Canadian physical therapists' interest in Web-based and computer-assisted continuing education.

Key Words: Computer-assisted education, Continuing education, Distance learning, Internet.

In recent years, the expansion of specialized knowledge has led Canadian and other professional organizations and regulatory bodies to expect physical therapists to maintain and upgrade their competency through continuing education. (1-5) Internal pressures for self-regulation and an increase in public awareness and accountability in health care also have contributed to this expectation. (6,7) For the health care practitioner, continuing education can enhance professional growth, personal achievement, and expertise, and it can provide formal recognition of specialized skills. (6) For the health care consumer, continuing education can be used to identify experts and ensure a high quality of care based on current evidence. (6)

The population distribution and geographic barriers in Canada make it problematic for physical therapists in remote and rural areas to access continuing education (8,9) (Fig. 1 (10)). This lack of access leads many physical therapists in rural areas to feel professionally isolated because of a scarcity of resources and the inability to consult other health care professionals and experts in their field. (9,11) This isolation is especially problematic for physical therapists in smaller specialty areas such as cardiopulmonary practice. (12) Because there is less demand for courses in these areas, fewer courses are available and they are offered primarily in larger population centers. For example, the 2003 education calendar of the Canadian Physiotherapy Association indicated that 12 out of 15 continuing education courses offered over a 4-month period were geared toward orthopedic practice (primarily manual therapy courses) and only 1 course was offered outside a large city. (13) With or without professional isolation, multiple work and family responsibilities, coupled with the travel costs and lost time from work, make it very difficult for physical therapists to attend continuing education conferences and workshops. (14,15) Distance education that uses computer assisted learning (CAL), including both Web-based and CD-ROM technologies, can be a solution to these problems, because it can provide increased access to education. (15,16)

[FIGURE 1 OMITTED]

Computer technology is shaping the current generation of distance learning and is being used by many health care professionals. (17-19) Web-based learning can overcome the "problem" of distance by providing learners with opportunities to interact with the instructor and each other using discussion groups, e-mail lists, news groups and bulletin boards, real-time chat rooms, or audio- and video-conferencing. (17,20,21) Although these media have been criticized for removing "real-world interaction," some authors (22,23) have argued that they enable interaction with a larger, more diverse community of learners. In addition, students who are unlikely to speak up and ask questions in a classroom situation often are comfortable sending questions to the instructor via e-mail and participating in discussions via chat rooms or bulletin boards. (24) Web-based education that incorporates sound pedagogy and instructional design and effective facilitation of learning can positively influence interaction among learners. (17,25,26) This enhanced interaction is a valuable benefit because most of the 109 educational theories examined by Bertrand (27) identified "interaction" as important to learning.

Other benefits of Web-based instruction include access to up-to-date information and to a large pool of expertise and resources. (23) Learners and instructors also can develop skills and knowledge of current technology that are relevant to current practice. (28) CD-ROM applications provide another interactive, multimedia learning tool and are beneficial in enhancing distance education. (29,30) In addition, Web-based and CD-ROM technologies allow for an increased ability to participate in continuing education by providing flexibility in the time and place of education. (20,30)

Not all areas of physical therapy education, however, can be addressed using CAL. The acquisition of psychomotor (hands-on) skills, for example, may not be conducive to CAL. On the other hand, CAL is particularly advantageous for cognitive learning, such as case-based learning (31) and problem-based learning, (19) and has been used more by health care professionals in recent years.

Despite the many benefits, Bates (32) identified fear as the greatest barrier to using technology triggered by discomfort with technology and the lack of knowledge and skill in using it. Other disadvantages of CAL identified by learners include technical difficulties (eg, the server is "down"), lack of technical support, limited access to computers, and lack of technical skill in using computer software. (24) Course developers also have identified lack of technical support, limited access to adequate computer equipment, and a large time investment as barriers to developing CD-ROM and Web-based courses. (24,33)

The success of continuing education programs depends highly on the interest of their users and their accessibility. It is important, therefore, to assess the readiness of physical therapists to undertake CAL that uses Web-based and CD-ROM technology and to determine the factors that may influence their ability to participate in CAL. The purposes of this study were: (1) to survey Canadian physical therapists to determine their interest in participating in continuing education using CAL methods (Web-based or CD-ROM learning) and (2) to determine whether their interest in participating in CAL was related to type of employment, area of practice, education, computer skill and access, and other demographic variables.

