E Health Behaviour Change


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How can tools like the Internet support changing complicated and complex behaviours like cigarette smoking? This presentation outlines the way an eHealth promotion strategy can help people quit smoking and prevent others from starting using illustrations from the Smoking Zine program developed by the Youth Voices Research Group at the University of Toronto

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  • Language – despite the attempts by many to standardize it – is not top-down. It is dynamic and constantly in flux. Slang is one way that young people can take control of language and resist the conventions of society, while still finding a mechanism to communicate with one another.
  • This is a critical point. When we work with young people, we are often concerned primarily with the part of the equation that deals with information coming in, yet in a networked world it is also about what information goes out and how that knowledge is exchanged with others.
  • In the health field, the implications of poor quality information can literally be the differences between life and death. Content quality is something we pay particular attention to, yet often have little influence over.
  • Controlling for demographic and Internet use characteristics, youth who received an aggressive sexual solicitation were almost 2.5 times as likely to report experiencing physical abuse, sexual abuse or high parent conflict.
  • E Health Behaviour Change

    1. 1. Public  eHealth:  Promo1ng  personal   and  popula1on  health  through  ICT's   Cameron  D.  Norman  PhD   Assistant  Professor   Dalla  Lana  School  of  Public  Health   University  of  Toronto  
    2. 2. Public  eHealth  &  Behaviour  Change      If  you  want  to   understand   something,  try   to  change  it   –  Kurt  Lewin  (1951)  
    3. 3. Ten  Great  Public  Health  Achievements   -­‐-­‐  United  States,  1900-­‐1999     •  VaccinaNon     •  Motor-­‐vehicle  safety     •  Safer  workplaces     •  Control  of  infecNous  diseases     •  Decline  in  deaths  from  coronary  heart  disease  and  stroke     •  Safer  and  healthier  foods     •  Healthier  mothers  and  babies     •  Family  planning     •  FluoridaNon  of  drinking  water     •  RecogniNon  of  tobacco  use  as  a  health  hazard   Centers  for  Disease  Control  (1999).  Morbidity  &  Mortality     Weekly  Report,  48  (12),  241-­‐243.  
    4. 4. Cancer   •  In  the  United  States,  the  overall  cancer  death   rate  decreased  by  12%  between  1991  and   2003.     •  A  significant  proporNon  of  this  decline  (40%)  is   not  due  to  breakthroughs  in  molecular   medicine,  gene  therapy,  or  other  highly   technical  treatments,  but  to  a  behavioral   intervenNon:  smoking  cessa1on   •  Thun,  M.  J.  et  al.(2006).  Tobacco  Control,  15,  345-­‐347.    
    5. 5. Obesity   Overweight  (BMI  =  25-­‐29.9)  associated  with  a  loss  of  >  3  years;   BMI  >  30  associated  with  loss  of  7  years  
    6. 6. Cardiac  RehabilitaNon   •  “Although  the  efficacy  of   stand-­‐alone  psychosocial   intervenNons  remains   unclear,  both  exercise  and   mulNfactorial  cardiac   rehabilitaNon  with   psychosocial   intervenNons  have  dem-­‐   onstrated  a  reducNon  in   cardiac  events.”   Rozanski,  Blumenthal,  Davidson,  Saab  &  Kubansky  (2005).  Journal  of  the  American   College  of  Cardiology,  45  (5),  637-­‐651.  
    7. 7. HIV  /  AIDS   •  “Interpersonal,   structured  adherence   support  was  associated   with  improved  long-­‐ term  medicaNon   adherence  and  virologic   and  immunologic  HIV   outcomes”   Mannheimer,  S.B.  et  al.  (2006).  JAIDS,  43,    S41-­‐S47  
    8. 8. Chronic  Disease  Management   •  “Chronic  disease  self-­‐ management  programs   probably  have  a   beneficial  effect  on   some  (but  not  all)   physiologic  outcomes   that  have  been  assessed   in  controlled  trials”   Chodosh,  J.  et  al.  (2005).  Annals  of  Internal  Medicine,  143,  427-­‐438.    
