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Elliott Parker
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How People Learn Using Interactive Cancer Communication Systems
Abstract
To provide insights about how women with breast cancer learn from 
Interactive Cancer
Communication System (ICCS), this study examines how using different 
service types
employing conceptually distinct pedagogical methods relates to 
learning outcomes. As
expected, findings supported the constructivist idea that interactive 
computer programs
may supplement the learning potential of information services 
delivered via transmissionoriented
methods. Contrary to expectations, however, those who used information
services benefited less if they were more frequent users of 
communication services.
1
How People Learn Using Interactive Cancer Communication Systems
How People Learn Using Interactive Cancer Communication Systems
Introduction
While interactive cancer communication systems (ICCSs) have been found to
improve cancer patients' ability to find the information they want 
(e.g., Gustafson et al.,
2001), research often fails to specify how people actually learn in 
these settings. A
common, but inadequate, understanding of online health education for 
cancer patients is
that people are passive receivers of information or "vessels into 
which knowledge is
poured" (Berryman, 1991). This assumption encourages transmission, or 
one-way, views
of knowledge that undervalue active learning and the degree to which 
knowledge is
constructed as a result of communicating with others or interacting 
with educational tools
that put information into context so people can make sense of it for 
their own particular
life context. Importantly, evidence demonstrates that learners do 
poorly in transferring
newly learned skills and knowledge to new situations when presented 
out of context of its
use. The act of learning involves gaining understanding. Context is 
critical for
understanding as "context gives meaning to learning" (Berryman, 1991).
Educational theories of learning have broadly focused on two views of 
learning in
education: education as a transmission process, and education as a 
constructivist process.
In a transmission view of education, the learner acquires knowledge 
in a one-way process
in which the instructor, peer, or a Web resource teaches via the 
provision of information.
For example, one common pedagogical method found in nearly all ICCSs 
is posting
health information that is available for patients to read at their 
convenience (e.g.,
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How People Learn Using Interactive Cancer Communication Systems
Gustafson et al, 2002), which viewed in isolation can clearly be 
interpreted as a
transmission approach to health education. However convenient and 
appropriate it may
be to provide patients access to educational materials on the Web, 
this approach alone
does not take into account that a great amount of learning occurs as 
a result of interaction
with others such as peers, experts, or mentors (Pea & Gomez, 1992) 
and increasingly
through use of interactive computer tools that don't just transmit 
information but also
take into account users' priorities, values and life context. 
Transmission approaches to
education can be used with learning tools and technologies, such as 
Internet learning
portals and communities of learning, but the transmission approach 
alone minimizes the
potential role of these powerful technologies when used as the 
primary educational
strategy (Warschauer, 2003).
Alternatively, a constructivist approach to learning encourages 
active learners to
communicate with each other and interact with different resources in 
maximizing
learning potential among students (Edelson et al., 1995). The 
constructivist perspective
conceives of communication as a two-way process in which meaning is 
created by both
parties, by means of dialogue (Dervin, 1981). In this model, 
communication is a
transformative and creative experience for all involved and is more 
than just the "passing
of static knowledge back and forth between participants" (Pea, 1994). 
Interactions
between learners and with the instructor or educational program offer 
the potential to
result in new, re-framed, or additional understanding. In this 
approach, learning is linked
to the learner's discovery of external phenomenon (Piaget, 1970), and 
is in agreement
with educational philosopher John Dewey's laboratory school approach 
in its focus
(McDermott, 1981).
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How People Learn Using Interactive Cancer Communication Systems
Within a comprehensive ICCS, there is the opportunity to employ both
transmission and constructivist pedagogical strategies in enhancing 
learning outcomes for
cancer patients. Passive venues such as static information may be 
conceived of as
following a transmission approach to learning within an ICCS while 
online discussion
and interactive programs may be considered to be more consistent with 
constructivist
models of learning (Mayer, 2004).