Method

Sample

The sample was derived from 2 populations: (1) physical therapists who were members of a cardiopulmonary special interest group and (2) licensed physical therapists from 8 of 10 provincial physical therapy licensing bodies across Canada (2 eastern provinces chose not to participate because of a lack of office support staff to assist with survey administration). All Canadian physical therapists with membership in the cardiopulmonary special interest groups of the Canadian Physiotherapy Cardiorespiratory Society (CPCRS) (N=136) or the Cardiorespiratory Division of the Canadian Physiotherapy Association (CR-CPA) (N=285) were surveyed because the executive committees of these specialty groups showed a particular interest in gaining information on CAL. A random sample (N=13,942) of the remaining licensed physical therapists across Canada was surveyed. Names of potential respondents were obtained from provincial licensing bodies, and each person was assigned a random number. From this group, 7% of the physical therapists (n=976) were randomly chosen to receive survey questionnaires. The sample size was calculated based on a known population size, an estimated standard deviation of 50%, (34) and a minimum detectable difference of 10%. Statistical power was set at 0.80, level of significance (alpha) was equal to .05, and beta was equal to .05. (35) This resulted in a sample size of 700. We expected an 80% response rate, so a minimum of 875 survey respondents were required. An extra 101 survey questionnaires (for a total of 976) were sent to ensure an adequate response. Cross-checking of membership in CPCRS, CR-CPA, and the random sample was performed to avoid duplication of mailed survey questionnaires to potential respondents.

Questionnaire

A 3-part questionnaire was developed by the authors (available upon request from the authors). For the purposes of the survey, participants were given the following operational definition of CAL: "all or parts of course being offered by CD-ROM or on different Web sites accessed via the Internet ... discussion of course-related issues via e-mail discussion or Web-based chat rooms." Part 1 explored interest in continuing education courses specifically related to cardiopulmonary content, and the results from this part are not reported here. The primary question in part 2 asked the respondents to indicate whether they were interested in any of the following: Web-based distance courses, CD-ROM-based distance courses, distance correspondence courses, face-to-face courses, none of the above, or all of the above. Part 3 contained questions about the demographic characteristics of the sample as well as items regarding access to computers, the Internet, and CAL. An open-ended comment section in each part of the questionnaire enabled respondents to include information that was not covered by the survey questions. Only the primary question from part 2 and the information from part 3 were used for the purposes of our study.

Parts 2 and 3 of the questionnaire had been used previously for occupational therapists and physical therapists in British Columbia (n=395) who responded to a distance education needs assessment.15 The entire questionnaire (parts 1-3) was pretested on 31 physical therapists and occupational therapists from academic and clinical settings to identify missing or ambiguous items. Once ambiguous items were clarified, the entire questionnaire was pilot tested with 25 physical therapists to ensure clarity. These data were not included within the final data set for analysis.

Survey Questionnaire Mailing and Responses

A summary of the survey questionnaire mailing and responses is shown in Figure 2. On February 1, 2001, questionnaires were mailed to the sample of physical therapists (n=1,426) with a cover letter explaining the purpose of the study. Self-addressed, stamped envelopes were provided to encourage responses, and participants also were given the choice to fax their completed questionnaire. To improve response rates, a postcard reminder was sent 5 weeks after the initial mailing and a second copy of the survey questionnaire was sent to nonrespondents 3 months after the initial mailing. Identification numbers were placed on the questionnaires and return envelopes to help identify nonrespondents for more efficient follow-up mailings. Data collection was discontinued on July 11, 2001.

[FIGURE 2 OMITTED]

Statistical Analysis

Data were analyzed using Statistical Package for the Social Sciences (SPSS), version 10. * Descriptive statistics (frequency, percentage, and median) were used to describe the demographic characteristics of the respondents and nonrespondents.

