Comparison of the effect of electronic learning and blended learning on the empowerment of the caregivers of cancer patients under chemotherapy

Cancer is a chronic disease that affects individuals as well as their families. E-learning is a common method of education for patients and caregivers. The present study aimed to compare the impact of E-learning and blended learning on the empowerment of caregivers of cancer patients under chemotherapy. This clinical trial was performed in the main chemotherapy center of Shiraz University of Medical Sciences during October 2018–December 2020. A total of 123 caregivers of cancer patients who were under chemotherapy were selected through simple random sampling and were divided into two intervention groups and one control group. The empowerment of the caregivers was evaluated using the caregivers’ empowerment questionnaire in all three groups at the beginning of the study, immediately after the intervention, and 1 month after the intervention. The data were analyzed by descriptive statistics and statistical tests using the SPSS software, version 22. The results revealed no significant difference between the two groups regarding the knowledge score (p = 0.3). However, the first intervention group had a better attitude compared to the two other groups after the intervention (p = 0.003). Moreover, the mean score of performance increased significantly in both intervention groups (p = 0.000). No significant differences were observed among the three groups in terms of the demographic data, knowledge, attitude, and performance (p > 0.05). The results indicated that both electronic and blended learning affected the attitude and performance of the patients’ caregivers. Therefore, blended learning can be applied for enhancing the empowerment of caregivers.


Introduction
Cancer accounts for about 12% of mortalities throughout the world. In developed and developing countries, cancer is the second and third cause of mortality, respectively [1]. According to the statistics provided by the World Health Organization (WHO) in 2018, approximately 1.7 million new cases and 600 thousand deaths due to cancer occurred annually in the USA [2]. In Iran, there were 110,000 cancer cases and 56000 deaths in 2018 [3].
Insufficient healthcare infrastructure, limited therapeutic options, and rapid disease progression lead to a high mortality rate due to cancer [4]. These patients have to accept long-term treatments with chemotherapy agents because of the chronic nature of the disease. The side effects of these treatments include nausea, hair loss, fatigue, muscle pain, skin burns, weight changes, and psychological issues [5]. Besides, repeated hospitalizations for treatment make a normal life for patients and their families impossible. In this context, families are directly responsible for taking care of patients. Occurrence of a severe problem for one of the family members causes the care needs to augment and problems to arise.
Studies on the quality of life of patients suffering from cancer have indicated the effect of cancer on the physical, psychological, social, and economic aspects of a patient's family [6]. Requests for sooner discharge from hospital and care at home are increasing due to elevated demands for nonhospital care and a larger number of people with cancer history. The latter issue may be challenging for a long time [7].
An informal caregiver is a friend, parent, or relative who supports the patient in all aspects of performance and life [8]. In other words, informal caregivers are relatives, friends, or partners who have a strong relationship with and provide assistance (physical and emotional) to a patient with a lifethreatening, incurable illness [9]. Family caregivers have a positive impact on the compatibility of patients and play a key role in the management of different dimensions of patient care [10]. These caregivers may face diverse problems such as social seclusion, loss of identity, economic issues, and deficient information [11].
Nowadays, determining the needs of patients and their caregivers is essential because of the growing trend of chronic diseases and limited hospital resources [6]. The caregivers of patients with cancer may encounter major challenges, the most important of which being not receiving the required information about the disease and their health status. In case they are provided with the required information, caregivers can promote personally, physically, and psychologically and will be able to provide more efficient care [12]. On the other hand, not having sufficient information about taking care of and supporting patients results in inadequate care and leaving the patient [13].
To date, information technology with its influences on all domains of life is considered one of the most necessary tools in the field of education [14]. There are diverse methods such as electronic learning for educating caregivers. Electronic learning is a technique carried out by modern communication mechanisms such as computers, computer networks, images, maps, and electronic ports. In electronic learning, the educational content is prepared and provided for individuals via computers and networks. The benefits of this learning method include learning at any time and place as well as preventing the waste of time [15]. Electronic learning tools enable learners to learn individually or in groups [16]. Blended learning is a combination of face-to-face and electronic methods, which eliminates the disadvantages of both techniques [17]. With the development of technologies in the field of education, new styles of educational activities have emerged, which are known as blended learning. The benefits of this type of learning and blended learning environments have attracted different people to this learning method [18]. Blended training can also affect the therapeutic education of caregivers of cancer patients under chemotherapy. Therefore, the present study aims to evaluate the impact of blended learning on the empowerment of caregivers of cancer patients under chemotherapy who referred to the specialized clinic of Shiraz University of Medical Sciences. Along with the therapeutic education of caregivers, patients' information about their illness and the correct way of care increases, because of distance learning that is beneficial for both patients and their primary caregivers.

