Wrapping Up

       Thank you for wandering down the rabbit hole with me.  mHealth, eHealth and technology in healthcare is a fast and furiously changing field.  Like Alice in Wonderland, sometimes technology looks and feels incredibly unbelievable and upside down at the same time.  Less than 2 decades ago who would believe that today we would be able to use a mobile phone to check our insulin levels, help people stop smoking or track disease surveillance rates with a small device in our hands that we also use for making phone calls?

Today, we have tools that help us stay connected to others in the privacy of our own homes.  Tools that allow us opportunities to seek information in real time and our own time, and empower us as consumers of health to be partners in healthcare decisions rather than passive patients. These are the tools of future health educators.

My message to future health educators is this; believe in the incredible but also remember these technology apps and methods don’t all work for all populations, and interactive communication technology is not a panacea for all that ails us in public health. Yet, it is a powerful instrument for engagement, continuity of care, and education as well as accessible to most.  Use them wisely, study them well, and stay curious.

FDA Regulations and mHealth

With lightening advances in technology, the medical services landscape has been intensely impacted.  Both the practitioner and the patient feel these impacts.  Practitioners have medical apps available to them that allow for faster and more accurate diagnosis or calculations, and patients use apps to check their pulse, calculate insulin levels, or even diagnose melanoma through a smartphone lens.  The mHealth revolution has put more power into the hands of the digitally engaged patient (Lupton, 2013).  However, newer studies are reporting that apps and some technology that patients might be utilizing do not work effectively or sometimes even correctly.  For example, an app utilized by a large pharmaceutical company found that their technology did not accurately measure joint swelling for rheumatoid patients by 50% in some instances (Hamel, Cortez, Cohen, & Kesselheim, 2014).  Furthermore, many marketing claims are made about popular mHealth apps that have no empirical evidence to support effectiveness of the app (Lewis, & Wyatt 2014; Hamel, Cortez, Cohen, & Kesselheim, 2014).  In addition, critics point to the potential concerns related to the safety and security of patient medical data, stating if one small problem arises in the technology, security of that data could be severely compromised.  Who hasn’t been affected by a virus or a bug in today’s connected world?

Nonetheless, progress can’t be stopped.  The FDA in July 2013 made a statement that it would regulate only apps that were intended as medical devices and the risk to the patient if the device did not function as intended (Hamel, Cortez, Cohen, & Kesselheim, 2014).   For example, a device that monitors eye movement to diagnose imbalance disorders.  However, the agency stated it would not regulate apps that pose a lower risk to patients such as tracking asthma inhaler use or behavioral symptom tracking.  Yet, many professionals point out these apps deemed “low risk” by the FDA may have significant adverse effects if there was a malfunction.   He definition of risk and the definition of medical device are the key components of this debate.

Other sides of the debate list increased regulation can dampen and impeded technology progress.  Moreover, with the proliferation of mHealth and medical technology advances the FDA does not have the resources to effectively monitor every potential risk and device.

References

Hamel, M. B., Cortez, N. G., Cohen, I. G., & Kesselheim, A. S. (2014). FDA regulation of mobile health technologies. New England Journal of Medicine,371(4), 372-379.

Lewis, T. L., & Wyatt, J. C. (2014). Mhealth and mobile medical apps: A framework to assess risk and promote safer use. Journal of medical Internet research, 16(9).

Lupton, D. (2013). The digitally engaged patient: self-monitoring and self-care in the digital health era. Social Theory & Health, 11(3), 256-270.

So what if there is an app for that? 

Opportunities for the effective use of technology 

for health promotion and health education.

 The video posted is an edited version of the 20 minute course presentation for Strategies in Health Education Delivery.  The lecture is adapted from the lesson plan found under the same titled tab. Our assignment is to write about how we felt about our presentation.
     I have never viewed a presentation I have delivered, as a result this was a valuable exercise for me.   The topic and material presented, appeared to be well received and timely for the audience.  I was pleased with the powerpoint in terms of visual graphics.  I recognize that I stumbled a bit in my language which I attribute to adapting a 90 minute lecture down to 20 minutes, and of course a bit of normal anxiety. 
     With regard to my presentation style, I see that I use my hands a lot!  This movement seems to be a bit distracting.  For 20+ years I have led psychotherapy and psycho-educational groups and presented many lectures while teaching graduate school.  I now see that my style of presenting is relaxed as if I am leading a group.  I believe I may need to change that style for a more professional countenance.  Although, a relaxed presentation will more than likely result in a more effective outcome, nonetheless I could use some "tightening up".   