Logistic regressions and odds ratios (ORs) with their 95% confidence intervals (CIs) were determined for each independent variable related to interest in CAL. Logistic regression is used for categorical data where the dependent variable has only 2 outcomes (eg, interest or no interest in CAL). (36) Logistic regression coefficients were interpreted using ORs, which indicated the likelihood of the person being interested or not interested in CAL. For OR analysis, we chose one level of each variable as a reference group for comparison of responses within each variable. For example, if a population greater than 1 million was the reference group, then relative ORs for all other levels within that variable would be computed based on the reference group's values. Because respondents were able to indicate more than one area of practice, each area of practice was managed as a separate variable with respondents classified as either practicing in that area or not. Year of graduation was managed as a continuous variable. Because the data were not normally distributed, the Mann-Whitney U test was used to detect differences.

Results

Of 1,426 survey questionnaires mailed, 69 were returned (nonresponses); of these nonresponses, 58 were unopened and 11 were duplicates. From the remaining 1,357 potential survey responses (414 from the cardiopulmonary special interest groups and 943 from the licensing body sample), 757 responses were received, yielding an overall response rate of 56% (Fig. 2). Of the 757 responses received, 25 participants did not complete the survey (5 from the cardiopulmonary special interest groups and 20 from the licensing body sample), stating that it was not applicable. A total of 732 survey questionnaires were complete (97% of all returned questionnaires). This included 285 respondents who were members of cardiopulmonary special interest groups (70% response rate) and 447 respondents from the random sample of provincial licensing bodies (48% response rate).

Table 1 compares employment characteristics of the survey respondents and all licensed physical therapists in Ontario (the Canadian province with the largest population of physical therapists). Survey respondents from the licensing body appeared similar to physical therapists from Ontario in the proportion of full-time and part-time workers, proportion of public sector to private sector workers, distribution of areas of practice, and highest professional (entry-level) degree. Survey respondents from the cardiopulmonary interest groups included a greater proportion of physical therapists working in the public sector and a greater proportion practicing in the area of cardiopulmonary physical therapy care than the Ontario licensed physical therapists.

The results of the survey showed that 78% of all respondents were interested in participating in CAL. Most (82.1%) of the survey respondents from the cardiopulmonary special interest groups and 56.4% of those from the general licensing body were interested in CAL. Physical therapists belonging to the cardiopulmonary interest groups were 2.5 times more likely to be interested in CAL than the respondents from the random sample of provincial licensing bodies (OR=2.50, 95% CI=1.63-3.81, P=.0001). Table 2 summarizes the factors that were related to interest in taking courses by CAL.

Education

Respondents whose median year of graduation was 1991 were more likely to be interested in taking courses by CAL than respondents whose median year of graduation was 1988 (P<.01). Respondents with a doctoral or master's degree (OR=5.29, 95% CI=1.93-14.51, P=.001) or bachelor's degree (OR=2.82, 95% CI=1.10-7.19, P=.03) were more likely to be interested in CAL than those who had a diplomat (Tab. 2). Previous experience with Web-based courses was not related to interest in participating in CAL.

Computer/Internet Access and Skill

Respondents who had access to the Internet were 6.6 times more likely to be interested in CAL than those without Internet access (OR=6.60, 95% CI=3.82-11.42, P=.0001; Tab. 2). Those who had access to the Internet at both home and work were more likely to be interested in CAL than those with access only at work (OR=4.23, 95% CI=2.28-7.85, P=.0001; Tab. 2). The number of hours of Internet access also was a relevant factor; respondents with 2 or more hours of Internet access per week were more likely to be interested in CAL than those with less than 2 hours per week of Internet access (Tab. 2).

Another important factor was self-rated computer and Internet skills. Respondents who rated themselves as having novice computer skills were 7.7 times more likely to be interested in CAL than those who rated themselves as having no skills (OR=7.68, 95% CI=3.08-19.14, P=.0001; Tab. 2). Sixty-one percent of respondents who rated themselves as having novice computer skills and 62% of those with intermediate computer skills were interested in taking a course that introduced them to the computing skills needed to engage in CAL (results not shown in Tab. 2). Interest in a course that introduced them to computing skills was higher among those who rated themselves as having novice or intermediate skills than among those who rated themselves as having no computer skills (50% were interested in taking a computing skills course), advanced computer skills (45%), or expert computer skills (0%) (P<.001).

