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Proud and happy to call myself a ‘Master of Arts’

From E-Learning V

Fig.1. Mr Kung Fu – was he the master or the pupil?

When I completed enough modules early last year to graduate as a ‘Master of Arts: Open and Distance Education’ I felt like a fraud; I’d scraped through, more importantly I didn’t feel I was ‘fluent’ enough in the subject. One module, H817 had been replaced and had felt a little dated at the time. This is why I’ve ended up doing a couple more MA modules from the MAODE – I have only one missing from the full set (H817 Open) which I may do in due course. I could even put it towards an M.Ed (Masters degree in Education) for which I also need the compulsory 60 point module Educational Enquiry which next registers a year from now.

From E-Learning V

Fig.2 The forgetting curve

Confidence to call myself a ‘Master’ and belief by others that I know my subject led me to being asked to join the Open University advisory panel on the MAODE and in the same week to join the board of advisors for a national educational body that recently met. Now I feel I have enough of ‘the knowledge’ at my fingertips. I prepared for this first meeting my searching through this blog: it shouldn’t surprise me to know how much I’d forgotten, studying why and how we forget is very much a part of education – it is summed up in the Forgetting Curve (fig.2) that Hermann Ebbinghaus thought up over a hundred years ago.

From E-Learning V

Fig.3. SatNav (not me)

It intrigues me that no gadget we own can circumvent this: that in fact, take a SatNav for example, let’s assume that it takes you on a journey in the correct direction. Let’s say you keep using the SatNav regardless. You could probably turn it off after two or three of these trips as your brain lays down the landmarks in your longterm memory. Thinking of which, I think the SatNav makes an excellent model for e-learning; just image you need to learn 120 absolute facts as a junior doctor – you could have your SatNav ‘peg’ the facts to specific points of a familiar journey. When you sit the exam it’s then as easy as driving this route in your mind’s eye visualisation everyone of the facts along the way.

I wander, cloud like.

I’m writing up my notes from this national advisory panel and over the next four years can hopefully nod at the courses that appear on which I’ve had some influence. Still not there yet, but I’m one heck of a long way further on since February 2010 when I re-booted this malarkey.

The answer has to be a P.hD. And I guess the only place to do that would be with the Open University. I went off the boil on that one a year ago, though I did secure a couple of interviews but came away suitably crushed.

It will have taken by then, at least ten years, more like 12 or 13, to call myself a ‘Digital Scholar’.

How to take notes for effective studying and assessment

Fig.1. The muddy sides of the River Ouse, Piddinghoe. At low tide.

We are very good at forgetting: it’s vital.

We see, feel, sense far too much in our daily lives (which includes when asleep). Come to think of it what on earth was I doing on a student exchange to North America last night where I am twenty years older than my hosts … (probably sums up how I feel about the workplace).

See. Some memories are made for us, or by us whether or not we want them.

Learning though requires us to gather, create and retain stuff. Some of this stuff is forgettable; it doesn’t resonate, or is poorly taught or expressed. Or we simply don’t get it the way it is expressed, or the first time around.

Fig.2 Neuroscience of dummies

Make it a memory

At an OU Residential School the session on revision was packed. The tips made us laugh: sucking a choice of Polo Fruit sweets by subject theme – when you come to the exam repeat and each sweet will link you to that period of revision. Odd. But it worked often enough for me to convince me of its value.

Fig.4. Ebbinghaus and his ‘Forgetting Curve’

The science from the likes of Hermann Ebbinghaus and his ‘Forgetting Curve’ simply indicates how something fades, unless you go back to it a few times over several days over which period you make it stick. It doesn’t say anything about the ‘stickiness’ of the memory in the first place. Sometimes this stickiness is made for you. There is drama, there is an explosion. Most likely, by chance, the learning is anchored by some unrelated event like the fire alarm going off – that won’t work for 50 different things though.

Fig. 5 Multiple ways of making ‘it’ stick: read (book and e-book), highlight, tag and take notes.

If the module, or your tutor isn’t doing it for you then the next step is to dig around for a book, video or image that does it for you.

Most likely, and of far greater value, is for you to turn that lesson into a memory of your own creation. There is always value in taking notes, so never listen to the presenter who says ‘no need to take notes I’ll give you the slides afterwards’. Never trust the quality of the slides. What the person said will be of more value then the slides. You, and your handwriting, and your doodles are how it starts to become a memory. Then when you write up or rewrite those notes you do it again. You make it into something.

Fig.6 The River Ouse at low tide.

I’m fixating on the horror of drowning in a shell-hole in the First World War.

Ever since I was a boy those images of cowboys and Arabian princes sinking into quicksand has horrified me. What must it have been like? Walking the dog by the River Ouse at low tide just as it turned the gurgling of water backing up and filtering into the muddy bank gave me the shivers. That sound was ominous. It made a memory of the walk and the thought. It’s also what is sustaining me as I work at a short story.

Fig. 7 A family memory of a wedding in California. Will it stick?

We’ve talked about ‘memory making’ in the family.

It is the event, and the sharing of the event. My late mother-in-law was horrified that her daughter couldn’t remember a road-trip they did across the US when she was 13. I concluded that she hadn’t remembered much, or couldn’t remember much when it was mentioned out of the blue, as the trip was never shared. Conversations are and were always about current and future events. This is why it helps to get the old photo albums out from time to time. But there’s a loss. Do we make them anymore? Visiting a mislabelled album online is never the same.