Dumb Ways to Die; Laughing our way to public health

Dumb ways to die; Laughing our way to public health

     I recently stumbled upon a great example of how technology and digital media have come together. A PSA from Melbourne Metro (the mass transit carrier) used YouTube via the internet illustrating how PSA's can be effective by utilizing popular entertainment communication channels. This digital video launched November 2013 as a PSA to increase train safety, went viral and the video had 11 million views in 4 days (Lister, 2013). Riding the coattails of the successful PSA, a mobile phone game was launched in 2013. The game app spouts 10 million downloads and is played by achieving higher levels by keeping dumb characters safe, at each level you are encouraged to take the safety around trains pledge.

 A new "Laugh Model" has been proposed for using social media for effectively targeting health promotion (Lister, 2013). A presentation at the National Conference on Health Communication, Marketing and Media in 2013 suggests that creating health messages that will reach today's audience will need to incorporate an edutainment centered approach. The model suggests the following core ideas; motive replacement, health need assessment, product development, non-traditional partners, behavioral monitoring and sustainability (Lister, 2013).  The presenters suggest this model will decrease the need for public funding for PSA's.

Reference

Lister, C. (2013, August). Laugh Model: Restructuring the Framework of Public Health in Social      Media. In 2013 National Conference on Health Communication, Marketing, and Media. CDC.     Retrieved from https://cdc.confex.com/nphic/nphic13/webprogram/Paper33216.html

Title of Health Intervention

“So what if there is an app for that?” 

Opportunities for the effective use of technology in health promotion and education.

 

Health Topic and Intended Audience

The National Commission for Health Education Credentialing (NCHE) calls for core competencies training in the use of technology for professional health educators.  

The role of mobile phone communication technology and use of the internet has increased exponentially over the last decade.  Consumers use these technologies to access health information and health messages more often than ever before.  At least 61% of adults use the internet to look for health information according to the Pew Research center and almost one fifth have health applications installed on their mobile phone (Fox & Dugan, 2012).   As a result, mobile phones and the internet are rapidly becoming a universal tool for health educators to communicate their messages.

Today’s health educators have multiple technological methods at their disposal for use in communicating health messages and promoting public health. Current technology offers cost effective options for message promotion and delivery of health education.  It was only 2007 that Apple introduced the first iPhone, ushering in the smartphone revolution.  Smartphones allow for the integration of internet access on the go.  Health educators and researchers are harnessing the power of the mobile phone and internet technology to deliver health communication messages, interventions and education, screen and monitor biological data, observe epidemiologic information about global disease outbreaks, and train global health workers on the frontlines of community health services (Fiordelli & Schulz, 2013; Riley et.al, 2011). Smartphones that can connect to the internet allow for optimal dissemination of a message that can be tailored and can be interactively used.

This lesson plan will address advanced level health educator students and demonstrate the opportunities of technology-based interventions and messages as a component of a comprehensive health promotion program.

  

Setting

Classroom setting with health studies graduate and postgraduate students.  A regular scheduled class time.  Optimally, the room is wired for Wi-Fi and students have an avenue for accessing the internet either through the use of their mobile phone or a computer or tablet.
           

Estimated Time

Presentation will take about 90 minutes.  This can be shortened if necessary (see detailed scripts).  Although, it is recognized that learners are best suited to a shorter time frame the presentation takes into account the real life application of the topic.  This topic addresses not only a professional issue but is engaging on a personal level as well, which is applicable to adult learners (Gilbert, Sawyer, & McNeill, 2010). The timing of each slide and segment is produced in a rhythm such that it is interactive in between slides of data presentation.  There should not be more than 10 minutes of time before active engagement and interaction are to take place as part of the script.