Type and Area of Practice

Physical therapists who identified pulmonary as their main area of practice were more likely to be interested in CAL than those practicing in other settings (OR=1.77, 95% CI=1.15-2.74, P=.008). Those who identified orthopedics as their primary practice were less likely to be interested in CAL than those respondents not practicing in that setting (OR=0.64, 95% CI=0.44-0.95, P=.025). For all other practice areas, the 95% CI for the OR contained the null value 1.0, indicating that respondents in those practice settings were not any more or less likely to be interested in CAL than respondents not practicing in those settings. (36) Type of employer (private versus public) and type of work (full-time, part-time) were not related to interest in CAL (Tab. 2).

Geographic Distribution

The size of community and the time or distance required to travel to courses varied for respondents from different regions of the country (Tab. 3, Fig. 1); however, these factors were unrelated to interest in participating in CAL. To provide perspective to Figure 1, Canada is about 4,000 miles from the east coast to the west coast, with a population of approximately 31,500,000; only 4 of 9 Canadian metropolitan centers with a population greater than 500,000 are outside of southern Ontario and Quebec. (10) Region of residence and size of community also were not related to interest in CAL (Tab. 2).

Discussion

The main finding of this study is that 78% of all Canadian physical therapists surveyed were interested in CAL, with more than 80% of those with special interest in cardiopulmonary physical therapy and 56% of licensed physical therapists indicating interest in CAL. At present, there are few CAL continuing education opportunities in physical therapy. The findings from this study and the apparent success of the online transitional doctor of physical therapy programs reported by Coyne, (17) however, suggest that physical therapists may seek continuing education courses that use CAL.

A continuing education study in British Columbia showed that 80% of physical therapists and occupational therapists indicated interest in Web programs or combined Web and face-to-face programs, (15) which is similar to the finding among our sample of physical therapists from the cardiopulmonary special interest groups. In 1997, Tassone and Speechley (9) found that CAL was ranked as the least interesting method of learning by physical therapists in Ontario compared with traditional modes of instruction (eg, face-to face courses). Although we did not compare CAL to other methods of instruction, the high interest in CAL in our sample may reflect the rapid increase in use of computers and increased exposure to user-friendly software and the Internet over the past 5 years, making physical therapists much more inclined to use computer and Internet technology in their education.

Interest in CAL and Computer Access and Skills

The finding that physical therapists who had more computer access were more likely to be interested in participating in CAL is similar to findings on other professional groups. (37,38) In a survey of physicians in early 1995, 76.5% had access to a personal computer, but only 44.1% had access to CD-ROM drives and 36.3% had access to online services. (38) A greater number of physicians with computer access or online access were interested in computer-assisted medical education than those without computer or online access. (38) Since then, the use of CD-ROMs and the Internet has become more widespread, improving access to CAL. Consequently, it is likely that physical therapists with more computer access also will be able to take advantage of the convenience that CAL provides and participate in Web-based and CD-ROM courses that fit their schedule, when more CAL is available.

We found that respondents with novice, intermediate, and advanced computer skills were more likely than those without computer skills to be interested in CAL. Mamary and Charles (39) recognized a lack of computer and Internet skills in a group of physicians as a barrier to participating in CAL. These authors suggested that computer instruction could be provided at conferences to promote the use of CAL in distance education. In our survey, respondents who rated themselves as having novice or intermediate computer skills were more interested in taking a course that would teach them the skills needed to engage in CAL than those who rated themselves as having advanced or expert computer skills. An introductory course may increase participants' comfort with using a computer and enhance their interest in taking continuing education using CAL methods. The level of computer literacy and comfort with newer technologies required for distance learning are more likely to exist in those people who graduated more recently. (38) This may explain our finding that those respondents who graduated earlier (median of 1988) were less likely to be interested in undertaking CAL than respondents who graduated more recently (median of 1991).

