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Mobile phone population health programmes - Dr. Robyn Whittaker
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Mobile phone population health programmes - Dr. Robyn Whittaker


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Presentation from Dr. Robyn Whittaker on the use of texting/sms to improve health in New Zealand and Beyond.

Presentation from Dr. Robyn Whittaker on the use of texting/sms to improve health in New Zealand and Beyond.

Published in: Health & Medicine, Business

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  • Six month quit rates
    Control group quit rates increased significantly from 6 weeks to 6 months, possibly because they were receiving a month of free texting on completion of final data collection, and may have thought this was dependent on reporting quitting
    Differential loss to follow-up where more control group participants provided 6 month data (again as there was an incentive for this group to do so, the intervention group had already received their month of free texting on quit day – a design fault that was instigated by the wireless company). In an intention-to-treat analysis, more missing data in the intervention group meant more were designated as smokers for the final analysis. Assuming those lost to follow-up are smoking is the standard treatment of missing data in smoking cessation trials
  • This intervention has since been implemented as a national programme free to consumers. Run by The Quit Group as a quitline service
    Funded by Ministry of Health for three years as a pilot with evaluation
    First year evaluation is available (I have a copy) at Approx 4000 clients with very minimal promotion. Six-month quit rates around 16%. Feedback that texts were timely, relevant, motivating, supportive and easy to read. Some thought there were too many texts. Most were satisfied and would use it again or recommend to a friend
  • STOMP has been licensed to HSAGlobal a NZ health IT company. They are providing the intervention for the NZ service. They won a Telecommunications Users Assn of NZ innovations award for this programme. As part of their suite of services, they are providing STOMP to Telus, a large telco in Canada. At this time Telus have been providing STOMP to their employees only with similar quit rates of around 16%. Telus won an award for this as an employee health and wellness programme. HSAGlobal also ran a small time-limited project with STOMP in Arizona.
  • In collaboration with the London School of Hygiene and Tropical Medicine, we have been runnning a large RCT on STOMP in the UK. They recruited 5,900 participants across the country and we provided the intervention from the University of Auckland. The trial has just finished and results will be available shortly (they are good!).
  • Next we wanted to see what new mobile telecommunications technology could offer wrt continually improving the intervention to keep it relevant and engaging, and to provide richer, theoretically-based content.
  • Social cognitive theory uses observational learning to enhance self-efficacy for behaivour change – by watching someone else (like you) attempt the behaviour, struggle but succeed, you feel that you may be able to do it, and pick up techniques to use yourself. “if they can do it then so can I”
    Also used known effective behaviour change techniques for smoking cessation (setting quit date, goal setting, positive reinforcement, social support, weighing up positive and negative outcome expectations, information on nicotine addiction and withdrawal symptoms, trigger situation and cues to smoking, planning to avoid those situations)
    Adolescent development principles around engagement and involvement
    Social marketing techniques in development, involvement of target audience, pre-testing etc
  • 2-way interaction via texting in keywords and receiving immediate and context-specific video and text messages back. Crave was designed for ‘bored’, ‘stressed’, out ‘drinking’ with friends.
  • Characterisations of four characters
    Siblings, girl 17yrs, boy 15yrs, Maori/pakeha, average SES, and dog
    Auditioned & contracted a scriptwriter
    Profession animator (Victor Gaitan) from Brotwon team
    Teens as voices
    Common and some more serious teen situations to illustrate key messages
  • Important not to leave them in the lurch at the end
    Mobile website with ‘toolbox’ summary of content under our three words
    Info on who to contact if they have problems & how to contact us
    Monthly quiz to remind them of info, prompt them to keep trying it, & win prizes
  • Recruited participants in high schools across Auckland – pitch study participation to one year group at a time and sign up as many as possible
    Screening RADS, identify those with existing depression or risk of self-harm and refer to School Guidance Counsellor to follow usual school protocols
    All others were individually randomised to either Intervention or Attention control programme - computerised allocation for concealment, students and researchers blind to allocation
  • Transcript

