Health Education Technology in the 21st Century. Presented by Dr. Lorien Abroms, ScD at the George Washington University Milken Institute School of Public Health.
2. 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:
3. Topics I’ll cover
I. Use of technology
II. Current Uses & Evidence
• Text Messaging Programs
• Smartphone apps
• Social Media
• Electronic Health Records
5. Reach of Mobile Phones
90% of US adults
88% text message, top activity
64%+ have smartphones, almost
90% among young adults
75% have used phone to look up
health information
(Pew 2014; CTIA 2014)
6.
7.
8. “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”
9.
10. 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
11. Topics I’ll cover
I. Use of technology
II. Current uses and Evidence
• Text Messaging Programs
• Smartphone apps
• Social Media
• Electronic Health Records
12. • 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
13. Cessation programs should:
Ask for tobacco use status
Advise every user to quit
Assess willingness to quit
Assist with a quit plan
Recommend approved meds
Practical counseling
Intra-treatment social support
Connect to a quitline
Arrange for follow-up
15. 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
17. 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
19. Attributes that may promote
Smoking Cessation (Efficacy)
1. Help anywhere and anytime
2. Proactive messages interrupt
you
3. Interactive help
4. Personalized help
5. Increase contact time
6. Unobtrusive and confidential
7. (Goes with smoking)
Source: Abroms, Padmanabhan, and Evans 2011
20. Whittaker et al. Meta-Analysis. Cochrane.
2012
RR 1.7; 70% increase over control
21. 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
22. Abroms et al. 2014 (N=503)
Abroms et al. Am J Prev Medicine. 2014
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
1 month 3 months 6 months
Text2Quit
Control
NoSmokinginthePast7days
30.5%
14.5%
33.2%
19.9%
31.7%
20.7%
24. 0 5 10 15 20 25 30
Other/Not clear
Self-efficacy
Quantity/Frequency
Social Control
Skills/Info
Encouragement
Social Support
Global Help
On Demand Tools
Constant/Reminder
9.9
3.3
5
5.5
7.7
14.9
15.5
20.4
21
26
Percent (%)
What Did You Like About Text2Quit? (1 Month)
(n=181)
“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
25. 0 5 10 15 20 25 30 35 40 45 50
Other/Not clear
Message Tailoring
Text as a Trigger
Technical Issues
Message Timing
Content/Info
Lacked Personal Interaction
Message Frequency
Nothing
6.7
2.4
2.9
3.8
5.3
6.7
7.2
18.2
46.8
Percent (%)
What Did You Dislike About Text2Quit? (1 Month)
(n=173)
“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
26. 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
28. 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
29. Google App Installs (2015)
3,025,000-12,302,000 installs from top
50 “Quit Smoking” Apps since end
2012
30. Popular App Types:
iPhone and Android
N=98
Other = informational brochure, substitute cigarette,
game, lung health tester
33. Evidence: Cessation programs
should:
Ask for tobacco use status
Advise every user to quit
Assess willingness to quit
Assist with a quit plan
Recommend approved meds
Practical counseling
Intra-treatment social support
Connect to a quitline
Enhance motivation
Arrange for follow-up
34. 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
39. 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)
41. Facebook app: Ubiquitous
Cobb et al. , unpublished
N=9000
• randomized to
12 conditions
Outcome:
diffusion through
social network
42. 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
44. 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
46. 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.
47. N=11, most observational
With 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)
48. Summary of EHR attributes
All Studies (N=15)
Setting
Clinic
Dental Office
Hospital
Mixed
12 (80%)
1 (6.67%)
1 (6.67%)
1 (6.67%)
Type of EHR
EPIC
Logician
VistA
Practice Partner
Not 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 Features
Ask for tobacco status
Assess willingness to quit
Advise every user to quit/Brief Treatment
Referral to Counseling
Assist with patient education (materials)
Assist via referral to quitline
Assist with medication ordering
Arrange 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
49. Apple HealthKit
Personal health record
EHR (Epic) can read data
points patient is willing
to share
Trials underway
51. 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)
52. 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”
53. 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
54. 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
55. 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:
56. 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.
58. 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
59. 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)
61. 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
62. 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
63. 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)