Interest in CAL and Experience of CAL

Previous experience with CAL also may influence a person's interest in participating; however, we did not find that experience with CAL increased the likelihood that respondents would be interested in CAL. This may have been due to only a small number of respondents having prior CAL experience. Our results parallel the British Columbia needs assessment findings. (37) Only a few respondents in each of these studies who expressed interest in Web-based learning had experienced it. The limited availability of CAL courses for physical therapists limits the opportunities that the therapists have to experience CAL or hear about it from others.

Interest in CAL and Geographic Distribution

The population of Canada is distributed more densely along the southern border of the country, in Quebec, Ontario, and western Canada (Fig. 1), and this distribution was reflected in the survey responses. Respondents living in less densely populated regions of Canada (ie, territories, eastern Canada, and northern regions of Quebec, Ontario, and western Canada) tended to report longer distances and time for travel to traditional "onsite" instruction. These factors have been shown to influence participation in continuing education activities. (8,14) For example, those physical therapists living in the middle of the westernmost province of British Columbia would have a 10-hour drive to Vancouver where most of the physical therapy courses are offered in this province. Although CAL eliminates the time and expense associated with travel, the size of the community, region of residence, travel distance, and travel time were not related to interest in CAL in our study. At face value, this outcome was surprising but might reflect the fact that other factors--such as experience with and access to technology, willingness to try something new, and family and employer support--may be more important in influencing CAL participation than distance alone. The University of British Columbia (located in Vancouver) finding that 82% of students who take other online courses at this university are from the Vancouver area supports the contention that distance from a major center offering face-to-face courses is not the only factor associated with interest in participating in CAL. (40)

Interest in CAL and Area of Practice

Among our respondents, those who identified themselves as primarily practicing in orthopedics were less likely to be interested in participating in CAL than respondents who were not practicing in the orthopedic area. Those with pulmonary as their primary practice area were more likely to be interested in CAL than respondents who were not practicing in the pulmonary practice area. Because orthopedics comprises the majority of physical therapist practice in Canada, (12) a large number of courses are offered in this area. (13) A series of courses offered by the Orthopedic Division of the Canadian Physiotherapy Association provides a wide selection and availability of continuing education opportunities throughout Canada for physical therapists in orthopedics. The 1999 British Columbia continuing education study indicated that physical therapists acknowledged that these courses are primarily psychomotor (hands-on) and require onsite instruction. (40) It is well recognized that Web-based learning is most suitable for acquiring and learning to apply new knowledge (ie, cognitive learning). (32,41,42) Thus, the trend for physical therapists practicing in orthopedics to be less interested in participating in CAL may reflect the perceived nature of the knowledge and skills to be learned and the availability of existing continuing education.

The difference between physical therapists from the general licensing body and those in the cardiopulmonary interest groups also may be attributed to the type of content that can be taught using CAL methods (ie, hands-on orthopedic courses are not suited to CAL). When analyzed separately, however, the significant factors related to CAL were not different between the respondents from the cardiopulmonary interest groups and those from the licensing body.

Although the findings of this study indicate interest in CAL, this interest does not necessarily translate into enrollment into CAL courses. At present, the limited availability of CAL opportunities in physical therapy continuing education makes it difficult to predict with confidence the extent to which interest in CAL will translate into enrollment by physical therapists. Even if physical therapists are interested in CAL, a variety of factors are likely to influence decisions to take and complete a CAL course. Yoon (43) suggested that, when selecting an online education course, adult learners most frequently ask "What is in it for me?" and "Will this work for me?" Although perceptions of efficiency and accessibility of CAL have been associated with enrolment, (44,45) research is needed to determine the extent to which these and other factors related to student success in CAL prompt physical therapists to enroll in CAL courses.

Limitations

This survey did not attempt to differentiate between Web-based and CD-ROM learning but rather examined interest in undertaking any form of CAL for continuing education. Computer technologies provide different benefits for distance education. CD-ROM packages integrate text, animation, and video clips, providing a dynamic learning format, (30) Web-based learning provides the added benefit of enabling interaction among people separated by distance, through e-mail, chat rooms, and bulletin boards. (17,22,26) Future studies should examine the differential benefits and application of these formats in continuing education for physical therapists.