    9. 9. Tobacco  Use   •  Tobacco  was  responsible  for  more  than  100  million  deaths   worldwide  in  the  20th  century  and  is  forecast  to  kill  at  least   one  billion  more  in  the  century  to  come  [1]   –  80%  of  such  deaths  are  projected  to  occur  in  the  developing   world  [2]   •  Half  of  the  current  smokers  today  (about  650  million   people)  will  die  as  a  result  of  tobacco  use,  with  tobacco  use   accounNng  for  the  premature  death  of  4.9  million  people   worldwide  [3].     1.  World  Health  OrganizaNon:  WHO  Report  on  the  global  tobacco  epidemic,   2008:  The  MPOWER  Package.  Geneva,  CH:  World  Health  OrganizaNon;   2008.   2.  Sabrie  E,  Glantz  SA:  The  tobacco  industry  in  developing  countries.  BriJsh   Medical  Journal  2006,  332:313-­‐314.   3.  Shafey  O,  Dolwick  S,  Guindon  GE  (Eds.):  Tobacco  Control  Country  Profiles   2003.  Atlanta,  GA:  American  Cancer  Society;  2003.  
    10. 10. Knowledge  TranslaNon   •  Volume  of  informaNon  and  knowledge  is   currently  greater  than  ever  before,  yet  relaNvely   linle  is  being  translated  into  pracNce  across  the   spectrum  of  discovery  and  pracNce   •  Hyan,  Best  &  Norman  (2008).  Knowledge  integraNon:   Conceptualizing  communicaNons  in  cancer  control  systems.   PaJent  EducaJon  &  Counseling,  71,  319-­‐327.   •  EsNmates  that  it  is  taking  up  to  17  years  to   translate  innovaNons  into  everyday  clinical   pracNce   •  Balas  EA,  Boren  SA.  (2000).  Managing  clinical  knowledge  for   health  care  improvement.  In:  Yearbook  of  medical   informaNcs.  p.  65–70.  
    11. 11. Looking  Forward  to  Change   •  The  only   people  who   truly  welcome   change  are  wet   babies  
    13. 13. Some  Wisdom  from  Kurt  Lewin   (1890-­‐1947)   “There  is  nothing  so  pracNcal  as  a  good  theory”  
    14. 14. Likelihood  of  AcNon  Scale   A  person  more  likely  to  act  if…   •  View  themselves  as  personally  suscepNble   •  Sees  the  (potenNal)  problem  as  serious   •  Believes  change  will  reduce  risk   •  Assesses  pros  as  outweighing  cons  of  change   •  Believes  that  others  endorse  change   •  Is  moNvated  to  comply  with  others’  wishes  
    15. 15. Likelihood  of  AcNon  Scale   A  person  more  likely  to  act  if…   •  Environment  is  supporNve  of  acNon   •  Person  has  necessary  knowledge  and  skills   •  Confident  that  they  can  carry  out  acNon   •  Intrinsically  moNvated  to  change   Skinner,  H.A.    Promo1ng  Health  Through  Organiza1onal  Change.  San  Francisco:  Benjamin  Cummings  Publishers,  2002.;     Norman,  C.D.,  Maley,  O.,  Li,  X.,  &  Skinner,  H.A.  Using  the  Internet  to  iniNate  and  assist  smoking  prevenNon  in  schools:    A  randomized  controlled  trial.  Health  Psychology,  2008,  27,  799-­‐810.  
    16. 16. Health  Belief  Model  
    17. 17. Theory  of  Reasoned  AcNon/Planned   Behaviour  
    18. 18. Social  CogniNve  Theory   •  Emphasizes  the  reciprocal  role  of  environment   (physical,  social,  cultural)  and  behaviour   –  Social  learning     •  EvaluaNng  expectaNons  and  capabiliNes  -­‐-­‐   focus  on  skill  development  and  self-­‐efficacy   (confidence)  
    19. 19. Self-­‐DeterminaNon  Theory   •  People  are  more  likely  to  change  if  they   genuinely  want  to  change   –  “want  to  change”  vs.  “have  to  change”   •  RelaNng  goals  of  change  to  personal  values,   preferences  &  aspiraNons   •  Emphasis  on  supporNng  an  individual’s   autonomy  (freedom)  to  make  decisions  about   their  life  
    20. 20. TranstheoreNcal  Model  &  Stages  of   Change   •  Precontempla1on   –  No  desire  to  change  within  6  months   •  Contempla1on   –  Considering  change  within  6  months   •  Prepara1on   –  Considering  change  within  30  days   •  Ac1on   –  AcNvely  engaged  in  change  behaviours   •  Maintenance   –  Maintaining  changed  state  
    21. 21. Why  InformaNon  Technology?   •  Allows  for  tailoring  and  customized  programming  for   diverse  audiences   •  24/7  &  “always  on”   •  Easily  modifiable   •  AnracNve  and  interacNve   •  Scalable  &  portable   •  Permits  a  conversaNon  on  health  behaviour  at  a   populaNon  level  (Web  2.0)  