Study protocol and target sample
This clinical trial was performed as an experimental study with a pretest-posttest design on two intervention groups and one control group. The study aimed to compare the impact of electronic learning and blended learning on the empowerment of caregivers of cancer patients under chemotherapy who referred to the specialized clinic of Shiraz University of Medical Sciences. The study setting was Shahid Motahari chemotherapy center, Shiraz University of Medical Sciences, Shiraz, Iran. This center provides services everyday in both morning and afternoon shifts. The inclusion criteria of the study were aging over 18 years, Iranian nationality, having the ability to read and write in Persian, not having attended similar classes, and not suffering from psychological disorders. The exclusion criteria were incomplete questionnaires, unwillingness for continuing cooperation, and absence for more than one session. The patients were aware of the training program. Before starting the study, they were asked about the materials that they would like their caregivers to learn. The patients' responses were considered in preparing the educational content. They could have access to the educational content, as well.
In order to determine the sample size, a pilot study was carried out first. The pilot study was performed on 60 caregivers of patients suffering from cancer, and the final sample size was calculated as 123 individuals. The participants were randomly allocated to intervention and control groups. All the caregivers who met the inclusion criteria were enrolled into the study after signing informed consent forms. The data were collected using a questionnaire whose content and face validity were determined. In doing so, the questionnaire was delivered to ten specialized members of the University's Scientific Committee. They were required to present their ideas regarding the agreement of questions with aims as well as the impact coefficient, relevance, clarity, fluency, and necessity of questions. The comments were evaluated, and all items had impact coefficients over 1.5 and suitable face validity. After the omission of the unnecessary questions, the content validity ratio and content validity index were 1 and 0.8, respectively. The reliability of the questionnaire was confirmed by Cronbach's alpha of 8.7 and significance level of 0.05. The questionnaire consisted of two parts, the first of which addressed demographic characteristics including the age of the caregiver and the patient, gender of the caregiver and the patient, caregiver's income, education level of the caregiver and the patient, caregiver's and patient's number of the children, occupation of the caregiver and the patient, and disease duration. The second part contained 30 items for surveying caregivers' empowerment. This part of the questionnaire had three sections and evaluated the caregivers' knowledge, attitude, and performance. Questions 1-19, 20-25, and 26-30 were related to the caregivers' knowledge, attitude, and performance, respectively. The knowledge section consisted of dichotomous questions, which had only one correct answer. Scores 1 and 0 were assigned to correct and incorrect responses, respectively. The attitude and performance questions were scored based on a five-point Likert scale. The total score of the questionnaire was 74. The knowledge scores could range from 0 to 19, with scores 0-6, 7-13, and 14-19 being considered weak, moderate, and good, respectively. The attitude scores ranged from 0 to 30, with scores 0-10, 11-20, and 21-30 representing weak, moderate, and good statuses, respectively. Finally, the performance scores ranged from 0 to 25, with scores 0-8, 9-16, and 17-25 being considered weak, moderate, and good, respectively.
Intervention group 1 (IG1) received face-to-face blended training as well as an educational CD. Intervention group 2 (IG2) received the content only in form of a CD. For IG1, three 90-min educational sessions were held by the researcher during three weeks. The sessions were repeated in small groups for the caregivers who could not attend the training sessions for any reason. In the first session, a pretest was performed, and the presented materials were related to cancer and its statistics, reasons, prevention measures, and screening tests as well as the important role of family caregivers. In the second session, the materials presented in the first session were reviewed; the definition of chemotherapy and some of its common side effects including nausea, vomiting, hair loss, anorexia, and xerostomia were explained; and approaches for handling these problems were discussed. In the third session, the contents of the first and second sessions were reviewed. Afterwards, the common side effects of chemotherapy including fatigue, hemorrhage, overweight, different infections, and nutritional problems as well as the relationship between chemotherapy and diabetes were discussed. Posttest was performed immediately after this session and 1 month later. It should be noted that the caregivers in the control group received the routine care of the ward. They were also provided with the educational CD after the termination of the study and data collection. The educational CD included the definition of cancer, causes of cancer, ways to prevent cancer, cancer and hypertension, cancer and diabetes, complications of chemotherapy, and solutions to reduce the side effects of chemotherapy.