Test-retest reliability establishes the consistency of responses on 2 or more occasions. (36) Measures of reliability provide an indication of the stability of the measurement over time and indicates whether the survey questions are being interpreted consistently. Although the test-retest reliability of data for this survey instrument was not evaluated, pilot testing was done to remove ambiguous items and ensure clarity of the survey questions as described in the Method section. This was done to ensure that respondents were interpreting the questions as intended by the authors.

Part 1 of the survey questionnaire provided examples of courses that were directed toward physical therapists with a special interest in the cardiopulmonary practice, and this emphasis may have influenced the results of parts 2 and 3. Although physical therapists in noncardiopulmonary practice may have interpreted the survey as being more related to cardiopulmonary practice than to their practice area, a reasonable response rate was obtained from the general, licensing body sample (50% response rate) and a large proportion of these physical therapists were interested in CAL (56.4%).

Conclusion

The results of this study indicate that a large percentage of Canadian physical therapists are interested in using CAL for continuing professional education. The large, positive interest in CAL indicates that this is an area that warrants further development for continuing education in physical therapy. Factors associated with increased interest in participating in CAL are primarily related to computer access and skills, including computer access at home and work versus only one location; 2 or more hours of Internet access per week versus less access; self-rated computer skills at the novice level versus no skills; education at the doctoral, master's, or bachelor's level versus diploma level; and primary practice area in pulmonary and not orthopedics. In addition to acquiring new knowledge and skills, physical therapists who use CAL will become familiar with current computer technology and obtain "virtual classroom" experience, both valuable resources for lifelong learning at a time when technology enhancements are likely to bring more Web-based continuing education opportunities.

Dr Reid provided concept/idea/research design, data collection, project management, fund procurement, subjects, facilities/equipment, and institutional liaisons. All authors provided writing and data analysis. Ms Stanton and Dr Reid provided consultation (including review of manuscript before submission). The authors acknowledge Alison Ritchie for data collection and Jonathan Money for data analysis. They also acknowledge Mr Money and Jean Shoveller for consultation.

The authors acknowledge the Canadian Physiotherapy Cardiorespiratory Society for funding this study.

Data from this study were presented, in part, in a poster at the meeting of the American Thoracic Society, May 16-21, 2003, Seattle, Wash, and in a poster at the Combined Sections Meeting of the American Physical Therapy Association, February 4-8, 2004, Nashville, Tenn.

This article was received October 17, 2003, and was accepted August 10, 2004.

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* SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606.

([dagger]) Diploma refers to an educational program of 3 years or less, bachelor's degree refers to a university degree of 3 or more years, and master's degree and doctoral degree refer to research (thesis)-based university degrees.

S Mathur, PT, MSc, is Sessional Instructor, School of Rehabilitation Sciences, University of British Columbia, T325-2211 Westbrook Mall, Vancouver, British Columbia, Canada V6T 2B5 ([e-mail]). Address all correspondence to Ms Mathur.

S Stanton, OT, BSR(OT), MA, AGDDE (T), is Associate Professor and Coordinator, Online Programs, Division of Occupational Therapy, School of Rehabilitation Sciences, University of British Columbia.

WD Reid, PT, PhD, BMR (PT), is Associate Professor, Division of Physical Therapy, University of British Columbia.

Table 1.
Characteristics of Survey Respondents Compared With
Canadian Physical Therapists Licensed in Ontario (a)

                           Ontario Licensed      Licensing
                           Physical Therapists   Body Sample
Characteristics            (n=5,192)             (n=447)

Employment status
  Full-time                   3,152 (62%)         287 (68%)
  Part-time                   1,567 (31%)         124 (30%)
  Inactive                      401 (8%)            8 (2%)

Sector
  Public                      2,557 (53%)         210 (56%)
  Private                     2,310 (47%)         166 (44%)

Area of practice
  Orthopedics                 1,636 (75%)         311 (62%)
  Cardiac                        57 (3%)           24 (5%)
  Pulmonary                     103 (5%)           57 (11%)
  Neurology                     392 (18%)         113 (22%)

Highest professional
    (entry-level) degree
  Diploma                     1,176 (21%)          70 (16%)
  Bachelor's                  4,298 (78%)         334 (77%)
  Master's                       66 (1%)           31 (7%)

