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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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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 [email protected]
Contact InformaNon
Cameron D. Norman PhD Dalla Lana School of Public Health
5th Floor Office 586, Health Sciences Building
416.978.1242