In order to provide insights about how people learn within ICCSs, this paper
reports on how using different types of services relates to specific 
learning outcomes
focusing on a particular ICCS called the Comprehensive Health 
Enhancement Support
System (CHESS) "Living with Breast Cancer" program, which is a computer-based
system that provides patients and their families with a wide range of 
services, including:
information, social support, decision support, and skills training. 
CHESS was developed
at the University of Wisconsin-Madison's Center for Health Systems 
Research and
Analysis (for more information on the CHESS breast cancer module, see 
Gustafson et al.,
1993, 1998, 1999, 2001; 2002; Hawkins et al., 1997; McTavish et al., 
1995; McTavish,
Pingree, Hawkins & Gustafson, 2003; Pingree et al., 1996; Rolnick et 
al., 1999; Shaw,
McTavish, Hawkins, Gustafson & Pingree, 2000; Shaw, Hawkins, 
McTavish, Pingree &
Gustafson, in press; Taylor et al., 1994).
CHESS Service Types and Theorized Effects on Learning
CHESS offers three basic types of services, which are explicated as 
they relate to
transmission-oriented and constructivist educational theories and 
described below:
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How People Learn Using Interactive Cancer Communication Systems
Information Services
Information services are the primary communication strategy used in 
most healtheducation
Web sites. They are user-driven in the sense that the user is the primary
determinant of where s/he goes and what s/he sees. There may be 
prompts from the
computer, but the computer is not, for the most part, guiding the 
user. The computer
tends to be a passive participant in the delivery of information to 
the user; it tends not to
guide or direct. Information services would be categorized as a 
transmission-oriented
pedagogical method. Examples of this would be Library Articles where 
the user asks to
see articles on certain topics, or Personal Stories where the user 
can read about the
experiences and thoughts of other individuals who faced the same 
sorts of challenges that
the user faces. The user selects these services, indicates the kind 
of information s/he
wants, and the computer delivers the information.
Communication Services
These services within CHESS are "conversational services" in that the computer
links people together so that they can communicate with one another 
via the computer.
Through such communication, the user is presumed to learn, and the 
medium by which
this information is acquired is the computer-mediated 
person-to-person connection. The
people linked might be two patients or a patient with an expert or 
clinician. In terms of
learning, research also indicates that informational support from 
other people can be
valuable to people coping with a chronic illness. Informational 
support refers to
receiving information from others regarding a variety of issues, and 
benefits include
5
How People Learn Using Interactive Cancer Communication Systems
sharing important information and learning how to get what you want 
(Gray, Fitch, Davis
& Phillips, 1997). Informational support can include sharing 
information about one's
own experiences with breast cancer so other women know what to expect 
or the sharing
of other medical information that one finds through other means 
(e.g., the Internet,
television, doctors, brochures). Furthermore, the constructivist 
framework argues that
much learning is social and takes place in "communities of practice" 
where people
interact with, and learn from, one another in similar activities 
(Lave, 1988). These may
be formal places such as a classroom, or less formal such as an online support
community. Sometimes learning is direct, but much more of this type 
of learning occurs
informally or incidentally.
Communication services in CHESS include text-based, asynchronous bulletin
board style Discussion Groups to anonymously share information and support.
Historically, the Discussion Group service has consistently been the 
most frequently used
service within CHESS (McTavish, Pingree, Hawkins & Gustafson, 2003). 
The groups
are monitored by a trained facilitator to ensure that discussions are 
supportive and do not
contain unchallenged inaccurate or harmful information. However, the 
facilitator does
not take an active role in guiding the women about what they should 
communicate about.
Communication services also include the ability to ask questions of a 
Cancer Information
Specialist trained by the National Cancer Institute and receive a 
response within 48 hours.
