Report on the development of D-learning course "Barrier contraception in prevention of STD"

The work on the project has started in October 2001, when first data of needs assessment has been obtained. Those data showed that medical personnel and public health specialists are not very good at knowing the details of condom manufacturing, quality controls and failure rate. Moreover, even the data on condom effectiveness were largely unknown to them. Though first collection of information was unstructured, more in forms of interview and discussions with physicians working at MAPS and students of different courses, the more formal MCQ testing performed in May 2002 showed that sample of physicians attending courses on STD prevention could correctly answer only about 25-30% of the questions regarding condoms testing, production and effectiveness.

Also a subject matter expert groups has been formed (including chief dermatovenerologist of St.Petersburg, Director of largest youth STD prevention clinics (Youth health center), general practitioners, etc.). Three meetings has been organized in November 2001 - February 2002

The first results of the need assessment allowed team to start searching for the materials to be used for the course. Two main sources has been identified:

"The condom monograph" published by Family Health International

"Scientific evidences of condom effectiveness in preventing sexually transmitted diseases" summary of the workshop organized by number of US federal agencies (including FDA and National Institutes of Allergy and Infectious Diseases) in the year 2000

The first source dealt more with condom production, testing, storage, quality control and failures, including consumer-dependent failures. The second analyzed data on condom effectiveness from the evidence-based health care position, trying to estimate real decrease in risk, associate with condom use. Both sources were a good complement to each other.

Both sources (about 200 pages totally) have been translated into Russian and were used for preparing the course materials.

The first analysis of existing materials showed that there is a need for obtaining additional materials specific for Russia dealing with condoms that are sold here, their properties, standards, regulating its production, acceptability, etc. Such information have been found and included in the materials necessary for study. Because of the paucity of the scientific data in this respect, team has been forced to analyze large amount of the data published in popular press. For example, materials on the testing of condoms on sale in Russia have been taken from Penthouse magazine, because no other data was available (analogous data from Consumer Report magazine were dedicated to US market and so are published in English as elective material).

Also during this period the collection of illustrative material for the site has been made (graphs, original photos of commercial sex workers in St.Petersburg, etc.)

The discussions of the structure of the course lead team to believe that participants should not be persuaded that STD are serious problem for the public health in Russia, but they need to have data to persuade others and they need to have tools for rough forecasting of the epidemic situation. Correspondingly the basics of mathematical epidemiology have to be included in the training curriculum. The data that are needed for the epidemics forecasting are existing situation with STD and sexual behavior data. The data on STD incidence for the last 10 years has been collected from Bureau of Medical Statistics of St.Petersburg and from project EpiNorth database. The data were collected in such a way that allowed comparison with other regions of North-West of Russia and Nordic neighbors.

The data on sexual behavior has been taken mostly from Russia Longitudinal Monitoring Study (RLMS) and additionally results of survey of sexual behavior made by MAPS researchers were introduced into presentation dedicated to the role of sexual networks in STD spread. Additional information that describes behavior of risk group (commercial sex workers and students) has been found and included in materials for study.

Detailed description of application of principles of mathematical epidemiology for STD forecasting is presented as separate part of the course completed with Excel worksheet for modeling experiments.

Also it was necessary to take into account that students of the course will have MD training, and so they would like to have some refreshing information about diagnosis and treatment of common STD. For such students it was decided to have elective part of the course, which is destined for self-control and self-study.

Because one of task for the students will be not only memorize some amount of information, but also be able to find new information on effectiveness to be currently up-to-date. For this reason last part of the course contains information on search in Internet. Because most important information is located not in the open part of Internet, but in specialized data bases like MEDLINE, only introduction in Internet search is provided. More detailed description is provided for the PubMed language, which is search language for the MEDLINE, specifically described are methodological filters that help in a rapid retrieval of important and valid information.

Correspondingly at present course consists of five basic parts (detailed description of the course structure is in Appendix)

Introduction part describes general rules for the course and setting up and using software for off-line knowledge testing - MCQ exam (MS-DOS based software supporting multiple data bases, examination and training modes, support of log-files [encrypted files with results of all starts for a given database with relatively weak Enigma encryption], decoding of the log-file with keyword "-declog", support of encoded database files (also Enigma))

The first part of course consists of three subparts: first describes objectives for the introduction course, second describes epidemiologic situation with STD in St.Petersburg and compares situation with Nordic neighbors. No self-study questions are included in this part of the course, as this information is only for orientation and not needed to be memorized. Third part of the introduction to the needs for prevention (main) is dealing with epidemics forecasting and include materials on sexual behavior, sexual networks and mathematical models in STD epidemiology.

