E Health Behaviour Change

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  

Public  eHealth  &  Behaviour  Change  

   If  you  want  to  understand  something,  try  to  change  it  

–  Kurt  Lewin  (1951)  

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.  

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.    

Overweight  (BMI  =  25-­‐29.9)  associated  with  a  loss  of  >  3  years;  BMI  >  30  associated  with  loss  of  7  years  

Obesity  

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.  

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  

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.    

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.  

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.  

Looking  Forward  to  Change  

• The  only  people  who  truly  welcome  change  are  wet  babies  

HOW  WE  CHANGE:  THEORIES  &  MODELS  OF  CHANGE  

Some  Wisdom  from  Kurt  Lewin  (1890-­‐1947)  

“There  is  nothing  so  pracNcal  as  a  good  theory”  

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  

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.  

Health  Belief  Model  

Theory  of  Reasoned  AcNon/Planned  Behaviour  

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)  

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  

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  

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)  

WEB-­‐ASSISTED  TOBACCO  INTERVENTIONS  

A  Case  Study  

First  Order  Web-­‐Assisted  Tobacco  IntervenNon  (WATI)  

Second  Order  WATI  

Third  Order  WATI  

•  Website  

•  Dowloadable  curriculum  guide  

•  Integrated  tools  for  student  collaboraNon  &  dialogue  within  and  between  classes  

Suppor1ng  Smoking  Preven1on  &  Cessa1on  with  Youth    

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  

Makin’  Cents:  Process/Concept  

•  This  stage  is  designed  to  raise  consciousness  of  the  cost  of  cigarene  purchases  relaNve  to  other  consumer  goods  

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  

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  

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  

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)  

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  

It’s  Your  Decision:  Process/Concept  

  This  stage  examines  the  pros  and  cons  of:  

  Being  a  non-­‐smoker  versus  

  Being  a  smoker  

  Decision  Balance  

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  

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  

Arabic  AdaptaNon  

Hebrew  AdaptaNon  

Chinese  AdaptaNon  

IntegraNng  the  Smoking  Zine  into  the  Classroom  

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  

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  

MAKING  EHEALTH  ACCESSIBLE:  THE  ROLE  OF  LITERACY  

Approaches  to  EvaluaNng  InformaNon  

Third  Party  Verifica1on  

•  “Seals  of  approval”  •  Expert-­‐reviewed  content  

approved  for  use  

•  Centralized,  straighyorward  process  

•  Slow,  resource-­‐intensive  and  subject  to  fraud  

Cri1cal  Appraisal  

•  “Informed  Consumer”  •  Individuals  are  

responsible  for  learning  how  to  evaluate  informaNon  

•  EvoluNonary,  responsive  and  can  be  tailored  to  individual  needs  

•  Complex  skill  set  

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]  

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  

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  

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).    

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  

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.

Health

Literacy

InformationLiteracy

TraditionalLiteracy

ScienceLiteracy

Computer

Literacy Media

Literacy

eHealthLiteracy

Norman  &  Skinner  (2006a).  JMIR,  8  (2)  e9  

General  Skills  

Health

Literacy

ComputerLiteracy

TraditionalLiteracy

ScienceLiteracy

Information

Literacy Media

Literacy

eHealthLiteracy

   Traditional  (Basic)  Literacy  &  Numeracy     Media  Literacy     Information  Literacy  

Specific  Skills  

Health

Literacy

ComputerLiteracy

TraditionalLiteracy

ScienceLiteracy

Information

Literacy

Media

Literacy

eHealthLiteracy

   Computer  Literacy     Science  Literacy     Health  Literacy  

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  

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