Health Education Technology in the 21st Century

Lorien Abroms, ScD.

Milken Institute School of Public Health

George Washington University

SOPHE Annual Meeting, Portland, OR

April 24, 2015

Dr. Lorien Abroms/GWU has licensed Text2Quit & Quit4Baby to Voxiva Inc.

This research was supported by NIH grants to Dr. Lorien Abroms, 5K07 CA124579-02 and 1R15CA167586

Funding Source:

Disclosure:

Topics I’ll cover

I. Use of technologyII. Current Uses & Evidence

• Text Messaging Programs• Smartphone apps• Social Media• Electronic Health

Records

Device Ownership 2002-2014

Reach of Mobile Phones90% of US adults

88% text message, top activity64%+ have smartphones, almost 90% among young adults

75% have used phone to look up health information

(Pew 2014; CTIA 2014)

“We Marry Them!” 82 % of mobile phone owners never

leave home without their phones 68 % sleep with device by bedside Invite them to interrupt us (at family

gatherings, at restaurant, at meetings)

Increasingly rate as something “not willing to live without”

The bottom line:

Communication technologies are proliferating in our daily lives.

They are with us throughout the day They’re here by invitation – we embrace

new ways of inviting them in

Topics I’ll cover

I. Use of technologyII. Current uses and

Evidence• Text Messaging Programs• Smartphone apps• Social Media• Electronic Health

Records

• Smoking is the leading preventable cause of death in the US

• 18% of US adults smoke• 13% among pregnant women

• Provides constant lens as we examine various technologies

• Well studied

A Focus on Smoking Cessation

Cessation programs should:Ask for tobacco use statusAdvise every user to quitAssess willingness to quitAssist with a quit plan Recommend approved meds Practical counseling Intra-treatment social supportConnect to a quitline

Arrange for follow-up

Text Messaging

Countries: New Zealand (2008), UK, Australia, Costa Rica, US

U.S.

Text2Quit (Text2quit.com) 130,000+ users since April 2012 Integrated with 1-800-QUITNOW in

10 States

SmokefreeTXT (smokefree.gov) Text QUIT to 47848 100,000+ users since Sept. 2012 Teen, Mom & Vet versions

Some Cessation Text Messaging Services

Text4Baby Core Partners:

Outreach Partners:

Telecoms industry support:

16

Text Messaging (SMS)Cessation Programs

• Automated text messages (SMS) for quitting smoking • Sent by a computer based on a message library and

algorithm (rules)• Messages are timed around quit date

• Proactive: Advice on quitting and manage cravings, medication msgs, and relapse messages.

• On-Demand: need additional motivation, having a craving, relapse.

• Interactive, personalized• 2-3 messages/day following quitdate

Advice on Quitting

Ex-smoker encouragement

On demand games & tips

Check-Ins

Attributes that may promote Smoking Cessation (Efficacy)1. Help anywhere and anytime2. Proactive messages interrupt you3. Interactive help4. Personalized help5. Increase contact time6. Unobtrusive and confidential 7. (Goes with smoking) Source: Abroms, Padmanabhan, and Evans 2011

Whittaker et al. Meta-Analysis. Cochrane. 2012

RR 1.7; 70% increase over control

Free et al. (2011) Lancet Text2Stop (N=5800)

5 msg/day first 5 weeks; then 3 msg/week for 26 weeks

Biochemically verified continuous abstinence at 6 months:10·7% txt2stop vs 4·9% control (p<0·0001)

No evidence that effect b/c drove use of quitline or NRT

Abroms et al. 2014 (N=503)

Abroms et al. Am J Prev Medicine. 2014

1 month 3 months 6 months0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

Tex-t2Quit

No S

mokin

g i

n t

he P

ast

7

days

30.5%

14.5%

33.2%

19.9%

31.7%

20.7%

US Preventive Services

Other/Not clear

Self-efficacy

Quantity/Frequency

Social Control

Skills/Info

Encouragement

Social Support

Global Help

On Demand Tools

Constant/Reminder

0 5 10 15 20 25 30

9.9

3.3

5

5.5

7.7

14.9

15.5

20.4

21

26

What Did You Like About Text2Quit? (1 Month)(n=181)

Percent (%)

“Made me feel accountable.” “[An] electronic conscience”

Texts constantly reminded me about my plan to quit.”“That you can [SMS] whenever you

are feeling the urge to smoke and in that time frame you are actually not smoking...”