Main part of the course consists also of three main parts: male latex condoms, non-latex condoms and evidence-based assessment of latex condoms effectiveness. The part dealing with male latex condoms describes basics of the condom manufacturing, acceptability of the condoms, condom failure and behavioral reasons for failure. Also it is described how the data from pregnancy studies could be extrapolated to the assessment of condom effectiveness. Separately such issues as latex permeability and latex allergy are addressed. Specific information on condoms used in Russia is provided, together with acceptability information and Russian standards. The evidence basis of latex condoms effectiveness is assessed for the two types of STDs: Discharge STDs (HIV, Gonorrhea, Chlamydiasis and Trichomoniasis) and Ulcerative STD (Herpes, Chancroid, Syphilis and HPV). The data presented in this part of the course are used for forecasting MCQ's

Last part of the course is dealing with search for materials on STD prevention in Internet. Short presentation is dedicated to the use of general search resources, like Google or AltaVista search engines. More detailed description of the PubMed search language is provided with accent on using Boolean operators in search, detailed description of MESH trees and what is MESH termini, shortly other MEDLINE fields are presented. Many reference tables are provided, translation table of the PubMed system is described and methodological filters are presented. The examples of the search results are provided, which could be used as training materials in the main part of the course (search results are presented, of course, in English).

Also a special page with utilities for PubMed search optimization is provided. Project team has downloaded from NLM Web-site MESH dictionary (more than 20 Mb), MESH tree description and Subject Heading description, transformed all databases into TomeRaider format. Before selecting this format study of the formats has been undertaken. The study consisted in identification available formats for delivery of textual information (at least 13 different formats has been identified and analyzed). The formats included PC-based formats such as MS Word, HTML, RTF, cross-platform formats such as Adobe PDF, specific formats of the handheld and palmheld computers (but available with readers for PC) such as Aportis DOC, iSILO, TCR and TomeRaider, as well as formats of electronic books (Rocket E-book). The formats has been compared as of compression degree (usability for transferring large volumes of information over narrow-band connection) and support of Cyrillic alphabet. Best formats for graphic containing and pure textual formats have been selected (see comparison table in Appendix 3). Tome Raider allowed fast search of the database with good compression properties. Conversion has created 9.5 Mb file of MESH termini which was compressed by TomeRider to the 4.2 Mb size (47% original size). What is also important that this format is compatible with many handheld and palmheld platforms (EPOC, Palm, PocketPC), not only with Windows. As is stated at the TomeRaider Web-site (http://www.tomeraider.com), TomeRaider is a fast, flexible and powerful cross-platform reference viewer giving instant and free access to hundreds of megabytes of encyclopedias, dictionaries, guides, religious works, philosophical texts, e-texts and novels in TomeRaider format. TomeRaider is combining the best elements of flat text documents with features of a database such as indexing, fast navigation and searching. In addition compression, rich-text formatting, bookmarks and hyperlinks enhance the TomeRaider further.

By-product of the project: methodology of workload estimation for D-learning courses, basing on the experience changes to the Ministry of Health order on D-learning has been proposed (August 2002)
Calculation of the workload so far

1 FTEH = 30 hours workload for preparing the materials (lowest expert estimation - St.Georges Medical School, London). For the course of this size it equals to the 3256 person-hours.

1 MCQ = 10 minutes in preparation + 7 minutes for Web-publishing (own estimation). For the course so far = 37 person-hours

At present all materials are published, some MCQ still to be added, group is formed, materials has been used for training purpose in May 2002, partly will be published in Russian Family Physician Journal as paper supplement to D-learning program.

At present course prepared for 9 weeks distance learning course (complete with elective part), or 108 full-time equivalent-hours (= 3 weeks full-time course)

Number of MCQ so far corresponds to the lower limit for the 3 weeks FTCE (2-5 MCQ per 2 full-time equivalent hours (FTEH) = 108-271 MCQ per course)

• Total size of the site - 22 MB (with exclusion of the MESH dictionary downloadable files), number of files - more than 1,000
• Number of pages with information (equivalent to printed pages) - 1085
• Number of pictures/graphs/illustrations - more than 170
• Number of MCQ tests created for the project - 175

The original material preparation

• Materials for the general forecasting of the STD epidemics has been written
• Presentations on mathematical modeling of STD spread prepared
• Materials for use local data in preventive programs targeting has been prepared
• Original data on sexual behavior in St.Petersburg has been identified

Software developed

• MS-DOS based program for the off-line knowledge testing
• VB Script based applets for on-line examination after compulsory modules
• JavaScript-based pages for on-line self-assessment during study
• Excel worksheet demonstrating approaches to the modeling epidemic spread

MCQ developed

• Introduction - 52 tests
• Male latex condoms - 76 tests
• STD diagnosis & treatment (elective) - 30 tests

I. Introduction

1. General course description
2. Work with off-line testing software
1. Setting up
2. Using MCQ exam software

II. Introduction into the needs for prevention

1. Objectives of the first part of the course
2. Epidemics of STD
1. STD incidence in St.Petersburg, 1990-2000
2. Comparison of St.Petersburg, Nordic countries and North-West region of Russia, 1999-2001
3. STD transmission dynamics
1. Sexual networks
2. Sexual behavior in Russia
1. RLMS review data
2. Some additional information on CSW
3. Basics of mathematical epidemiology