                           Cardiopulmonary
                           Interest Group
Characteristics            Sample (n=285)

Employment status
  Full-time                   203 (77%)
  Part-time                    43 (16%)
  Inactive                     19 (7%)

Sector
  Public                      211 (92%)
  Private                      18 (8%)

Area of practice
  Orthopedics                 100 (22%)
  Cardiac                      96 (22%)
  Pulmonary                   169 (38%)
  Neurology                    80 (18%)

Highest professional
    (entry-level) degree
  Diploma                      33 (12%)
  Bachelor's                  214 (78%)
  Master's                     26 (10%)

(a) Total number of responses may be less than total sample
size due to missing data. For area of practice, multiple
responses were permitted, allowing for the total number of
responses to exceed total sample size.

Table 2.
Factors Associated With Interest in Computer-Assisted Learning

Factor                 Level                 OR (95% CI) (a)

Sample                 Cardiopulmonary       2.50 (1.63-3.81)
                       Licensing body        Reference group

Level of education     Doctoral or           5.29 (1.93-14.51)
                       master's degree       2.82 (1.10-7.19)
                       Bachelor's degree     Reference group
                       Diploma

Previous experience    Yes                   1.06 (0.67-1.66)
with Web-based         No                    Reference group
courses

Access to Internet     Access                6.60 (3.82-11.42)
                       No access             Reference group

Location of Internet   Home and work         4.23 (2.28-7.85)
access                 Home only             1.43 (0.81-2.51)
                       Work only             Reference group

Hours of Internet      5 or more hours per   3.70 (2.22-6.17)
access                 week                  2.10 (1.04-4.24)
                       2-4 hours per week    Reference group
                       Less than 2 hours
                       per week

Self-rated computer    Expert or advanced    0.53 (0.22-1.25)
skills                 Intermediate          1.96 (0.89-4.34)
                       Novice                7.68 (3.08-19.14)
                       No skill              Reference group

Primary area of        Orthopedics           0.64 (0.44-0.95)
practice (A)           Pulmonary             1.77 (1.15-2.74)
                       Cardiac               1.46 (0.85-2.50)
                       Neurology             1.06 (0.70-1.62)
                       Other                 1.20 (0.79-7.83)

Type of work           Full-time             1.14 (0.48-2.72)
                       Part-time             1.02 (0.41-2.55)
                       Not practicing        1.13 (0.31-4.08)
                       Casual/locum          Reference group
                       (short-term
                       appointment that
                       may be full-time
                       or part-time)

Type of employer       Public sector         0.55 (0.29-1.04)
                       Both public and       1.04 (0.57-1.89)
                       private               Reference group
                       Private sector

Region                 Ontario               1.30 (0.87-1.95)
                       Quebec                1.10 (0.56-2.17)
                       Eastern Canada        1.44 (0.66-3.11)
                       Other                 N/A (too few cases)
                       Western Canada        Reference group

Size of community      <5,000                1.33 (0.50-3.52)
                       5,000-9,999           1.87 (0.60-5.78)
                       10,000-49,999         1.30 (0.66-2.59)
                       50,000-99,999         1.08 (0.53-2.20)
                       100,000-499,999       1.06 (0.60-1.86)
                       500,000-1 million     0.85 (0.46-1.55)
                       >1 million            Reference group

Mode of travel to      Car                   1.72 (0.98-3.02)
continuing             Bus                   2.22 (0.25-19.62)
education courses      Train                 1.85 (0.56-60.86)
                       Plane                 Reference group

Primary language       French                1.13 (0.56-2.26)
                       English and French    1.26 (0.44-3.61)
                       English               Reference group

Factor                 Level                 P

Sample                 Cardiopulmonary       .0001 (b)
                       Licensing body

Level of education     Doctoral or           .001 (b)
                       master's degree       .030 (b)
                       Bachelor's degree
                       Diploma

Previous experience    Yes                   .810
with Web-based         No
courses

Access to Internet     Access                .0001 (b)
                       No access

Location of Internet   Home and work         .0001 (b)
access                 Home only             .216
                       Work only