“Someone kind of there with you…” “Like a constantly concerned friend”

“Texts gave good ideas on how to fight cravings ….”

Abroms et al. 2013

Other/Not clear

Message Tailoring

Text as a Trigger

Technical Issues

Message Timing

Content/Info

Lacked Personal Interaction

Message Frequency

Nothing

0 5 10 15 20 25 30 35 40 45 50

6.7

2.4

2.9

3.8

5.3

6.7

7.2

18.2

46.8

What Did You Dislike About Text2Quit? (1 Month)(n=173)

Percent (%)

“OMG. TOO MANY TEXTS PER DAY.”

“I would like it more if there was an actual coach ...”

“Sometimes I would be doing really good…then I would get a text and it would make me start craving and thinking about smoking.”

Abroms et al. 2013

Design Considerations

+Spohr et al. 2015; ^Head et al. 2014

Effect• Message tailoring and

personalization ^• Decreasing vs. fixed

message frequency ^

No Effect• Text plus other modality. +^

• Extra protocols of messages

• On Demand messages• Social/peer to peer messages

Smartphone Apps

Sampling Process

100,000+ Apps in

iTunes Store

71 Apps

52 Apps

47 Apps in Sample

Power Search for “quit smoking”, “stop smoking”, and “smoking

cessation”

Assess relevance from app

description

Download available apps

15,000 consumer health apps; 400+ smoking cessation apps across Android and iOS (Abroms et al. 2013)

Google App Installs (2015)

 3,025,000-12,302,000 installs from top 50 “Quit Smoking” Apps since end 2012

Popular App Types: iPhone and Android

N=98Other = informational brochure, substitute cigarette, game, lung health tester

Calculator: QuitNow!

Game: Cigarette Fighter

Evidence: Cessation programs should:

Ask for tobacco use statusAdvise every user to quitAssess willingness to quitAssist with a quit plan Recommend approved meds Practical counseling Intra-treatment social supportConnect to a quitline

Enhance motivationArrange for follow-up

Popular Smoking Cessation Apps Overall Low Adherence: 12/42

Present in Apps (>50%)

Interactive Personalized

Advice to Quit Ask for tobacco

status

Lacking in Apps (<20%) Practical counseling on

how to quit (19.4%) Recommend meds (4.1%) Connecting to a quitline

(0.0 %) Social support (17.3%) Text alerts (12.2%)

Abroms et al. 2013

N=98

Emerging Evidence

CBT 28-day program:Ubhi HK1, Michie S, Kotz D, Wong WC, West R. 2015

Acceptance & Commitment Theory: Bricker JB, Mull KE, Kientz JA, Vilardaga R, Mercer LD, Akioka KJ, Heffner JL 2014

Quit Ninja: Craving manager: Personalized motivations that improve over time(Beckford et al.)

Social Media

Social Media: Fan Pages

Pages Groups Apps

Twitter Groups

RANDOMIZED CONTROLLED TRIAL OF TWEET2QUIT FOR SMOKING CESSATION

Private group with two daily msg: (1) a group discussion topic, (2) feedback on prior day tweeting

Outcome: 20% for control and 40% for Twitter participants

(Pechmann et al. 2015)

Facebook: Groups

Ramo et al. , 2013

Facebook app: Ubiquitous

Cobb et al. , unpublished

N=9000• randomized to 12 conditions

Outcome: diffusion through social network

Content Analysis Facebook Apps (Jacobs et al. 2014, JMIR)

N=9 apps fell into three broad categories: public pledge to

quit (n=3), quit-date-based calculator/tracker (n=4), or a multicomponent quit smoking program (n=2).

Allowed app-related posting within Facebook (ie, on self/other Facebook profile), had a within-app "community" feature (n=4)

Adherence index summary scores among Facebook apps were low overall (mean 15.1, SD 7.8, range 7-30)

Untapped opportunity

Electronic Health Records (EHR)

In the US, high adoption of electronic health records (EHR), especially among large clinical practices.