Interactive Services
In interactive services, the computer takes a more active role in 
guiding the user,
making suggestions, offering feedback, identifying deficits, and 
shaping the user's
6
How People Learn Using Interactive Cancer Communication Systems
behavior. In these services, the computer plays a role traditionally 
identified as
counseling or teaching. Interactive systems use data about users to offer more
appropriate feedback because they appraise computer users' particular 
contexts and/or
preferences. Interactive services include the following: Action Plan 
that helps women
make healthy lifestyle changes; Decision Aid, which empowers women to make
treatment decisions based on their own values and priorities, Health 
Tracking that tracks
women's symptoms and psychosocial status over time; and Journaling, 
which guides
women though a series of guided writing exercises intended to help 
them make sense of
their cancer experience and improve emotional well being.
Hypotheses
There are two primary hypotheses being examined in this study. The first
hypothesis, seeking to reaffirm past literature, is to demonstrate 
that information,
communication and interactive services will each have an 
independently positive effect
on learning outcomes.
H1: Information, communication, and interactive service use will be positively
associated with health information competence.
Second, based upon constructivist theory, it is hypothesized that 
people who use
information services, which are delivered via a transmission-oriented 
educational model,
will show improved learning outcomes when used in combination with 
communication
services or interactive services that employ constructivist 
pedagogical methods. It is
7
How People Learn Using Interactive Cancer Communication Systems
expected that the acts of communicating with others or using 
Interactive Services that
take a more active role in guiding the user will enhance learning 
outcomes beyond merely
reading static information services alone.
H2: The effect of information service use on health information 
competence will
be amplified when people are more involved in communication or 
interactive serivces.
Methods
Data
The data analyzed in this study were collected as a part of a larger 
Digital Divide
Pilot Project (DDPP) where underserved breast cancer women in rural 
Wisconsin and
Detroit, Michigan were given access to CHESS for 4 months. Both 
pretest and a 4-month
posttest surveys were conducted with a sample of 231 patients (81% 
return rate from 286
subjects). Subjects were paid $15 for each completed pre- and 
post-test. 62.3% of the
DDPP participants were Caucasian, 35.9% African American, and 1.7% 
other minorities.
Patients were identified through a variety of sources, including the Cancer
Information Service, hospitals and clinics, public health 
departments, and the Medicaid
program. They were eligible if they were at or below 250% of the 
Federal Poverty Level,
within one year of diagnosis or had metastatic breast cancer, not 
homeless, and able to
read and understand an informed consent letter. All study 
participants were loaned a
computer and given Internet access for 4 months. They also received 
personal training to
learn how to use the computer and the Internet, but the majority of 
time was spent on
8
How People Learn Using Interactive Cancer Communication Systems
learning how to use CHESS. Recruitment began in Wisconsin in May 2001 
and ended in
April 2003. Detroit recruitment began in June 2001 and ended in April 2003.
Measures
Health information competence assessing a breast cancer patient's 
perception that
she could get and use health information serves as our dependent 
variable. This concept
is an appropriate constructivist measure for learning as it 
prioritizes the individual's selfperception
about whether she has the information she needs to cope with cancer rather
than objective knowledge that is constructed by experts. Information 
competence was
operationalized as an additive index (pretest _ = .75; posttest _ = 
.79) of five items that
asked, on a five-point scale ranging from 0 = never to 4 = always, if 
respondents know
what I want to learn about my health; can figure out how and where to 
get information;
health information is more difficult to obtain than other information 
(reversed); satisfied
with way I currently learn about health; or feel in control how and 
what I learn about my
health.
Antecedent Variables
We controlled for a number of variables that are expected to possibly 
influence
the relationship between independent and dependent variables in the 
model. Specifically,
we controlled for basic demographics including age (M = 51.58, SD = 
11.81), race
(62.3% Caucasian, 35.9% African American, and 1.7% other minorities), 
live alone
(72.7% 'no' and 27.3% 'yes'), and education (0.9% some junior high, 
10.4% some high
9
How People Learn Using Interactive Cancer Communication Systems
school, 31.2% high school degree, 29.9% some college, 12.1% associate 
or technical
degree, 12.1% bachelor's degree, and 3.5% graduate degree).