Fig. 8. My late grandfather John Arthur Wilson MM with the author Lyn Macdonald at the spot north of Poelcappelle, Belgium where he buried two of his mates – 75 years after the event. He recalled it ‘like yesterday’.

Recalling the First World War

Some veterans would talk, others remained silent. Those who did not want to remember could and did forget. My late grandfather was a talker; it drove my mother mad. I came to love his recollections. Clearly, there were events that would have burned themselves into the memories of these men, but unless they talked about it, in a veteran’s association or with family and friends it was not going to stick. No wonder veterans would seek each other out over the decades. Nudged by histories and movies their memories could be changed though; sometimes they came to say what was expected of them ‘the rats were huge, the generals useless, the German bunkers impenetrable, the mud up to your waist, the sound of the individual shells … ‘

In conclusion

Whatever activities and devices are built into your module, you are responsible and can only be responsible for making something of it. Take the hint. Engagement takes time so make the time for it. These days it is made easier through the Internet. You can keep a blog to share or as a learning journal; you can talk it over with fellow students either asynchronously in a forum (or blog), or synchronously in a webinar. You can ‘mash it up’ with images, grabs, doodles and annotations. You can make it your own. It’ll stick if you want it to but superglue requires effort. Someone else ‘sticks it’ for you and it won’t happen.

Can an email-prompted web-based e-learning platform aimed at undergraduates in the UK with moderate to persistent asthma improve compliance to their prescribed preventer drugs to 80%?

Fig. 1 Preventer, Reliever and volumetric. With good adherence the ‘brown one’ is taken as prescribed and the ‘blue one’ rarely needed. With poor adherence there is no brown on and there is dependence on the blue one. In this example a QVAR easibreather and a Venotlin inhaler. Mine. 

By presenting these ideas here I asking for support on how to make this research happen.

The medical profession is replacing the term ‘adherence’ with the term ‘compliance’. This reflects the desire to encourage self-management of prescribed drugs in concordance with health care providers (HCPs). For the purposes of this paper the terms should be considered interchangeable.

Asthma is a chronic and complex condition affecting the lungs that can be managed but not cured. (NHS Choices, 2013) (See Appendix 1 for a definition of ‘moderate to persistent asthma’). The World Health Organisation estimates that 300 million people globally are asthmatic (Web, 2001) while in the UK in 2010 5.4 million people were receiving treatment for asthma and there were 1,143 deaths. (Asthma, UK. 2013) An estimated 75% of hospital admissions for asthma are avoidable and as many as 90% of the deaths are preventable. (Asthma, UK. 2013) 80% compliance is the minimal level required for treatment to be effective (Lasmar et al., 2009).

Research construct

Asthmatics form a heterogeneous group that shows great diversity of triggers, effective medication, management strategies and outcomes. Research clusters asthmatics into four to six groups based on how they present and the drug regime they are on (Webb, 2011). Isolating a participant’s conditions and being confident that their medication is correct will be a challenge. For this reason, thorough in-depth interviews with participants, potentially with an HCP present, will be vital in order to set a benchmark.

A team at Harvard Medical School designed Qstream, the proposed e-learning platform (Kerfoot et al., 2008). Qstream (Fig.1.) takes its approach from an understanding of Ebbinghaus (Ebbinghaus, 1913) and how we forget and remember to provide a spaced-learning response that uses a combination of email alerts and interactive content to build knowledge. Its use has been researched with junior doctors in relation to their formal medical training and assessment (Kerfoot et al., 2008; Kerfoot et al., 2012) and in applied settings with healthcare practitioners to support informed decision-making. (Kerfoot et al., 2010)

Fig.1. Screengrab from Qstream homepage. (www.qstream.com)

On the basis of their research, Dr B Price Kerfoot says that ‘educational games work’ (Kerfoot et al., 2008. Kerfoot suggests that the next step is to use this approach with patients and ‘clinical decisions of greater complexity’ Kerfoot (2010:477). Research using Qstream involving people with chronic illnesses is planned to take place in North America in the Fall of 2013 (Vernon and Kerfoot, 2013).

What is the problem?

Too many people with a chronic illness, such as asthma, fail to take their medication as prescribed (Royal Pharmaceutical Society (RPS) of Great Britain, 1997; Hayes et al., 1979). This can lead to an exacerbation of the disease, risks hospitalization and even death. Non-compliancy rates are between 10-60% (Cochrane, 1992. Rand,1994), 30–50% (Horne, 1999), 50% (Di Matteo, Giordani, Lepper & Croghan, 2001; Kyngas, 2007 in Wales et al., 2011:148).

Reasons for non-compliance include medication side effects, expense of treatment, personal value judgments or religious or cultural beliefs about the proposed treatment, age–related debility, not having an action plan prescribed by an HCP, the patient not following the adequate treatment prescribed (Cerveri et al., (1999:288) or the presence of a mental disorder (e.g., schizophrenia, personality disorder).  American Psychiatric Association [DSM-5], (2013:726).

What is the opportunity?

According to McGavock et al., (1996) efforts to improve compliance have been unsuccessful; it is hoped that efforts using e-learning will be successful. The healthcare community – manufacturers, prescribers and frontline carers, recognise that education offers a way to reduce hospital admissions and deaths (Cerveri et al.,1999:288). The opportunity exists to increase compliance to 80% and therefore improve the health of millions of people with asthma.