Hours of Internet      5 or more hours per   .0001 (b)
access                 week                  .038 (b)
                       2-4 hours per week
                       Less than 2 hours
                       per week

Self-rated computer    Expert or advanced    .145
skills                 Intermediate          .095
                       Novice                .0001 (b)
                       No skill

Primary area of        Orthopedics           .025 (b)
practice (A)           Pulmonary             .008 (b)
                       Cardiac               .159
                       Neurology             .784
                       Other                 .384

Type of work           Full-time             .760
                       Part-time             .964
                       Not practicing        .851
                       Casual/locum
                       (short-term
                       appointment that
                       may be full-time
                       or part-time)

Type of employer       Public sector         .064
                       Both public and       .900
                       private
                       Private sector

Region                 Ontario               .206
                       Quebec                .774
                       Eastern Canada        .359
                       Other
                       Western Canada

Size of community      <5,000                .566
                       5,000-9,999           .279
                       10,000-49,999         .451
                       50,000-99,999         .829
                       100,000-499,999       .844
                       500,000-1 million     .587
                       >1 million

Mode of travel to      Car                   .058
continuing             Bus                   .472
education courses      Train                 .310
                       Plane

Primary language       French                .736
                       English and French    .671
                       English

Factor                 Level                 n

Sample                 Cardiopulmonary       285
                       Licensing body        447

Level of education     Doctoral or            66
                       master's degree       548
                       Bachelor's degree     103
                       Diploma

Previous experience    Yes                   158
with Web-based         No                    539
courses

Access to Internet     Access                637
                       No access              61

Location of Internet   Home and work         310
access                 Home only             239
                       Work only              86

Hours of Internet      5 or more hours per    99
access                 week                   81
                       2-4 hours per week    446
                       Less than 2 hours
                       per week

Self-rated computer    Expert or advanced     56
skills                 Intermediate          285
                       Novice                300
                       No skill               57

Primary area of        Orthopedics           411
practice (A)           Pulmonary             226
                       Cardiac               120
                       Neurology             193
                       Other                 216

Type of work           Full-time             490
                       Part-time             167
                       Not practicing         27
                       Casual/locum           34
                       (short-term
                       appointment that
                       may be full-time
                       or part-time)

Type of employer       Public sector         411
                       Both public and        93
                       private               184
                       Private sector

Region                 Ontario               339
                       Quebec                 68
                       Eastern Canada         56
                       Other                   4
                       Western Canada        265

Size of community      <5,000                 37
                       5,000-9,999            33
                       10,000-49,999          97
                       50,000-99,999          78
                       100,000-499,999       184
                       500,000-1 million     120
                       >1 million            127

Mode of travel to      Car                   508
continuing             Bus                     7
education courses      Train                  74
                       Plane                  24

Primary language       French                 39
                       English and French     51
                       English               617

(a) CI = confidence interval.

(b) Denotes significance at P <.05.

(c) Analyzed as separate variables, reference group is
not used in the area of practice.

Table 3.
Distribution of Community Size and Travel Among Survey
Participants Across Canada (a)

                              Region (a)

                              Western
                              Canada    Ontario   Quebec
Variable                      (n=265)   (n=339)   (n=68)

Size of community
  >10,000                        30        26        5
  10,000-99,999                  62        73       23
  100,000-1 million             126       145       16
  >1 million                     26        84       19

Average length of travel
    to continuing education
    courses (expressed per
    survey participant)
  Travel distance (km) (c)     141.5     138.6     145.3
  Travel time (h)               2.07       1.62      1.6

                               Region (b)

                              Eastern   Territories
                              Canada    and Outside
Variable                      (n=56)    Canada (n=4)

Size of community
  >10,000                        13          0
  10,000-99,999                  18          3
  100,000-1 million              20          1
  >1 million                      0          0

Average length of travel
    to continuing education
    courses (expressed per
    survey participant)
  Travel distance (km) (c)     348.7       777.5
  Travel time (h)                2.79        3.37

(a) Total number of responses may be less than total sample size
due to missing data.

(b) See Figure 1 for schematic representation of regions.

(c) 1 cm = 0.6214 mile.