[TABLE 1 ABOUT HERE]
In addition, we controlled for disease related factors such as stage of cancer
(70.1% early stage and 29.9% late stage) and number of days between 
diagnosis and
intervention date (M = 117.48, SD = 130.30) because previous studies 
suggest both are
associated with patient's levels of psychological adjustment and 
distress (Carroll, 1998;
Keller, 1998). Finally, the pretest counterpart of the dependent 
variable (M = 2.39, SD =
.72) was also controlled.
CHESS use
A browser was developed by our research team to automatically collect use data
on an individual keystroke level as participants used the system. 
This capability enabled
us to track each user's code name, data, time spent, and URL of every Web page
requested.
The key variables of interest are three measures of CHESS service use:
Information (M = 35.46, Mdn = 16.89, SD = 56.78), Communication (M = 
581.82, Mdn =
110.85, SD = 1426.31), and Interactive service (M = 27.84, Mdn = 
9.88, SD = 52.86).
These measures are operationalized as total time spent (as measured 
by minutes) in each
service during the four-month study period. In addition, we took the 
logarithm of CHESS
use and used these as our independent variables because of the 
positively skewed
distribution of the variables.
10
How People Learn Using Interactive Cancer Communication Systems
[TABLE 2 ABOUT HERE]
Analytic framework
Hierarchical regression analysis was performed to test the effect of CHESS
service use on the information competence. To examine main effect of 
three types of
CHESS service use (H1), the group of control variables including 
demographics was
initially entered in a regression model and then the pretest score of 
the dependent variable
(i.e., information competence) was also included. Next, each of CHESS 
service use was
added separately in order to assess whether this variable explained a 
significant additional
part of the model variance. Since the three CHESS use variables were 
highly correlated,
we followed this statistical guideline suggested by Agresti and 
Finlay (1999) as a way of
reducing the effects of multicollinearity.
To test interactive effect among CHESS service use (H2), the same procedures
were repeated with demographics and pretest information competence 
being controlled
first, followed by the main effects of three CHESS service use, and 
finally by two
interaction terms. To address the issue of multicollinearity between 
the product term and
its components, the main effect variables were standardized by 
translating them into zscores
prior to creating the interaction terms (Cohen & Cohen, 1983).
Results
Table 3 shows the results of a hierarchical regression model predicting breast
cancer patients' information competence. First, the influence of 
demographic variables
11
How People Learn Using Interactive Cancer Communication Systems
did not appear to be strong, although younger women tended to feel 
more competent in
dealing with health information than older women (_ = -.162, p < 
.01). As expected, the
pretest counterpart of the dependent variable had a strong 
significant relationship with the
dependent variable (_ = .485, p < .01). Taken together, the control 
variables accounted
for a significant portion of the variance in the criterion variable 
(26.3%, F(8,218)=9.734,
p < .01).
When amount of use of each of the three kinds of CHESS services were entered
separately after these control variables, two of the three CHESS use 
variables were
significant. Interactive service use had a significant relationship 
with information
competence (_ = .141, p < .05), even after controlling for 
demographic variables and a
pretest counterpart of the dependent variable. Information service 
use also had a
significant main effect on information competence (_ = .153, p < 
.01). However,
communication service use was not significantly associated with the 
dependent variable.
[TABLE 3 ABOUT HERE]
In addition to these main effects (H1), the two interaction terms 
were included to
test whether use of the communication or interactive service modify 
the effect of
information service use on patient's information competence (H2). As 
shown in Table 3,
the interaction between information and communication services was 
significant and
there was a trend toward interactive services amplifying the effects 
of information
services though this interaction did not reach significance. Contrary 
to our predictions,
there was a negative coefficient of the interaction between information and
communication service on health information competence (_ = -.235, p 
< .01). In order to
12
How People Learn Using Interactive Cancer Communication Systems
examine the negative sign of the beta, we plotted this finding in 
Figure 1. For both high
and low communication service users, information competence increased 
as patients used
the information services more. However, the growth was greater for 
users who used the
communication service less, which demonstrate that the use of 
communication service
lessened the potential benefit of information service use.
