point, it should be noted that this future work will only become realized should pending financial stimulus be allocated to rural health networks for greater broadband access to the internet. Recent initiatives in the United States have suggested that this enhanced, internet access for rural America is forthcoming for these underserved areas. Furthermore, future researchers using this proposed converged networking approach to technologically-mediated disease self-management education should be confident that patients/providers are prepared with instruction and training to use the internet and all related applications. Without patient/provider access and efficacy with regard to internet/software navigation, the fruits of the internet as a telemedicine application can be very limited. It is suggested that such attempts be formatively pilot tested in areas of higher socioeconomic status, before broad-based implementation in rural, underserved areas is attempted. The aforementioned mobile COPD self-management education service, in a converged networking environment, would be especially useful in a technologically capable sample of rural COPD patients, because the majority of focus group participants expressed difficulty transporting themselves from their homes to their rural health clinic and often could only do so with assistance from friends and family members. Patient populations living in urban regions may not be affected by this geographic barrier; thus, the proposed intervention may be less appropriate in areas with a dense populous.
Focus group data proved extremely useful to identify and confirm patients' learning needs. Engaging in such formative qualitative inquiries may prove invaluable when attempting to meet the self-management education needs of diverse patients who are difficult to reach. It would stand to reason that results from this study suggest that the prospect of using self-management education DVD content could potentially stimulate high utilization rates among rural COPD patients, which could overcome significant barriers relative to widespread distribution of COPD self-management techniques. By disseminating targeted educational technology resources to underserved populations, health educators may be able to broaden the reach of COPD self-management messages and help patients feel more satisfied with the patient education they receive.