A variety of programmes have tested a potential solution to non-adherence. (Byer & Myers, 2000; Hand, 1998; Tettersell, 1993), while Hacihasanoğlu and Goözuöm (2011) showed that patient education on medication adherence is effective. A variety of studies on e-learning in healthcare have used emails linked to multiple-choice questions and answers to improve patients’ knowledge and behaviours (Volpp et al. 2009; Kato et al. 2008).

The hypothesis

The hypothesis is that as a result of greater compliance through a ‘spaced learning’ e-learning education programme, non-compliant moderately persistent asthmatics will show changes in measurements of their illness and changes in their medication beliefs. (Based on Petrie et al., 2012:76).

Desired outcomes / results

Having completed a programme of e-learning using Qstream people with moderate to persistent asthma who had been noncompliant (under 80% compliant) should show changes in their illness and medication beliefs, improved compliance to their preventer inhaler and measured improvement across a range of physiological measures. (Based on Petrie et al., 2012:76) As a result of what they learn, the research will address patient perceptions, such as beliefs (Horne & Weinman, 2002), worries about long term use of steroids (Apter et al., 2003), fears and other concerns (Kaptein, Klok, Moss-Morrs & Brand, 2010). For example, 28% of asthma patients think that drugs are bad and not necessary while 12% think that drugs may not be not bad but aren’t necessary. Cerveri et al., (1999:292).

Achieving a reasonable level of compliance with treatment regimes has been shown to improve the health outcomes of patients undergoing treatment and reduce demands on health resources (Bender, Milgrom, Wamboldt & Rand, 2000; Dunbar-Jacob, Burke & Puczynski, 1995).

The long-term and broader opportunity exists to reduce hospitalizations, reduce costs, improve and extend lives.

Learning Theories

The learning theories that form the basis of Qstream are behaviourist (Skinner, 1974) and cognitive (Wenger, 1987; Hutchins, 1993; Anderson, 1983; Piaget, 1952) with problem solving, explanations and re-combinations. In line with this behaviourist approach early versions of Qstream worked best in formal learning contexts, for example first year medical students needing to pass an exam on anatomy. (Kerfoot et al., 2008) and practical clinical guidelines (Kerfoot et al., 2009). By complementing traditional medical training, with clear goals and the motivation to pass, the attraction of the platform are clear in this context. This stimulus-response approach, builds on the work of Ebbinghaus (1913) (Fig. 2)

Fig. 2. A typical forgetting curve for newly learned information. After Ebbinghaus (1913)

Through association, the learner takes a number of steps to build a composite skill. (Skinner, 1984; Gagné, 1985) (Fig.3) An accurate reproduction of knowledge can be assessed or demonstrated in drill and practice.

Fig.3. Screengrab from Qstream showing how a participant receives feedback on their response to a multiple-choice question.

Later and current versions of Qstream include components of peer competition, participant interaction and collaboration. This constructivist approach takes the view that learners build their own structures (Piaget, 1954). It also suites task orientated learning (Bruner, 1993) and assimilative learning. This constructed and socio-constructed approach to learning is less suited to assessment simply by looking at exam grades, therefore in-depth interviews or comprehensive self-reporting surveys are required to elicit what took place and the level of knowledge attained especially as evidence of learning by people with asthma won’t be elicited through formal assessment.

Why undergraduates?

The research shows that younger asthma patients in the age 14-25 years are less likely to use their preventer medication than older patients (Diette et al., 1999; Legorreta et al., 1998), which makes ‘young people an important group to target for improving adherence and reducing their underuse of preventer-inhaler corticosteroids’, (Pertie et al., 2012:75). For this reason, and to exploit study parameters of population size and geography, a university undergraduate population is proposed.

METHODOLOGY/METHODS

A mixed-method approach will be adopted with qualitative and quantitative components. In-depth pre and post intervention interviews will form the qualitative element, while the quantitative component will be based on several hundred student participants taking part in a randomized controlled trial and use analytics generated by the Qstream platform. The aim is to interview approximately 30 students in-depth within the parameters of a single university. For example, Adams, Pill & Jones, (1997) favoured in depth interviews with a carefully selected and eligible number of patients before and after intervention. For quantitative analysis the far larger pool of participants will be drawn from a UK wide undergraduate student population using platforms such as The Student Room (www.thestudentroom.com. The Student Room, 2013) and Asthma UK to recruit participants. According to Kerfoot & Baker (2012) an individual randomized control trial is preferable were there is a large sample size. Extending to a sample of four UK universities might increase the potential number of participants to 9000+ (See Appendix 2). Self-reporting screening would be used to ensure that only those in the desired group took part.

Based on UK statistics on asthma in the population, it can be calculated that at, for example, the University of Southampton from a total undergraduate population of 17,000 there are likely to be between 485 and 586 students with moderate to severe asthma. (This intentionally excludes those likely to have a mild form of the disease, and those with a profoundly severe form of the condition). (See Appendix 2 for break down of likely respondents). Asthma UK (2013) suggests that amongst asthmatics 48% consider themselves to be at risk. If this percentage of potential participants volunteered then the starting population for the proposed research is likely to be around 250. It is reasonable to suggest that by working with four different universities of a similar size the total population for a randomized control trial would increase to 1,000.

Identifying those who are moderate to severe asthmatics and agreeing criteria has confounded asthma studies in the past, therefore great care will be required to set parameters, the simplest being that where an asthmatic has been prescribed only two medications, a preventer inhaler (known as the ‘brown one’) and the reliever inhaler (the ‘blue one’) that their condition is considered to be ‘moderate to severe’.