However, consistent with our hypotheses, the relationship between the
information service use and information competence was stronger for 
patients who spent
more time in the interactive service than for patients who do not (_ 
= .153, p < .10).
[FIGURE 1 AND 2 ABOUT HERE]
Discussion
These findings partially support the first hypothesis in finding that 
information
and interactive Services contribute to health information competence 
while use of
communication services did not contribute to enhanced educational outcomes.
This study also partially supports the constructivist idea in the 
second hypothesis
that more active pedagogical methods will enhance learning. While use of
Communication services did not enhance learning outcomes, results did 
indicate that
intelligently designed computer programs may supplement and extend 
the learning
potential of information services delivered via a 
transmission-oriented pedagogical
approach. Researchers should continue to examine the best way to 
develop interactive
services that can optimize specified learning outcomes.
One limitation of this study is that it looks at self-reported information
competence as a measure of learning and future research might also employ a
13
How People Learn Using Interactive Cancer Communication Systems
methodology that allows for a more objective measure of breast cancer 
knowledge.
However, one of the theoretical arguments of constructivist learning 
is that knowledge
should be constructed in a way that is most meaningful to the 
learners themselves rather
than a one-way model of education. Surely, however, there is room for 
some expertguided
learning in health education, as research indicates that women do 
sometimes have
misperceptions about breast cancer treatments and causes.
Another limitation of this research is that it quantifies use of communication
services in terms of minutes but it seems likely that the mechanism 
for the effects of
communication services is not how much time they use the services for 
but rather the
type of issues people talk about (e.g., Shaw, Hawkins, McTavish, 
Pingree & Gustafson,
in press). Communicating about the weather or what happened over the 
holidays may
provide a sense of community between members but it is unlikely to 
produce any tangible
educational outcomes. As Mayer (2004) argues, the volume of 
discussion should not be
expected to contribute to learning if the content of those 
conversations does not directly
relate to the educational effects being measured. Future research 
should look not just at
how much dialogue occurs between patients within ICCSs but also what 
they talk about
to determine how both the quantity and quality of interaction effects 
learning outcomes.
On this note, it is worth reminding the user that while a trained facilitator
monitored the Discussion Groups in this study, by design the 
facilitator did not take a
very active role in guiding conversation around specific educational 
objectives. That
said, the CHESS model of online support groups is more structured 
than the vast majority
of support groups on the Web, which do not have a facilitator at all 
(Klemm at al., 2003).
No studies have been conducted on the effects of having a facilitator 
or not within online
14
How People Learn Using Interactive Cancer Communication Systems
support groups, and future research should examine the added benefit 
of a facilitator who
takes a more active role in guiding conversation around educational 
objectives.
It is also important to note that this secondary analysis only 
examined information
competence as an outcome, which was the most relevant dependent 
variable available for
measuring the educational effects of using the various types of 
services available within
CHESS. These findings say nothing about any number of other benefits 
that may have
occurred as a result of using the communication services such as 
enhanced social support
or emotional well-being, which are results that have been found in 
previous CHESS
studies (Shaw, Hawkins, McTavish, Pingree & Gustafson, in press; 
Shaw, McTavish,
Hawkins, Gustafson & Pingree, 2000).
Another thing to remember is that use of communication services did 
not decrease
information competence but rather those who used information services 
benefited less if
they were more frequent users of communication services. While this 
finding runs
counter to the hypotheses put forth in this paper, it is consistent 
with some previous
research on CHESS effects, which has found that more balanced use of 
time between
information and Discussion Group have more positive results than 
those who use the
system with a more lopsided bias toward use of the communication 
services (Pingree,
Hawkins, McTavish & Gustafson, 2002) and generally speaking the total 
amount of
minutes spent in by users in the communication services (particularly 
Discussion Group)
was far more than was spent in either the information or interactive services.