    • 1. ISO 9001 Registered Dr Robyn Whittaker Clinical Trials Research Unit, University of Auckland Mobile phone population health programmes
    • 2. Clinical Trials Research Unit • Investigator-lead clinical trials of innovative health interventions – 55 research and operational support staff – Since 2001: enrolled 79,000 participants into 48 research projects in 334 study centres across 24 countries in all continents – Collaborations in Australia, USA, UK, China • ISO 9001:2000 quality management systems certified for Clinical Trial Research and Epidemiological studies • All research carried out to meet GCP, GCRP and FDA Guidelines
    • 3. Mobile phones are … Everywhere! • NZ > 100% penetration • US 25% households ‘wireless’ • Developing world “reach further than other technology and health infrastructures” [mHealth for Development, UN Foundation]
    • 4. Mobile health … means different things to different people includes using low end technology (messaging) to reach large populations directly and individually
    • 5. These mHealth programs can be… • Integrated into daily lives • Proactive & direct • Anywhere • Timely & time sensitive • Personalised & tailored • Provide social support • Easily scaled up to whole populations
    • 6. CTRU’s m-health programmes Txt messaging stop smoking support Video messaging stop smoking support Multimedia messaging depression prevention 1999 2010
    • 7. ISO 9001 Registered
    • 8. Text Messages • Cessation messages – Support, quit tips, behaviour change processes, goal setting processes, education, positive reinforcement, enhancing self-efficacy • Interest messages – Keywords: sport, fashion, technology, trivia • Maori messages – Support/motivation, language, traditions
    • 9. Development process • Focus groups • Interests from current youth publications • Messages drafted & turned into text lingo • Review by 18-35 year-olds • Refined • Used to develop Maori messages – Maori experts and students • Entered into database by keywords
    • 10. Examples of messages • Who else r u givng up Smoking 4? Write down 4 people who will get a kick outa u kickng butt. Your son, daughter, mum, dad, m8's? • Failed 2 QT b4 & believ you'll fail again? Rewrite ur belief 2 "I have the power 2 stick 2 my plan, I have gr8 support, I am stronger each day"
    • 11. Examples of Māori messages • Achievement - whakatutu ki tanga. All the things we achieve are things we have first imagined and then made happen. • Frnds,whanua,hauora,mana,wairua all gr8 reasons to me mutu (should quit) • Maori traditions -Instead of smking, explor ur Kainga tuturu (ur true home on whanau/tribal land). Y not make contact and get in touch wth ur past!
    • 12. STOMP flowchart Voice or web registration •smoking history, triggers etc0 weeks Quit Day •free text messaging begins1-3 weeks Daily text message countdown + action plan Quit calendar web page Personalised text message tips Introduction to CellPall (“quit buddy”) Text your friends “TXT crave” 4 personalised text message tips per day Quiz or poll eg “top 5 reasons to quit” Web page Quit Meter (eg $ saved), profiles Target Date Quit Relapse 6 weeks 26 weeks
    • 13. STOMP Trial participants 0% 5% 10% 15% 20% 25% 30% 35% 16-19 20-24 25-29 30-34 35-39 40-44 45+ Age %Recruited 59% Female 21% Maori, 58% European Mean Age 25 yrs N=1705
    • 14. STOMP results • 28% self-reported point prevalence quit rate after 6 weeks – double the control group 13% (RR2.20, 95% CI 1.79-2.70) • Intervention as effective for Māori as non-Māori
    • 15. % quit at 6 weeks Age Gender Ethnicity Income Region 0% 10% 20% 30% 40% <=19 yrs 20-29 yrs >=30 yrs female male Maori Other <$15k $15-30k >$30k Auckland Other NI South Island STOMP Control Overall relative risk 2.8, 95% CI 2.1-3.5, p <0.0001
    • 16. % quit at 6 weeks No of cigarettes Type of cigarettes No of previous quit attempts 0% 5% 10% 15% 20% 25% 30% 35% <=10 10-19 >=20 ready made roll your own both 0-1 2-3 4+ STOMP Control
    • 17. Treatment effects at 6, 12 & 26 wks Māori/non-Māori Control N (%) Active N (%) RR (95%CI) P value 6 weeks - Māori 20 (11.2) 46 (26.1) 2.34 (1.44, 3.79) 0.0003 - non-Māori 89 (13.2) 193 (28.6) 2.16 (1.72, 2.71) <.0001 12 weeks - Maori 35 (19.6 47 (26.7) 1.37 (0.93, 2.01) 0.11 - non-Māori 125 (18.5) 200 (29.6) 1.60 (1.31, 1.94) <.0001 26 weeks - Māori 33 (18.4) 38 (21.6) 1.17 (0.77, 1.78) 0.46 - non-Māori 169 (25.1) 178 (26.3) 1.05 (0.88, 1.26) 0.60 Assumes all participants with missing smoking status were smoking
    • 18. ISO 9001 Registered
    • 19. Advances in technology.. • Capitalise on novelty factor • Video messaging – richer content – role modeling to provide observational learning, normalize behavior, enhance self-efficacy (from social cognitive theory) • Interest/distraction possibilities • Engagement possibilities
