key: cord-0807721-x0yrnnux
authors: Wu, Qiwei L.; Street, Richard L.
title: Factors Affecting Cancer Patients’ Electronic Communication with Providers: Implications for COVID-19 Induced Transitions to Telehealth
date: 2020-09-28
journal: Patient Educ Couns
DOI: 10.1016/j.pec.2020.09.036
sha: 6a0b91d3e5fc210e9463e3f8099a373a174c6f77
doc_id: 807721
cord_uid: x0yrnnux

OBJECTIVE: Because of the pandemic, electronic communication between patients and clinicians has taken on increasing significance in the delivery of cancer care. The study explored personal, clinical, and technology factors predicting cancer survivors’ electronic communication with clinicians. METHODS: Data for this investigation came from the Health Information National Trends Survey (HINTS5, Cycle 2) that included 593 respondents who previously or currently had cancer. Multivariate regression analyses were used to predict electronic communication with clinicians. Predictors included demographic variables and health status, technology use (online health information-seeking behavior, tracking of health-related data such as using a Fitbit), and quality of past communication experiences with clinicians. RESULTS: In this pre COVID-19 sample, 42% respondents (N = 252) did not engage in any type of electronic communication (e.g., emailing, texting, data sharing) with providers. In multivariate analyses, predictors of more electronic communication with clinicians included frequency of seeking health-related information online (ß = .267, p < .001) and better communication experiences with clinicians (ß = .028, p = .034), while no demographic variable showed significance. The technology use variables (online health information seeking, health tracking) were significantly higher predictors of electronic communication with clinicians (ΔR(2) = .142, p < .001) than was past experiences with clinicians (ΔR(2) = .029, p = .016). CONCLUSIONS: Access and past experience with interactive media technologies are strong predictors of cancer patients’ electronic communication than with clinicians. Adoption of telehealth technology likely depends as much on patients’ relationships with technology as it does their relationships with clinicians. PRACTICE IMPLICATIONS: Since Covid-19, cancer care providers have turned to telehealth provide patients with needed cancer care services. Enhancing patients’ digital competence and experience with electronic communication will help them more easily navigate telehealth care. Providers can leverage their relationship with patients to facilitate more effective use of telehealth services.

public's use of cancer-related information and changing communication trends and practices, including their e-communication with clinicians.

Although pre COVID-19, this survey does allow for an examination of factors associated with cancer survivors' willingness to engage in e-communication with clinicians via secure messaging, emailing, and data sharing. While HINTS does not address synchronous telehealth visits per se, these forms of e-communication (e.g., patient portals, text messages) have become even more important since the pandemic so that patients can access information, lab results, support resources, and have interactions with clinicians [3, 10, 11] .

In order to identify factors affecting patients' willingness to use e-communication with cancer care providers, this investigation embraces a key premise of social cognitive theory (SCT) [12] that posits that an individual's behavior is a function of personal factors and environmental influences. Given past research, we expect personal characteristics (e.g., higher education, health status, younger age) may influence one's e-communication with providers [13, 14] . Cancer patients' interactions with their environments would include their relationships with health care providers as well as their relationships with technology. Some research indicates each may independently influence e-communication with clinicians [15, 16] . Guided by SCT, this investigation examined the following research question:

RQ: To what extent do cancer patients' demographic and health-related characteristics, past health care experiences (frequency of seeing providers, quality of communication), and use of technology for health-related purposes (seeking online health information, using health tracking devices such as Fitbit) predict their utilization of e-communication with providers?

J o u r n a l P r e -p r o o f

We used the 2018 HINTS data, a nationally representative mail survey gathered in the US from January 2018 to May 2018, and included 593 respondents who had a previous cancer diagnosis. Table 1 shows the study variables and how they were measured. The outcome variable, e-communication with clinicians, was the sum of whether in the past year respondents had texted, emailed, and/or electronically shared information with a health care provider (scale range 0-3). To answer the research question, predictor variables were grouped into 3 categories based on the premises of SCT-(a) personal and health-related (age, education, race/ethnicity, gender, time since cancer diagnoses, physical and mental health status), (b) past experiences with health care providers (how many visits with providers over past 12 months, quality of past communication experiences), and (c) use of technology for health-related purposes (using the Internet to seek health information, using technology to track health data).