Finally, while this article takes an important step forward in contributing to
understanding how people learn from ICCSs, the correlational analysis 
is only suggestive
and an experimental design would provide the opportunity to more 
precisely understand
15
How People Learn Using Interactive Cancer Communication Systems
how different types of service utilization contribute to health 
education outcomes. A
current clinical trial funded by the National Cancer Institute being 
conducted at the
University of Wisconsin-Madison Center of Excellence in Cancer Communication
Research is employing an experimental design looking at the 
differential effects of
providing users different configurations of CHESS services including 
information,
communication (person-to-person) and interactive (computer-driven 
tailoring and
coaching) services. While it is hypothesized that there will be some 
knowledge from
providing users information services alone, it is expected that 
offering information
services in combination with communication and interactive services 
will demonstrate
significantly stronger outcomes. Results of this study will be 
forthcoming and should
allow the opportunity to quantitatively demonstrate the added value 
of constructivist
pedagogical methods. This article represents part of this effort by 
offering a theoretical
framework and some quantitative insights about how users appear to 
learn as a result of
using ICCSs.
16
How People Learn Using Interactive Cancer Communication Systems
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How People Learn Using Interactive Cancer Communication Systems
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How People Learn Using Interactive Cancer Communication Systems
Table 1. Demographic characteristics (N = 231)
Age
Mean (SD)
Ethnicity
Caucasian
African American
Other minorities
Live alone
Yes
Education
Some junior high
Some high school
High school degree
Some college
Associate or technical degree
Bachelor's degree
Graduate degree
Days between diagnosis and intervention
Mean (SD)
Stage of cancer
Early stage (stage 0,1,2)
51.58 (11.81)
144 (62.3%)
83 (35.9%)
4 (1.7%)
63 (27.3%)
2 (0.9%)
24 (10.4%)
72 (31.2%)
69 (29.9%)
28 (12.1%)
28 (12.1%)
8 (3.5%)
117.48 (130.30)
162 (70.1%)
21
How People Learn Using Interactive Cancer Communication Systems
Table 2. Descriptive statistics of CHESS service use during four 
months (minutes)
Mean
30.23
433.45
SD
40.60
830.86
34.42
Median
16.33
104.46
9.22 22.86
CHESS service use
Information service
Communication service
Interactive service
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How People Learn Using Interactive Cancer Communication Systems
Table 3. Hierarchical regression analysis predicting information 
competence (posttest)
Control variables
Age
Ethnicity
Live alone
Education
Days between diagnosis and
intervention
Early or late stage
Incremental R2 (%)
Information Competence (pretest)
Incremental R2 (%)
CHESS use
Interactive service l
Communication service l
Information service l
Incremental R2 (%)
Interactions
Information service ¥
Communication service
Information service ¥
Interactive service
Incremental R2 (%)
Total R2 (%)
Note:
- Main effects of CHESS use were entered separately to the regression 
model in order to
avoid multicollinearity problems. However, incremental R2 of 'CHESS use' block
(2.6%) reflects the value when all three variables are entered together.
- l Log transformed due to the high skewness.
- p <.10*, p < .05**, p <.01***
2.3**
31.1***
Beta (standardized)
-.162
.039
.040
.037
.096
-.063
.485
.141
.093
.153
-.235
.153
t
-2.630***
.640
.662
.649
1.653
-1.082
4.3
8.308***
22.0***
2.410**
1.495
2.635***
2.6*
-2.628***
1.707*
23
How People Learn Using Interactive Cancer Communication Systems
Figure 1. Interaction between Information and Communication service 
use in predicting
four-month information competence (estimated marginal means).
Note:
- Pretest information competence was controlled.
24
Figure 2. Interaction between Information and Interactive service use 
in predicting fourmonth
information competence (estimated marginal means).
3.0
2.9
2.8
2.7
2.6
Low
Note:
- Pretest information competence was controlled.
Information Competence
How People Learn Using Interactive Cancer Communication Systems
Interactive service High
Interactive service Low
Information service
High
25