Having a sound basis for giving a person’s baseline, for both compliance and knowledge of asthma and how it is treated, will indicate if an improvement in adherence has been made and whether this e-learning approach has been effective.

To have a physical measure you can audit the prescriptions issued or weigh the inhalers to establish how much has been expelled, however Spector (1985) found cases of both miss-application and trial firing.  A blood test is definitive, but this could only be carried out by an HCP. The alternative is to ask patients how they got on, however patients are thought to overestimate their actual drug use by between 30 and 50% (Spector, 1985; Sacket and Snow, 1979). In the case of people with asthma, Horn (1992:126) found that 11% who claimed to have inhaled salbutamol in the preceding four hours had no detectable drug in their urine.

Whilst therefore there are advantages in conducting interviews, patients are giving a subjective measure of their treatment compliance (Sawyer, Rosier and Phelan, 1995). This method suffers from being the most inaccurate of any available (Horn, 1999:126), however the alternative requires a series of tests that need to be administered by an HCP.

This ethnographic investigation would be open and exploratory  (RPS, 1997). A system of meanings would be taken either from transcripts (Scherman and Löwhagen, 2004:4) or preferably from audio recordings as current best practice in medical market research favours working from the audio as nuances of meaning are more likely to be apparent (Kazmer & Xie, 2008).

Given the complexity of influencing compliance and the desire to use this as a measure of effective learning, structured and semi-structured in depth interviews will take place. In addition physiological improvements to lung functionality need to be measured for a sample of the participants to offer an objective indicator that a change of behaviour has occurred.

Other influences on outcomes that should be revealed in a semi-structured interview include issues of identity in relation to learning (Kirkup, 2001; and Hughes, 2007) and motivation, what Resnik (2008) describes as ‘passion based learning’.

The text from these interviews will be analysed for clusters of meaning, aiming to pick out nuanced responses, potentially from video but at least from audio recording of interviews (Kazmer & Xie, 2008), which according to Webb (2011) is preferable to working from text alone

The aim would be to reveal the experiences of those interviewed and so come to a view of ‘understandings and misunderstandings’ about their condition, the role their prescribed ‘preventer’ medication plays and the value of Qstream.

Qstream offers a variety of ways to monitor and measure activity on the platform (fig. 4) . This is how data and metadata from several hundred participants would be analysed. (Appendix 3 lists the affordances of using a Qstream private site)

Fig. 4. Screengrab showing example of analytics available on a group of 356 learners.

TIME LINE CHART


Fig. 5. Simplified model of research. Punch (2006: KL 487 )

Phase One

  1. Submit Proposal

  2. Seek and secure funding

  3. Purchase UK license for Qstream.

  4. Undertake training on the Qstream platform

  5. Seek approval from appropriate ethics committee

  6. Speak to and engage subject matter experts and HCPs: consultant, GP, practice nurse, welfare office and disability officer.

  7. Consider the merit of ‘reversibility testing’ which involves taking measurements of asthmatics’ breathing before and after the Qstream ‘trial’.

  8. Prepare content for Qstream: text, images, multiple-choice questions. Contents to include: bite-size video, interactive notes and legalese.

  9. Prepare recruitment communications (posters, email campaign, university and student websites, the student rooms, Asthma UK.)

  10. Test platform on university server

  11. Email links to online survey

  12. Screen potential participants to under 1000 and divide for randomized controlled trial. See Kerfoot et al. 2010:332 Flowchart of a randomized controlled trial.

  13. Filter the sample for in-depth interviewing from those enquiring about respiratory symptoms, attacks of asthma, use of asthma allergies, together with questions on how they have or usually gain knowledge on the disease, its treatment and their diagnosis and compliance behaviours. This is likely to be kept to one geographical and healthcare region based on the population of a single university.

  14. Conduct initial interviews from this filter group to establish eligibility.

Eligibility for interviews and physiological testing would be based on patients with the indicated symptoms though excluding patients with serious social problems and severe learning difficulties. (Franklin et al., 2006)

  • Who?

  • How many?

  • Age?

  • Gender?

  • Where referred?

  • How long diagnosed for?

  • Smoking or not?

Aim to recruit 30+ students for in-depth interviews and <1000 for a randomized controlled trial using the Qstream platform.

Confirm participants, ensure that they understand the terms and nature of the research and request that they read and agree to these and that participation is voluntary, information will be confidential and their written consent is required.

Invite all or some to complete either an asthma Journal or, as they have been shown to be effective, an audio log. Patient-reported outcomes would help us understand the impact of drugs on patients’ lives and activities. “Are patients really doing better? Can they sleep through the night rather than waking up with a sense of shortness of breath?” Bohen (2013: 863)

Phase Two

Pre-Qstream Interviews

  • Conduct in-depth interviews to establish baselines for compliance as well as knowledge of asthma as a chronic illness with responses given on a Likert Scale. (Horne, 1999).

  • Video or audio record.

  • Horn’s ‘Offer Self Image Questionnaire’ (1977) will be used as part of the in-depth interview to Horn (199:126) considered this a central part of compliance assessment strategy. The chronic disease compliance instrument (CDCI) (Kyngas, Skaar-Chandler, and Duff, 2000) will be adapted and its use considered.