    • 20. STUB IT Content • Video diary messages of young people quitting smoking • Real life stories • Effective quitting tips & techniques Hi from the team at STUB IT. Please view your latest video with this link http://digitest/ quitmedia/1234
    • 21. Other functions • CRAVE – context specific txts & videos on demand • RELAPSE – 3 messages over next few hours – prompted to increase push messages • Website – Change aspects of your programme
    • 22. What did you like most? The support • I am not alone • Messages supporting me and helping me along • The constant/daily support • Felt like I was quitting as a group • Real people doing it • That people were sharing their own experiences so I was not feeling alone • Good motivation from the video messages • Being reminded others were doing it too
    • 23. Developed mHealth program • Based on Cognitive Behavioural Therapy • Teach proven skills and techniques to improve resilience and prevent onset of depression • For teens 13 -17 years • Particularly for Māori & Pacific girls • Positively framed • Engaging!
    • 24. Development process Focus groups Expert Group Pre-testing with youth Cultural advisors CBT key messages Creative advisors Branding Characters & contexts Writing Creating & filming
    • 25. “Spot, Sort, Do” Animated cartoons mobile website Video clips youth and celebs Education al messages Contacts & summary Short catchy key message in txt ‘Brotown’ style Reality TV or ‘youtube’ style 2 messages/day for 2 months Access for 12 months
    • 26. MEMO Animations
    • 27. Screening (self-rated measures of depression) Screening (self-rated measures of depression) 9-day run-in programme delivered by mobile phone 9-day run-in programme delivered by mobile phone Face-to-face clinical assessmentFace-to-face clinical assessment Participant information and consent (parental assent) Participant information and consent (parental assent) Randomisatio n Randomisatio n CBT-based programme delivered by mobile phone CBT-based programme delivered by mobile phone Matching control programme delivered by mobile phone Matching control programme delivered by mobile phone Post-intervention assessment (self-ratings + satisfaction) Post-intervention assessment (self-ratings + satisfaction) Post-intervention assessment (self-ratings + satisfaction) Post-intervention assessment (self-ratings + satisfaction) 12 month f/up face-to-face clinical assessment 12 month f/up face-to-face clinical assessment 12 month f/up face-to-face clinical assessment 12 month f/up face-to-face clinical assessment Those with high scores excluded (referral for treatment or e-therapy) Those with high scores excluded (referral for treatment or e-therapy) Those with high scores excluded (referral for treatment or e-therapy) Those with high scores excluded (referral for treatment or e-therapy)
    • 28. ADAPT Trial • Recruited 850 students (13-17 years) in 15 schools • Post-programme interviews completed • Part-way through final follow-up interviews – Completed mid-2011
    • 29. Post-programme results • Did you find MEMO to be helpful? Yes 84% (349) • Would you recommend it to your friends? Yes 91% (379)
    • 30. Did MEMO help you to… % n Be more positive 67% 279 Relax 53% 222 Get rid of negative thoughts 50% 210 Have fun 45% 186 Help other people 42% 177 Solve problems 33% 138 Get support when I need it 29% 122 Deal with issues at school 26% 109
    • 31. What they liked… N=417 Really liked Liked N/A Disliked Really disliked Videos from teens 12% 60% 24% 4% 0.5% Videos from celebs 21% 58% 16% 4% 1% Animated cartoons 23% 43% 23% 10% 1% Text messages 9% 51% 32% 7% 1% Receiving messages daily 5% 37% 31% 23% 4% The free stuff 52% 39% 8% 1% 0
    • 32. Publications • STOMP – Rodgers A, et al. Tobacco Control 2005 – Bramley D, et al. NZMJ 2006 • STUB IT – Whittaker R, et al. Journal of Medical Internet Research (JMIR) 2008 and ‘in press’ • Mobile phones & cessation – Whittaker R, Smith M. International Journal of Mobile Marketing (IJMM) 2008 – Whittaker R, et al. Cochrane Systematic Review 2009
    • 33. Next mobile progs for CTRU • Mobile phone-based physical activity intervention for cardiovascular rehabilitation patients • Wider cardiac rehab mobile phone based intervention • Medication adherence & self- management intervention
    • 34. Harkness fellowship • Can mobile health increase access to health information and services for underserved populations? • What lessons can we learn from NZ and US initiatives? • How can we move ahead and implement mhealth to improve population health outcomes? The Commonwealth Fund
    • 35. Two parts • Evaluation of text4baby – Free national health information text messages – Large public-private partnership with support from wireless networks – Local promotion – Messages relevant to stage – Aims to improve maternal/infant health • Key informant interviews
    • 36. Contacts Dr Robyn Whittaker Twitter: rawegd