Meaningful use /ACA requires adoption of EHR and inclusion of smoking status field

For smoking cessation, could be used : During clinical visit, to remind clinicians to record tobacco

use, to give brief advice to quit, to prescribe medications and to refer to cessation counseling.

To create a registry of smokers for outreach

Link to the provision of electronic cessation programs

Do they actually help patients quit?

About EHR

Use of Alerts

Mathias et al., 2012

Registry model of prevention and health promotion.

Identify patients from EHR

Send invitation via SMS Patient opts-in

GW MFA: Get SMS to improve your health. Reply 1 to opt into SMS quit smoking program & start your journey to a smokefree you.

N=11, most observationalWith introduction of EHR, documentation of tobacco use and referral to cessation counseling increased

No effect on patient smoking cessation

High variability in how tasks were achieved

Cochrane Review EHR and smoking cessation(Boyle et al. 2011)

Summary of EHR attributes

  All Studies (N=15)

SettingClinicDental OfficeHospitalMixed

 12 (80%)1 (6.67%)1 (6.67%)1 (6.67%)

Type of EHREPICLogicianVistAPractice PartnerNot specified

 3 (20%)2 (13.33%)1 (6.67%)1 (6.67%)8 (53.33%)

Use of Alert 6 (40%)Presence of Best Practice Advisory 2 (13.33%)Clinical Decision Support FeaturesAsk for tobacco statusAssess willingness to quitAdvise every user to quit/Brief TreatmentReferral to CounselingAssist with patient education (materials)Assist via referral to quitlineAssist with medication orderingArrange follow-up

 15 (100%)8 (53.33%)6 (40%) 7 (46.67%)5 (33.33%)7 (46.67%)9 (60%)3 (20%)

Presence of Order set 7 (46.67%)

Shindler-Ruwisch, Bernstein, & Abroms ; in progress

Apple HealthKit

Personal health record

EHR (Epic) can read data points patient is willing to share

Trials underway

Conclusions

Summary

I. Use of technology: high & growing

II. Current uses and Evidence• Text Messaging Programs

(14)• Smartphone apps (3)• Social Media (3)• Electronic Health Records

(11)

Challenges More research

Do new programs/platforms work? How to optimize them?

Integration with each other and with health systems

Not either or: Don’t forget that we have access to people too

Privacy & Security Balance patient privacy with care

Phenomena of “On and Off the Grid”

Reach. Opportunity to Reach people where they are

Efficacy. Opportunity to supplement in-person clinician, phone counseling and other traditional models

Efficacy. Opportunity to create new behavior change models (and theories!) Tracking and feedback Timing as secondary to content Social support, influence, norms Gaming

Opportunity

Integration with health systems EHR & health educators as designers

Packs of cigarettes with mCessation on the warning label

Next Generation of Programs Smartphone apps integrated with texting Sensors—lighters to track opening a pack

of cigs; CO monitors for feedback on phones

Social Media Avatars/Games iWatch apps

The future…

To quit, text “Quit” to 47848

BeFree Study Team: Leah Leavitt, MPH(c), Jennifer Schindler-Ruwisch, MPH, Laura Macherelli, MPH(c)

Smartphone App Analysis Team:Lee Westmaas PhD (ACS), Jeuneviette Bontemps-Jones (ACS), Rathna Ramani MPH

New Mexico Quitline Team: Phil Carrol, Kelly Carpenter (Alere), Booke Magnussun (Alere), Judy Mendel MPH

Thank-you ! Acknowledgements:

References & Selected Readings Abroms LC, Ahuja M, Kodl, Y, Thaweethai L, Sims J, Winickoff J, Windsor RA. (2012a) Text2Quit:results from a pilot test of a personalized, interactive mobile health smoking cessation program. Journal of Health Communication (2012).   Abroms LC, Ahuja M, Windsor RA. (2012b). Text2Quit:results from a randomized trial of a personalized, interactive mobile health smoking cessation program. Presented

at SRNT, 2013.   Abroms LC, Padmanabhan N, Evans WD. (2011a). Mobile Phones for Health Communication to Promote Behavior Change. eHealth applications: Promising strategies for behavior change. Noar, S. M., & Harrington, N. G. (Eds.). New York: Routledge, (in-press).   Abroms LC, Padmanabhan N, Thaweethai L, Phillips T. (2011b). A content analysis of iPhone apps for smoking cessation. American Journal of Preventive Medicine. 40(3):279-85.   Brendryen H, Drozd F, Kraft P. A Digital Smoking Cessation Program Delivered Through Internet and Cell Phone Without Nicotine Replacement (Happy Ending): Randomized Controlled Trial. J Med Internet Res. 2008; 10(5):e51.   Cole-Lewis H, Kershaw T. Text messaging as a tool for behavior change in disease prevention and management. Epidemiologic Rev. 2010; 32(1):56-69.   Free C, Knight R, Robertson S, Whittaker R, Edwards P, Zhou W, Rodgers A, Cairns J, Kenward MG, Roberts I. (2011). Smoking cessation support delivered via mobile

phone text messaging (txt2stop): a single-blind, randomised trial. Lancet. 378(9785):49-55.   Free et al. 2013.Review of mHealth. Plos One.   Guide to Community Preventive Services. (2011). Increasing tobacco use cessation: mobile phone-based interventions. Accessed on 2/22/12 at :

http://www.thecommunityguide.org/tobacco/cessation/mobilephone.html   Naughton F, Prevost AT, Gilbert H, Sutton S. (2012). Randomized Controlled Trial Evaluation of a Tailored Leaflet and SMS Text Message Self-help Intervention for

Pregnant Smokers (MiQuit). Nicotine Tob Res. Feb 6.   Rodgers A, Corbett T, Bramley D. Do U Smoke after TXT? Results of a randomized trial of smoking cessation using mobile phone text messaging. Tobacco Control.

2005;14(4): 255-261.   The Quit Group. Evaluation of the first year of the Txt2Quit Services (Online) July 31, 2009: [Cited: March 2011]Available at: http://www.quit.org.nz/file/research/FINAL%202008-09%20Txt2Quit%20evaluation%20report%2020090731.pdf   Whittaker R, Borland R, Bullen C, Lin RB, McRobbie H, Rodgers A. Mobile phone-based interventions for smoking .The Cochrane Library, 2009;(4).   Whittaker R, Maddison R, McRobbie H. A Multimedia Mobile Phone-Based Youth Smoking Cessation Intervention Findings From Content Development and Piloting

Studies, Journal of Medical Internet Research, 2008;10(5): e49.   Whittaker R. et al. The Cochrance Library, 2012.

{

Behavior is motivated by rational/conscious and non-conscious processes-Elephant and the Rider-

Five broad purposes for use of social media in public health/health promotion have been proposed: (a)

communicate with consumers for market insights (Centers for Disease Control and Prevention [CDC], 2010, Kruse, 2010); (b) establish and promote a brand with

consumers (Kruse, 2010); (c) disseminate critical information (CDC, 2010); (d) expand reach to include broader, more

diverse audiences (CDC, 2010); and (e) foster public

engagement and partnerships with consumers (CDC, 2010).

Types of uses in health promotion

social media as evidenced by the finding that 60% of

state health departments now use at least one application

(Thackeray, VanWagenen, Koch Smith, Neiger, & Prier,

2011). In addition, one third of adults use social media to

access health information, and nearly 80% of physicians

who consult with patients online use social media channels

to create or share medical content (Hughes, 2010).Use of social media for health (Neiger et al. 2013)

Games

Game

A game is a rule-based activity that involves challenge to reach a goal and that provides feedback on progress made toward that goal (Leiberman 2011)

Rules Goals Feedback

What is Gamification?

Game design principles applied to non-games

Goal: engage with the audience Goal: encourage desired behaviors Result: mastery and autonomy Result: transform routine into

excitement

Players told to crush as many virtual cigarettes as possible. Players encountered the targets while wandering through a fictional medieval castle depicted on a computer screen. By the end of the 12-week support program, 15% of the cigarette crushers said they quit smoking, compared with just 2% of the ball-gripping group. (Girard 2009)