  • Complete physiological measurements: blood test, skin test and assessment of lung function and spirometry and airway challenge. Cerveri et al., (1999:289)

Run Qstream e-learning programme for 12 weeks

Phase Three

Post-Qstream Interviews

  • Conduct in-depth interviews to re-assess compliance. Aim to gauge how and if this has changed and why amongst the 30 selected for this purpose. Assess verbally for knowledge of asthma. Include questions on the Qstream platform itself. According to Van Dijik, 2005) questions after the intervention should include operational skills, managing the software on different platforms and how they got on with the multiple-choice process skills.

  • Video or audio record.

  • Repeat of physiological measures to understand if there have been improvements in, for example, lung function.

Analyse data and metadata generated by the Qstream platform

  • Listen through interviews and undertake cluster analysis of ideas and issues in order to establish patterns of meaning.

  • Is there a correlation between compliance and reduction in the severity of asthma?

  • Is there a correlation between increased compliance and completing the Qstream e-learning module?

Write up and report findings.

Follow up a year later to see if the impact of the learning is maintained over time through changing behaviours.

Limitations

No study of a therapeutic regime can be considered fully valid without some documentation of whether the patients took their treatment. Horn (1992:127) Establishing valid data on whether people take their medication as prescribed will be a challenge.

No single method of assessment of compliance with (anti-asthma) therapy is ideal nor does any one method give a full picture of the pattern of compliance. Usually the chosen method(s) will require to be validated specifically for the particular circumstances under investigation.

An issue arises with using an Internet and mobile alert system where potentially limited or broken Internet access or paid-for Wi-Fi impinges on the student’s access to the resources. Care will be taken both over how content is scripted and produced, as well as securing a robust platform. Kerfoot and Baker (2012:13) had problems in relation to: ‘server errors’,  ‘attrition’ (Kerfoot & Baker, 2012:4), ‘fatigue’ (Kerfoot et al., 2010) and technical hitches due to spam blockers (Shaw et al., 2011) as well as the challenging nature of the content. (In Vernon, 2013)

It is also reasonable to suggest that those who are noncompliant to regularly taking their prescribed medicine could also be ‘noncompliant’ to the features of Qstream – a twice or thrice weekly prompt to take a few minutes to answer some questions.

A UK license for up to 1,000 participants to use the Qstream platform is $15,000 per annum.

In research carried out by ZoRA et al. (1989). Only 1 in 17 diary sheets completed by asthmatic children (under age 14) were accurate to within 10% of the number of puffs used. Whilst the participants in this research are older, any completion of a dairy sheet will include errors and inaccuracies.

Overestimation in self-reporting is well known and probably due to a desire to please. (Cochrane, 1995. Cochrane 1998)

Failure of a therapeutic regime can only be ascribed to poor compliance if appropriate drugs are being prescribed in adequate dosage that historically has tended not to be the situation in the management of asthma. (Horn, 1992:127)

The population using the Internet is diverse. This impacts on research in relation to access and having a representative group of participants. (Eynon, 2009). The use of Qstream in a student population favours use of a mobile device for ease of response to email prompts. It is suggested that 53.7% of people in the UK will be using smartphones by 2014 with those aged 18-25 by far the largest group followed by teenagers (New Media Trend Watch, 2013) whilst it is estimated that nearly 38% will have tablets by this time. (eMarketer, 2013).

Ethics

For ethical reasons an institutional review board would be approached for approval to perform this study. (Kerfoot & Baker, 2012:2)  (In Vernon, 2013)

  • A standardized form will be used to obtain informed consent from participants.

  • Well Being, confidentiality and anonymity will be stressed.

  • Rights will be clearly explained

  • The personal safety of those conducting the research will be considered.

  • Conflicts of Interest will be declared, for example, Dr Kerfoot is on the board of Qstream.

  • Unintended consequences will be considered.

  • People have to have the freedom to make mistakes in relation how they elect to adhere, or not, to the prescription drugs they are prescribed. Mental Healthcare Act.

Validity and reliability

If one hope is to correlate a physiological change with improved knowledge an array of factors need to be isolated and measured. Data from both a qualitative and a quantitative approach, the clusters of issues and ideas from analysing what is said in pre and post interviews and the activity on the Qstream platform will offer some indication of what is taking place and why.

Implications for future policies, practice and further research

1) Socio-constructed learning and connectivism

It is further hypothesized that effective compliance is most likely to be achieved where in addition to the patient, the related HCPs engage in the proposed e-learning programme. Social interaction has an important role to play in learning. (Vygotsky, 1978) Donath (2002) shows how through exchanging information a person gains recognition and that social learning of this kind provides affiliation. This suggests value in having HCPs, even family, especially parents and guardians, of younger people with asthma taking part in a Qstream learning programme and exploiting how we connect in networks (Kit Yee et al., 2011) Wang (2008:05) considers the importance in learning of both the student and instructor. HCPs would play the role of ‘intermediaries’ (Laurillard, 1993).