1. Transmission probability for different STDs
1. Estimation methods
2. Per-act probability
3. Per-partnership probability
2. Reproductive rate and simple SIS models
1. Duration of infectivity
2. Mean partner change rate
1. Value of behavioral surveys
2. Direct estimation
3. Estimation by subgroups
3. Reproductive rate and reproductive number
3. Estimation of prevalence based on SIS model
4. Other models for STD transmission
1. SIR models
2. Modelling software (Stella)
3. Microsimulation models

1. EXAM

III. Barrier methods for prevention

1. Short historical introduction
2. Male latex condoms
1. Pregnancy and STD
1. Factors that influence pregnancy rates
2. Effectiveness of latex condoms against diseases
3. Latex membrane permeability
2. Basics of the condom manufacturing
1. Latex formulation
2. Specifications and tests
1. Laboratory tests
1. Leakage
2. Dimensions
3. Tensile properties
4. Air-brust test
2. Deterioration tests
3. Laboratory tests and human use
1. Cross-sectional studies
2. Prospective studies
3. Other design of the studies
4. Condom packaging
5. Dry powders
6. Latex allergy
3. Acceptability of the condoms
1. Reasons for non-use
2. Changing behavior
4. Condom failure
1. Definition and human trials
2. Artificial aging
3. Alternative methods
4. Unpublished studies
5. Behavioral basis of condom failure
1. Definition of condom failure
2. Groups of people experiencing failure
3. Physical and demographical characteristics related to condom failure
4. Behavioral factors of failure
6. Product choices
1. Lubricant
2. Width
3. Thickness
4. Formulation
5. Shape/texture
6. Materials
7. Additional information about LC
1. Price
2. Expiry data
3. Country of origin and quality
4. Some information on condoms, available in Russia
1. Testing results (Penthouse magazine,2002)
2. Testing results (Consumer Reports,1999)
8. Conclusion and correct usage of the condoms
1. Production
2. Size
3. Standards
4. LC and HIV
5. Correct use
3. EXAM
4. Non-latex condoms
1. Synthetic elastomeric condoms
2. The female condom
3. Male natural skin condom
5. Evidence-based assessment of LC effectiveness
1. Theoretical approach
2. Discharge STD
1. HIV
2. Gonorrhea
3. Chlamidiasis
4. Trichomoniasis
3. Ulcerative STD
1. Herpes
2. Chancroid
3. Syphilis
4. HPV

IV. Signs, symptoms and treatment of STDs (elective)

1. General description of STDs
1. Gonorrhea
2. Chlamydia
3. Lymphogranuloma
4. Pelvic inflammatory disease
5. Syphilis
6. Herpes
7. Donovanosis
8. Chancroid
9. HPV
10. Antibiotic STD treatment
2. Gonorrhea
1. Male gonorrhea
2. Female gonorrhea
3. Chlamydia
1. Epidemiology
2. Symptoms and signs
3. Diagnosis & treatment
1. Canadian STD guidlines
4. Prognosis
4. Syphilis
1. History
2. Epidemiology
3. Q&A on syphilis
5. Viral hepatitis
1. Acute hepatitis
2. Chronic hepatitis
6. HIV
1. Classification
2. Diagnosis
3. Treatment and prevention
1. Harrison's principles of Internal Medicine on HIV
4. Epidemiology and anti-epidemic measures
7. Herpes
1. Herpes simplex
1. General outline
2. Topic infection
2. Chickenpox
8. Other STDs and putative STDs
1. Gardnerellesis
2. Candidosis
3. Molluscum contagiosum
4. Mycoplasmosis
5. Lice
6. Trichomoniasis
7. Condiloma
8. Scabies
9. Ureaplasmosis

V. Information on STD prevention in Internet

1. Search for STD prevention information
2. MEDLINE search
1. Boolean operators
2. MESH termini
3. Other MEDLINE fields
4. Translation table
5. Methodological filters
6. PubMed Utilities

Technical data for MCQ exam software

MCQ exam ver. 2.4 (Russian version shell, 2002)

SPECIFICATION:

Operation system: MS-DOS ver 3.0+

Hardware: IBM PC/XT and compatible (?), graphic card recommended

Size: examination module and configuration file

(usmle24r.exe, usmler.ini, enigma.cfg) - 121K

utilities:

.idx creator (doidx.exe) - 41K

.key creator (dokey.exe) - 46K

.stx creator (usmlesta.exe) - 38K

total program files: 246 K

Databases: none, format compatible to USMLE 3.0+

Additional comment: fast program for deploying exam software

through narrow-band connection, supports:

- Encrypted databases (regulated by ".enc" files)

- Encryption in main module

- Log file with all starts logged

- Explanation/exam mode in one module

(regulated by password ".pas" file)

- Mouse/keyboard entry

- Multianswer MCQ support

- Comments support

Comparison of the compression provided by several texts reading programs. Text source was file of about 300 pages (101397 words).

1 - with help of the program E-Book

2 - with help of the program BigDoc