Data analysis
The data were analyzed by descriptive statistics such as frequency and percentage as well as analytical tests including chi-square test, independent t test, paired t test, and repeated measures analysis of variance. The analyses were conducted using the SPSS software, version 22.

Results
The results revealed no significant difference among the three groups in terms of demographic characteristics. The mean score of knowledge increased among the caregivers in the two intervention groups (p = 0.002), but no significant difference was observed between the two groups in this regard (p = 0.3). The mean scores of knowledge in the two intervention groups and the control group before the intervention, immediately post-intervention, and 1-month post-intervention have been presented in Table 1. In IG1, the mean score of knowledge was 5.68 ± 2.92 in the pretest, 8.53 ± 3.23 immediately after the intervention, and 8.41 ± 3.42 1 month after the intervention. In IG2, the mean score of knowledge was 3.26 ± 6.02 in the pretest, 9 ± 3.92 immediately after the intervention, and 8.7 ± 3.42 one month after the intervention. The mean score of knowledge in the posttest was categorized as good. In the control group, no elevation was observed in the mean score of knowledge immediately post-intervention, because this group had not received any training. Considering the mean score of knowledge in the two intervention groups 1-month post-intervention, forgetting the materials and not using the educational CD and manuals might have led to a reduction in the mean score of knowledge. The data in Table 1 are analyzed utilizing twoway analysis of variance by ranks. The results demonstrated that training was effective in improving the knowledge of the caregivers of cancer patients under chemotherapy. Therefore, it can be a step towards a higher care quality at home. The results revealed an increase in the mean score of attitude in all study groups, but IG1 had a better attitude following the intervention compared to the two other groups (p = 0.003). The mean scores of attitude in the two intervention groups and the control group in the pretest, immediately post-intervention, and 1-month post-intervention have been shown in Table 2. Accordingly, the mean score of attitude in IG1 was 22.7 ± 3.002 prior to the intervention, 24.75 ± 2.82 immediately post-intervention, and 24.8 ± 2.77 1-month post-intervention. In IG2, the mean score of attitude was 22.6 ± 2.55, 24.29 ± 2.2, and 24.41 ± 1.98 in the pretest, immediately post-intervention, and 1-month post-intervention, respectively. This elevation in the mean score indicated that the educational intervention enhanced the caregivers' attitude. The mean score of attitude also raised in both groups month after the intervention. This could be justified by the fact that the caregivers in the two intervention groups had educational CDs and supplements. The mean score of attitude in the posttest was categorized as good.
The mean score of performance increased significantly in both intervention groups after the intervention (p = 0 for both). Yet, the IG1 participants showed a better performance (p = 0.007). The mean scores of performance in the two intervention groups and the control group in the pretest, immediately after the intervention, and 1 month after the intervention have been presented in Table 3. In IG1, the mean score of performance was 18.87 ± 2.66 in the pretest, which increased to 21.07 ±2.1 immediately postintervention and 21.38 ± 2.03 1-month post-intervention. In IG2, the mean score of performance was 18.85 ± 2.23 in the pretest, 20.7 ± 2.05 immediately after the intervention, and 20.78 ± 1.95 1 month after that. The results indicated that the educational intervention exerted a positive impact on both intervention groups. However, the mean score of performance had a more prominent elevation in the IG1 participants who received blended training through discussion, presentation, and educational CD compared to the IG2 participants who were trained only by the educational CD. The findings demonstrated that discussion and presentation were more effective in the caregivers' performance. The mean score of performance was categorized as good after the intervention. The results showed no significant correlation between the demographic characteristics and knowledge, attitude, and performance.