This not only invokes ideas of values relating to communities of practice (Lave and Wenger, 1991) but also, in our digital age, to ‘connectivism’ (Siemens, 2006; Calvani, 2009: de Waard, 2011) – where ‘nodes of readily available information’ are linked to and shared between learners. (Edudemic, 2013) The asthmatic as a learner can question their own knowledge and understanding by connecting with others, as part of a ‘community of practice’ (Lave and Wenger, 1991), from the periphery (Brown, 2002; Brown, 2007) and vicariously (Cox, 2006). Connecting with other people with asthmatics online is supported by the Asthma UK website (Asthma UK, 2013)

2) Use of narrative and creative content

Fig. 5 Screengrab introducing a series of animated videos on design. Open Learn (2013)

The quality and style of scriptwriting using the Qstream platform will impact on effectiveness. (Laurillard, 2000 and Jewell and Hooper, 2011) understand the role of narrative in learning. Resnik and Chang (2008) talk about the need for e-learning to be self-revealing, pleasurable and fun, with a ‘low threshold and high ceiling, supporting collaboration, plugins and making it iterative’ and ‘tinkerable’. The Open University, through Open Learn, often use rich video content to engage audiences, for example with a series of short video in ‘Design in a nutshell’. (Open Learn, 2013)

3) Further personalisation of e-learning

Intelligent Web pages that can adapt themselves to a person’s linguistic and other competence are examples of more ambitious applications that we might look forward to in coming decades. (Hara et al., 2006:352)

4) Extend duration of study period

This study would initially be restricted to a single term or academic year, though it could be extended, for example, to include first year undergraduates through the 3 to 4 year duration of their undergraduate studies. Ostojic et al.,  (2005) carried out a 4-month trial, whilst trials run by Kerfoot (2008-2012) have run for as long as 45 weeks.

5) Include other chronic illnesses:

Allergic rhinitis is comorbid with asthma (Bousquet at al., 2013) warranting its inclusion in future research alongside studies on asthma. Other chronic illnesses that may benefit from Qstream’s use by patients includes diabetes, epilepsy, Parkinson’s and Alzheimer’s.

6) Consider ‘Big Data’, Web 2.0, Pedagogy 2.0

There is the potential of automatic real-time data gathering relating to inhaler use with a microchip and the use of wearable technology even an ingestible smart pill (Engineer Online 2012; Arnold, 2013) in medicine. Supported by enhanced patient knowledge of their illness. Armed with this data, analysed automatically, and read by the patient or an HCP, the drug regimen and response to it is closely monitored. Such patient analytics are akin to student performance analytics (Koller, 2012) providing HCPS and educators with the potential for gathering and analysing data and metadata from hundreds of thousands of participants.

Conclusion

The opportunity exists to develop an e-learning programme that change lives – that improves the health of those with moderate to persistent asthma. Research suggests that greater knowledge and understanding of a chronic medical condition and personal medical and lifestyle responses and self-management improves compliance. However, the way the illness presents are complex, the triggers and symptoms vary greatly. The approach suggested here also offers the chance to establish if learning brings about a change in behaviour that can be measured in a physiological response – improved lung function and the role an e-learning platform can play. In due course, if a reasonable percentage of the 300+ million asthmatics who are online engage with an e-learning programme such as this significant insights and improvements to health can be made.

REFERENCES

Adams, S., Pill, R., Jones, A. (1997) Medication, chronic illness and identity: the perspective of people with asthma. Soc Sci Med 1997; 45:189-201

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (Revised 5th ed.). Washington, DC: Author.

Arnold, M (2013), ‘A VIEW TO A PILL. (cover story)’, Medical Marketing & Media, 48, 6, pp. 26-30, Business Source Complete, EBSCOhost, viewed 26 June 2013.

Asthma UK (2013) Asthma facts and FAQs. http://www.asthma.org.uk/asthma-facts-and-statistics (Accessed 23rd June 2013)

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APPENDIX ONE

How to define asthma

MODERATE PERSISTENT – IN THE RESEARCH GROUP (aboutasthma.com)

Your asthma severity is classified as moderate persistent asthma when:

  • You have asthma symptoms daily.

  • You wake up from your asthma more than one night per week, but not every night.

  • You use your rescue inhaler daily.

  • Your asthma moderately interferes with your daily activities.

With moderate persistent asthma, you will need daily asthma medication with anti-inflammatory properties, as well as a second medication.

You are able to gain control of your asthma with two medications, what we call the ‘blue one’ and the ‘brown one’.

The brown one, the inhaled steroid, you take a couple of puffs in the morning and a couple at night.

The blue one, the reliever, or what in North America they call the ‘rescue’ inhaler, you take as required

Source:

National Heart, Lung, and Blood Institute. Accessed: May 20, 2010. Expert Panel Report 3 (EPR3): Guidelines for the Diagnosis and Management of Asthma

APPENDIX 2

% =/-5% too ill to attend ‘profound’

SOTON 17000 undergraduates

First years 5,000 – 5,500

Total Soton

9.5%

Total

Soton 11.5%

First Years

9.5%

First

Years

11.5%

Across4 UK

universities

Approx: students with asthma in the undergraduate population

1,615

1,955

475

575

64,500

Describing themselves as:

41% very mild

662

801

195

234

26,445

27% mild

436

528

128

155

17,415

19% moderate

307

371

90

109

12,255

11% severe (Wales et al., 2011)

178

215

52

63

7,095

Moderate to severe likely to be:

485

586

142

172

19,350

48% think they are at risk (Asthma UK)

232

263

68

82

3,405

53.7% smartphones by 2014

125

141

37

44

1,829

less 4% self exclude from digital devices

120

135

36

42

1,756

University of Southampton

Of an undergraduate population at the university of Southampton of 17,000 UK asthma statistics (Asthma UK, 2013) would suggest that between 1 in 10 and 1 in 12 are asthmatic (in a school population 1 in 12 has asthma, while there are 1 in 10 in the general population). Of these 5% have severe asthma and are unlikely to be attending university. This would suggest that between 9.5% and 11.5% as asthmatic. So between 1,615 and 1,955 asthmatic, of whom 662 to 801 likely to say that they are very mild and from 436 to 528 mild so have no medication, or a reliever at most (if they’re right). Between 307 and 371 moderate and 178 to 215 severe – so likely to be on a reliever at least at one end of the spectrum and a preventer too towards the more persistent or severe levels. i.e from 485 to 586. Of these 232 to 263 are likely to think they are ‘at risk’ (Asthma UK). Horn (1992) suggests that patients who admit to poor compliance may be more amenable to compliance modifying strategies; EU funded research into asthma has shown a significant willingness of those with this troublesome disease to take part in research (Cerveri et al., 2013) Whilst use of a smartphone does not define a person as digitally literate a self-reporting interview will isolate those who are … which might be, given use of e-learning in higher education, most of this group. A further reduction is given to exclude some who will not use these devices.