    22. 22. WEB-­‐ASSISTED   TOBACCO   INTERVENTIONS   A  Case  Study  
    23. 23. First  Order  Web-­‐Assisted  Tobacco   IntervenNon  (WATI)  
    24. 24. Second  Order  WATI  
    25. 25. Third  Order  WATI   •  Website   •  Dowloadable   curriculum  guide   •  Integrated  tools  for   student  collaboraNon   &  dialogue  within  and   between  classes  
    26. 26. Suppor1ng  Smoking  Preven1on  &   Cessa1on  with  Youth    
    27. 27. 1.  Makin’  Cents     ParNcipants  input  the  number  of  cigarene  packs  they   smoke  in  one  month;  market  value  is  calculated  into   annual  total     ParNcipants  spend  this  amount  in  virtual  shopping   mall     Helps  users  recognize  consumer  opNons,  the  value  of   a  dollar  relaNve  to  purchasing  power     Promotes  understanding  of  the  economic  impact  of   decision  to  smoke  and  economic  challenges  of  those   who  are  nicoNne  dependent  
    28. 28. Makin’  Cents:  Process/Concept   •  This  stage  is  designed   to  raise  consciousness   of  the  cost  of  cigarene   purchases  relaNve  to   other  consumer  goods  
    29. 29. 2.  It’s  Your  Life     ParNcipants  complete  short  assessment  about  their   smoking  behaviour  (frequency,  amount)     Program  tailored  to  whether  person  is  a  smoker,  non-­‐ smoker,  experimental/social  smoker     ParNcipants  become  aware  of  why  they  smoke,   smoking  panerns,  smoking  triggers  and  urges  
    30. 30. It’s  Your  Life:  Process/Concept   •  This  stage  is  both  an   assessment  of  smoking   status  and  provides   personalized  feedback   on  the  level  of  relaNve   risk  based  on  the   results  of  the   assessment  
    31. 31. 3.  To  Change  or  Not  to  Change   •  Allows  parNcipant  to  assess  readiness  to  change   (quit  or  reduce  smoking)   •  ParNcipants  assess  importance  of  change   •  ParNcipants  assess  their  confidence  in  being   able  to  change   •  Quiz  is  tailored  to  user’s  smoking  status   idenNfied  in  previous  stage  
    32. 32. To  Change  or  Not  to  Change:  Process/ Concept     This  component  assesses:     Readiness  to  change   (stage  of  change)     Confidence  (self-­‐efficacy)     Importance  for  change   (self-­‐determina7on)  
    33. 33. 4.  It’s  Your  Decision   •  Creates  a  decision  balance  displaying  pros  and   cons  of  smoking/being  smoke  free   •  ParNcipants  can  clearly  see  their  thoughts  about   smoking  and  reasons  to  quit,  cut  down,  or   remain  the  same   •  May  help  the  parNcipant  to  advance  their   readiness  to  change  
    34. 34. It’s  Your  Decision:  Process/Concept     This  stage  examines   the  pros  and  cons  of:     Being  a  non-­‐smoker   versus     Being  a  smoker     Decision  Balance  
    35. 35. 5.  What  Now?   •  This  secNon  brings  together  the  results  from   the  previous  stages   •  If  idenNfied  as  a  smoker,  the  Smoking  Zine  will   guide  them  in  creaNng  a  personalized  quit   programme   •  If  not  ready  to  quit,  then  parNcipant  is  guided   to  the  Personal  Forecast  quiz  secNon  
    36. 36. What  Now?   Process/Change     IdenNficaNon  of  readiness     Helps  to  develop  quit  plan       Date     Method  of  cessaNon     Support  mechanisms     Relapse  prevenNon  strategies     Outcome  rewards     Produces  a  cogniNve  behaviour   change  plan  and  a  cue  to  acJon  
    37. 37. Arabic  AdaptaNon  
    38. 38. Hebrew  AdaptaNon  
    39. 39. Chinese  AdaptaNon  
    40. 40. IntegraNng  the  Smoking  Zine  into  the   Classroom  
    41. 41. Virtual  Classroom  on     Tobacco  Control     Developed  in  partnership  with   TakingITGlobal,  youth-­‐driven  acNvism  and   educaNon  network     Goals:    To  posiNvely  influence  behavioural  intenNons   and  resistance  to  smoking  iniNaNon  among   young  people    To  inform  youth  about  global  tobacco  issues   and  understand  the  impact  of  their  choices    To  increase  the  number  of  youth  involved  in   tobacco  control  