Regression analyses were conducted in three blocks using the grouped variables. First, demographic and health variables were entered into the model (Model 1), followed by variables related to past experiences with providers (Model 2), and finally use of technology for health purposes (Model 3). To assess significance in variances explained, we observed the R-squared change in Models 2 and 3.

J o u r n a l P r e -p r o o f Most participants were females (N = 344, 58%) and reported good to excellent physical (N = 443, 74.7%) and mental health (N = 525, 88.5%) ( Table 2) . Education levels varied, and time since cancer first diagnosed cancer ranged from 0 to 87 years (M = 13.83, SD = 13.39).

Approximately 42% respondents (N = 252) had not engaged in any e-communication with providers.

In bivariate analyses, e-communication was higher among the younger (r = -.198, p < .001) and more educated respondents (r = .224, p < .001), as well as those who more often sought health information online (r = .480, p < .001), tracked health data (r = .430, p < .001), and who visited providers more often over the last 12 months (r = .173, p < .001).

In multivariate analysis, demographic and health factors (Model 1) explained 7. Table 3 for full regression results).

J o u r n a l P r e -p r o o f had some positive experiences using telehealth services, including saving personal protective equipment (PPE) and reducing the need for hospital services [22] . Other evidence indicates that telehealth has not increased physicians' workload and that both cancer patients and providers have expressed satisfaction with transitions to telehealth for certain services [23] . Recent surveys in various countries suggests that, while many patients still prefer in-person visits for some aspects of care, telehealth platforms offer a reasonable and satisfactory alternative for other cancer care services [11, 24, 25] . However, successful transitioning to telehealth for cancer care services will depend on patients' willingness and capacity to use digital forms of communication with their providers. Based on our findings, the quality of patients' relationships with clinicians and their experiences with using technology for health-related purposes will be important determinants.

This study has limitations. Our analysis was exploratory, and we did not examine patients' use of telehealth visits during COVID-19. Attitudes toward live telehealth visits were not assessed by HINTS, and factors affecting real-time virtual visits may be different from asynchronous e-communication. Also, as a cross-sectional survey, HINTS allows for identifying correlations among variables and not necessarily causation. Finally, HINTS did not query respondents' access to and quality of internet connectivity, which greatly affects one's experiences using telehealth.

The most important implication of our findings is that the transition from face-to-face to telehealth consultations involves more than simply adapting to a different medium for clinical encounters; it also depends on users' (both patients and clinicians) relationships with interactive J o u r n a l P r e -p r o o f media technology. Just as medical care transitioned from the biomedical model to the biopsychosocial model of clinical care [26] , health communication researchers need to think beyond the body, mind, and social dimensions of health to also include the technological context of health-related experiences. Our study suggests that cancer patients' relationships with technology for health-related purposes, along with their relationships with clinicians, are key components for successfully engaging cancer patients with telehealth.

There are at least two ways health care providers can help patients more smoothly transition to telehealth for some cancer care services. First, clinicians can develop strategies to promote and maintain effective clinician-patient communication when using digital platforms.

These include proactively using the technology to reach out to patients to stay connected, taking steps to offering longer time during virtual visits, and finding ways to maintain the humanness of supportive relationships [27] .

Second, transitioning to telehealth has been a learning curve for both providers and patients. In light of pre-COVID research showing that most patients do not discuss their use of health information technology (e.g., use of the internet for health information) with their providers [28] , clinicians could initiate conversations on this subject to guide patients' use of telehealth, address any concerns around its use, and assist patients in navigating various digital functions (e.g., online consultations, examinations, data sharing) afforded by virtual platforms [20] . The importance of having positive initial telehealth visits was shown in a recent study [29] Note. ** Correlation is significant at the 0.01 level (2-tailed), * Correlation is significant at the 0.05 level (2-tailed) J o u r n a l P r e -p r o o f 

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