Potentially conducted across four universities:

  • University of Southampton. 17,000 students.
  • City University, Finsbury, London. 17,000 students. Urban
  • University of Cumbria in Lancaster and Newton Rigg, Penrith. 10,500 students. Rural
  • University of Oxford. 20,000 students.

APPENDIX THREE

Benefits of a private site using Qstream

User admin

Batch invite

Batch enroll

History – invite, enroll

Delete

Email issue mgmt

User registration report

Access to learner email addresses

Reporting & analytics

User tagging

Management roles & reporting

Management summary engagement emails (weekly)

Engagement summary

Engagement detail & export

Learner performance summary

Learner performance detail & export

Snapshot analytics

Trend analytics

Question performance report

Question performance answer matrix

Question performance analytics

Site admin

Monitor site activity

Monitor comment activity for site

Site branding (logo, tagline, home page, Dashboard, URL)

Site localization (site branding translations)

Email branding (sender name, organization logo)

Private site publishing privileges

Course admin

Manage comment activity for course

Shut down courses

Basic course branding (course logo, course title)

Adv course branding (sender name, organization logo)

Private course catalog

Public course catalog listing

Private, closed courses

Open enrollment courses

Control course ‘operations’ (spacing, locked/unlocked)

Completion management (%, certificate, messaging)

Assign authors, co-authors

Assign moderators

Learner experience

Customized leaderboard gaming (email display, online display, invid, team, monthly, rollilng)

Localization

Mobile

Native app with notifications

Mobile interface

Course authoring

Course catalog description/listing

4 question types (MC, MCA, T/F, FIB)

Preview/validation of questions

Security

Auto login

Data security

Social & collaboration

Assign course moderator

Learners can post private or public comments

Comment management tools

We forget, it’s only natural – what can we do about it?

Fig.1. The Forgetting Curve. Ebbinghaus (1885)

‘The psychological conclusion demands a distribution of repetitions such that some of them should be produced at a later time, separated from the first repetition by a pause’. (Vygotsky, 1926)

More recently, in the last ten years in fact, Dr B Price Kerfoot of Harvard Medical School (2006) created a platform called SpacedEd (now Qstream) that uses multichoice questions, typically and most successfully with first year medical students, where sets of questions are randomised then sent out as text or email to tackle, I suppose, what Ebbinghaus (1885) identified with his ‘Forgetting Curve’. An evidence based paper on the effectiveness of ‘spaced learning’ showed how there was better retention three months, six months and a year down the line.

REFERENCE

Ebbinghaus, H (1885) Memory: A contribution to experimental psychology.

Kerfoot, B, P (2006) SPACED EDUCATION. Interactive Spaced-Education to Teach the Physical Examination: A randomized Controlled Trial.

Vygotsky, L (1926) Educational Psychology

FURTHER LINKS

Formative Tests Aid Retention

Lest we forget – memory games and other tactics to aid knowledge retention


Fig.1. Ebbinghaus (1885) The Forgetting Curve

‘The psychological conclusion demands a distribution of repetitions such that some of them should be produced at a later time, separated from the first repetition by a pause’. (Vygotsky, 1926)

More recently, in the last ten years in fact, Dr B Price Kerfoot of Harvard Medical School (2006) created a platform called SpacedEd that uses multichoice questions, typically and most successfully with first year medical students, where sets of questions are randomised then sent out as text or email to tackle, I suppose, what Ebbinghaus (1885) identified with his ‘Forgetting Curve’.

An evidence based paper on the effectiveness of ‘spaced learning’ showed how there was better retention three months, six months and a year down the line.

REFERENCE

Ebbinghaus, H (1885) Memory: A contribution to experimental phsychology.

Kerfoot, B, P (2006) SPACED EDUCATION. Interactive Spaced-Education to Teach the Physical Examination: A randomized Controlled Trial.

Vygotsky, L (1926) Educational Psychology

http://blog.questionmark.com/evidence-that-formative-tests-aid-retention-in-medical-education-an-interview-with-dr-douglas-larsen

E-learning – lest we forget, learning requires the creation and recall of memories

Ebbinghaus ‘Forgetting Curve’

What does this say in relation to disabled students? What chances do we give them to record, then repeat or store components of their learning experience?

Where learning takes place at the most basic level. In relatoin to accessibility anything that hinders access to and accommodation of this process is a potential barrier or impact to learning.

Learning, Accessibility and Memory

Ebbinghaus ‘Forgetting Curve’

What does this say in relation to disabled students? What chances do we give them to record, then repeat or store components of their learning experience?

Where learning takes place at the most basic level. In relatoin to accessibility anything that hinders access to and accommodation of this process is a potential barrier or impact to learning.