    42. 42. Virtual  Classroom  on     Tobacco  Control     Features  four  interrelated  units    Facts  and  Figures  examines  the  health  effects   of  tobacco,  both  first-­‐hand  and  second-­‐hand    The  Smoking  Zine  allows  students  to  explore   their  smoking  behaviours  and  intenNons    Denormaliza1on  invesNgates  how  the  tobacco   industry  targets  youth    Global  and  Social  Jus1ce  focuses  on  the   tobacco  industry’s  exploitaNve  pracNces  in  the   developing  world  
    44. 44. Approaches  to  EvaluaNng   InformaNon   Third  Party  Verifica1on   Cri1cal  Appraisal   •  “Seals  of  approval”   •  “Informed  Consumer”   •  Expert-­‐reviewed  content   •  Individuals  are   approved  for  use   responsible  for  learning   how  to  evaluate   •  Centralized,   informaNon   straighyorward  process   •  EvoluNonary,  responsive   •  Slow,  resource-­‐intensive   and  can  be  tailored  to   and  subject  to  fraud   individual  needs   •  Complex  skill  set  
    45. 45. Literacy  as  a  Tool  for  CommunicaNon   •  Literacy  refers  to  a  person’s  ability  to  communicate  at   a  level  that  allows  them  to  understand  the  world   around  them  [interpret  the  signals  coming  in]  and  to   contribute  to  that  world  through  personal  expression   that  is  meaningful  to  others  [sending  useful  signals   out]  
    46. 46. Literacy  is  about  Content   •  For  online  content  to  adequately  inform  it   must  be:   –  Accessible   –  Complete   –  Accurate   –  Timely   –  Evidence-­‐based  &  verifiable   –  Balanced   •  Many  media  messages  to  consumers  address   none  of  these  points!   See:  Eysenbach,  G.  (2002).  Infodemiology:  The  epidemiology  of  (mis)informaNon.    American  Journal  of  Medicine,  113  (0),  763-­‐765  
    47. 47. The  Role  of   Networks  in   Decision  Making   "In  a  world  where  individuals   make  decisions  based  not  only   on  their  own  judgments  but   also  on  the  judgments  of   others,  quality  is  not  enough”   WaXs,  D  (2003).  Six  Degrees:   The  science  of  a  connected   age.  New  York:  Norton,  p.250  
    48. 48. Bearman,  P.S.,  Moody,  J.  &  Stovel,  K.  (2004).  Chains  of  affecNon:   The  structure  of  adolescent  romanNc  and  sexual  networks.  American   Journal  of  Sociology,  110  (1).    
    49. 49. Viewing  Literacy  as  A  ConNnuum   •  Literacy  levels  are  not  dichotomous    (literate  /   illiterate)   •  Literacy  levels  ebb  and  flow  over  Nme  as  new   knowledge  is  formed,  new  experiences  take   place,  and  new  technologies  and  tools  are   introduced     •  What  passes  as  high  literacy  today  may  not  be   the  same  tomorrow  because  the  content  and   context  in  which  those  skills  are  applied  changes  
    50. 50. eHealth  Literacy   •  “the ability to seek, find, understand, and appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem.” •  Norman & Skinner (2006). Journal of Medical Internet Research 8(2) e9.
    51. 51. Traditional Literacy In Lite fo r rm ac at y io n Li t al t h cy e ra He eHealth Literacy Co terac Lite dia y Li rac mp y Me ute r Science Literacy Norman  &  Skinner  (2006a).  JMIR,  8  (2)  e9  
    52. 52. General  Skills   Traditional Literacy C ite om r a L pu c y te r Lit alth cy e ra He eHealth Literacy Inf itera Lit dia cy or L ma cy era Me tio n Science Literacy    Traditional  (Basic)  Literacy   &  Numeracy      Media  Literacy      Information  Literacy  
    53. 53. Specific  Skills   Traditional Literacy C ite om r L pu cy te a r Lit alth cy e ra He eHealth Literacy Inf itera Lite dia y orm cy rac L Me ati on Science    Computer  Literacy   Literacy    Science  Literacy      Health  Literacy  
    54. 54. Resources     Youth  Voices  Research     hnp://www.youthvoices.ca     The  Smoking  Zine     hnp://www.smokingzine.org     Taking  IT  Global     hnp://www.takingitglobal.org   Cameron  Norman   cameron.norman@utoronto.ca  
    55. 55. Contact  InformaNon   Cameron  D.  Norman  PhD   Dalla  Lana  School  of  Public  Health   5th  Floor  Office  586,  Health  Sciences  Building   416.978.1242   cameron.norman@utoronto.ca