Discussion
The current study aimed to compare the impacts of electronic learning and blended learning on the empowerment of the caregivers of cancer patients under chemotherapy. The findings demonstrated a significant difference among the three groups with regard to empowerment after the intervention. Furthermore, a significant difference was found between the pretest and posttest mean scores of knowledge, attitude, and performance in all the study groups.

The impact of blended learning on knowledge
The current study findings indicated that blended learning had a positive effect on the knowledge of the caregivers of cancer patients under chemotherapy. A similar investigation by Khoshnoodifar et al. (2019) evaluated the impact of traditional and electronic training on the knowledge, skills, and satisfaction of nurses concerning cardiopulmonary resuscitation. Their results were in line with those of the current study and showed a considerable increase in the participants' scores after the intervention. However, the awareness level

Impact of blended learning on attitude
The  Table 2).

Impact of blended learning on performance
The findings of the current study demonstrated that blended learning positively affected the performance of the caregivers of cancer patients under chemotherapy. Prusler et al.
(2019) conducted a quasi-experimental study on 45 caregivers in the USA to assess the effect of patients' access to caregivers and information. They reported that the presence of a caregiver for providing support in therapeutic and care measures was an important issue for patients (p < 0.001) [6]. Consequently, caregivers' knowledge, attitude, and performance are crucial due to their important role ( Table 3).

The effect of demographic characteristics on learning
Demographic characteristics including age and education level were influential factors in the present study. Khashabi et al. (2016) performed an investigation titled "the rate of the satisfaction of patients with periodontal diseases with training methods in Urmia dentistry clinic and the effect of age and gender on learning." This quasi-experimental study was carried out on 360 people referred to a dentistry clinic, and the data were collected using an evaluation checklist. The findings showed that age was effective in learning [25]. Moghimi et al. (2006) also conducted a study on 80 teachers in Mashhad, Iran titled "influence of the characteristics of the employees of Razavi Khorasan Education Organization on their participation in the recommendation system." The data were collected using a questionnaire. The results demonstrated that education level was an effective factor in individuals' learning and participation, which was in agreement with the present study findings (p < 0.05) [26].
The results of the present study and those of the previous investigations indicated that blended and electronic learning methods affected people's learning and empowerment and improved their knowledge, attitude, and performance. Strengthening has been considered a suitable approach for supporting patients and their caregivers [27]. Nurses, as the treatment personnel who are in direct contact with patients and their caregivers, can enhance the knowledge, attitude, and performance of caregivers through training [28].
In conclusion, the current study findings revealed the influence of blended learning on the empowerment of caregivers. As a result, blended learning can be applied for improving caregivers' empowerment, attitude, and performance. In this regard, Seif Zargar et al. carried out a research titled "impact of cognitive, visual, and aural treatment on cognitive performance considering gender and learning style" on 80 students. Their results demonstrated that gender had no effects on performance and learning [29].

Conclusion
Based on the findings, e-learning and blended learning had beneficial effects on the ability of the caregivers of patients suffering from cancer. Generally, caregivers of cancer patients experience numerous problems during patient care and, consequently, have different needs. To provide highquality patient care, caregivers must be empowered. By evaluating caregivers' needs and designing training programs with appropriate methods to help meet those needs, effective steps can be taken towards supporting them. Empowering caregivers to care for patients undergoing chemotherapy using electronic methods is an effective step for providing proper care and reducing the problems of caregivers and patients.

Study limitations
One of the present study limitations was the impossibility of assessing the long-term effects of the training on the caregivers and the patients. Another limitation was that the patients in the chemotherapy phase were not physically and emotionally prepared to participate in the program due to complications. Thus, some patients voluntarily took part in the program together with their caregivers and received the educational content.