Learner-centric learning and effectiveness of e-learning

Three weeks ago I sat a 3 hour written exam.

Over the course of the previous month I learnt five anagrams or mnemonics for EACH of the three blocks to be assessed (most of this I left to the last few days).

Prompted by serendipity (I was browsing the website of international e-learning agency Brightwave) into the work Ebbinghaus I have just attempted the ‘brain dump’ I did in the first ten minutes of the exam.

I gave each block a mnemonic: Block 1:’POVCC; Block 2: MHIVE; Block 3: MDMAP.

From the first block I could recall three mnemonics but complete none of them; same for Block 2; whereas with Block 3 I cannot remember a single one of the five mnemonics each of which would have given me a long list of factoids to exploit.

These anagrams were never meant to stick beyond the exam, but I wonder how much else I could recall in the appropriate context on differences in national management styles, what makes a creative organisation, the ‘Buffalo System’

for running a creative problem solving (CPS) workshop of the 12 precepts of CPS. (I could get 11/12 only because I also used a visualisation technique that I do recall, tripping up towards the end).

What is meant by learner–centric learning?

‘If we were to attempt a definition of the concept, obviously the interests, needs, abilities and preferred learning style(s) of the student would be pre-eminent’. James. Cory–Wright, February 2011.

‘Being learner-centric for its own sake without being relevant to desired business outcomes is mere indulgence’. James Cory–Wright, February 2011

A number of great thinkers ‘gurus’ of self-regulated education have pointed out the shortcomings of formal education

Ebbinghaus

After some number of repetitions, Ebbinghaus would attempt to recall the items on the list. It turned out that his ability to recall the items improved as the number of repetitions went up, rapidly at first and then more slowly, until finally the list was mastered. This was the world’s first learning curve.

The effect of over learning is to make the information more resistant to disruption or loss.

For example, the forgetting curve for over learned material is shallower, requiring more time to forget a given amount of the material.

I relate to this and having taken many exams in my life it is useful at last to have some terms to refer to it all. The only exam I have ever had to resit should have been the easiest, not the finals of a BA (Hons) as an Oxford Undergraduate (or the entrance exam which was tough enough), but a Level II Teaching Swimming Multi-choice paper that took an hour. I simply hadn’t put in the time, say six hours over as many days, repeating by writing it out and testing myself.

Whilst in an exam the student may forget, there are exams where you want them to retain the information: junior doctors, health & safety in a nuclear power plant, or one I was involved with ‘the packing and storage of uranium trioxide‘.

Savings is the most sensitive test of memory, as it will indicate some residual effect of previous learning even when recall and recognition do not.

Which is what I just did, three weeks after the event.

If I go to the website where I stored the original mind–maps and lists I know that I could quickly re–engage with the material. Like riding a bike, windsurfing or skiing? Though not recalling the lines of Mercutio from Romeo & Juliette which I performed in my late teens. I can however recite some Macbeth, but only because I have repeatedly tested myself on the lines since my mid–teens).

Ivan Illich

Illich claimed:

  • Most learning happens informally.
  • Institutionalized schooling hinders true learning.

The ideal education “system” allows people to choose what they learn and when they learn.

Informal Learning

Illich is quick to point out that people learn more from their day-to-day experiences than they learn from sitting inside a classroom.

‘Most learning happens casually, and even most intentional learning is not the result of programmed instruction’.

Illich believes that people of all ages should be able to choose what they learn and when they learn it and proposes that informal education can be supported through four services:

  • Libraries that store the materials needed for learning
  • Skills-based exchanges where people can develop specific abilities,
  • Peer-matching that allows learners to meet others interested in studying the same subject,
  • A database of educators available for assistance.

Becker  

From Wikipedia: Programmed Learning or Programmed Instruction is a learning methodology or technique first proposed by the behaviourist B. F. Skinner in 1958.

According to Skinner, the purpose of programmed learning is to “manage human learning under controlled conditions”.

Programmed learning has three elements:

  • it delivers information in small bites,
  • it is self-paced by the learner,
  • it provides immediate feedback, both positive and negative, to the learner.

It was popular in the late 1960s and through the 1970s, but pedagogical interest was lost in the early 1980s as it was difficult to implement and its limitations were not well understood by practitioners.

It was revived in the 1990s in the computerized Integrated Learning System (ILS) approach, primarily in the business and managerial context.

The value of Social Learning, lest you forget.

Ebbinghaus came up with the ‘Forgetting Curve’ to indicate how what we learn is soon forgotten unless we continue to engage with it, social learning is a painless way to repeat this engagement process. It also defies the latent loneliness of studying alone with your books and eBooks, LMS and PLE.

The historian EHCarr said ‘study a subject until you hear its people speak’, in a social learning context you hear these voices. A commentator on Radio 4 (search in my OU Student blog for the reference) said some months ago ‘research a subject until the narrative reveals itself’ which as my subject of interest is e-learning is achieved by doing this, over a 1000 e-learning posts in my blog and over two years on the Open University’s MA in Open & Distance Learning.

I picked up the name Ebbinghaus in a paper written by James Cory- Wright on the Brightwave website, responded to a prompt for disucssion in an Epic Linkedin Group and am posting all of this in my Open University Student Blog to  share with fellow travellers on the MAODE: H807, H808, H 800, H810, H809 and/or any ellectives a person  may choose to do as an alterantive.

Epic and Brightave, along with Kineo and others are part of the e-learning cluster in Brighton.

Find out more at Wired Sussex.

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