Materials Needed

Classroom setting

Sign in sheet with name, cell phone and email address columns (Appendix)

Students at desks or tables with chairs (traditional learning environment setting)

Participants should bring a cell phone, computer with internet access or tablet with internet access

WiFi or internet access for participants and instructor

PowerPoint Presentation on flash drive (Appendix)

Copies of PowerPoint handout for each participant and for presenter

Copies of evaluation tool in case of inability to access internet

Laptop computer for PowerPoint presentation with data projector, white screen preferably or white wall if screen not available.  Table for the laptop and Projector.

Electrical access, 2 extension power cords

Guiding Health Education Theory or Model 

Theory of Planned Behavior and Technology Acceptance Model. 
        The theory of planned behavior (TPB) proposes that behavior can be intentional and planned and that attitudes beliefs and intentions can be influential factors in behavior change.  Intention is influenced by attitude toward a behavior and the meaning of importance of the behavior (Ajzen, 1991). In addition the belief that one has control is central to the theory as well.  Key concepts of the theory are perceived control, intention and attitude. Constructs of perceived usefulness and perceived ease of use are rooted in the Technology Acceptance model. These constructs posit that technology is more readily adopted if the perceived use is seen as meaningful and if the perceived ease is within the realm of reach of the user (Davis, Bagozzi, & Warshaw, 1989).

This lesson is guided by TPB in that participants are exposed to the new behaviors, data will be presented to guide their belief system and attitude into accepting that technology is a useful tool for health promotion.  In addition the data will also illustrate that the subject matter of technology in health promotion is likely to be very effective given the current social environment.  In addition, perceived usefulness and ease of use will also be addressed, as the demonstrations during the lesson will reduce barriers to use and increase self-efficacy.

Goal               

1.     Advanced health educators will be exposed to the opportunities available for using information communication technology to augment health education and health promotion programs.

Objectives (10 pts)

      Impact/Outcome Objective

1.     By the end of the presentation, 95% of participants will be able to list on the presentation evaluation at least 2 ICT tools available to them for use with health campaigns.  Learning domain: cognitive.

2.     By the end of the presentation, 75% of participants will experience an increase in perceived usefulness with ICT tools as evidenced by self-report presentation evaluation and observation of instructor - measured by participant’s questions and verbal feedback. Learning domain: affective.

      Process objective

1.     By the end of 30 days, 20% of participants will have signed up for their own SMS example plan on www.healthtxts.com, as evidenced by self-report by follow up email response questionnaire. Learning domain: psychomotor.

2.     50% of participants will utilize at least one newly identified ICT tool in the next appropriate assignment, as measured by follow up email response questionnaire. Learning domain: psychomotor.

3.     50% of participants will experience perceived ease of use of newly identified ICT tools after implementation in an appropriate assignment, as measured by follow up email response questionnaire. Learning domain: affective

 Procedures

This teaching method will utilize presentation software PowerPoint.  The slides are attached and each has notes listed and the script for each slide is listed below.

Ask if everyone has internet access and who was able to bring a device to access their email?

Slide 1. “So what if there is an app for that?” (10-15 minutes)

Welcome the participants.  Introduce self and provide a short history of experience and education.  Discuss how asking “is there an app for that?” is the current lingo and ask everyone what was the last app they installed and did they use it and was it helpful and do they still use it.  This will break the ice and chances are people will hear something they didn’t know and most likely will ask more information about the app!  Be careful not to lose control of the participants, steer them back to topic if needed.

Slide 2.  Everywhere (3 minutes)

In a causal tone discuss the following points assigned to this slide.
The Apple iPhone was the first most successful smartphone introduced just 7 years ago.  It seems like it has been so much longer than 7 years ago.Today 90% of Americans use a mobile phone. The medical and health industries including public health are finding methods to integrate mobile usage into service delivery; also called mHealth. mHealth is defined as the use of wireless technology used to deliver health messages, interventions, health education and  even use as disease surveillance as a tracking tool. You can even have forms created and have them completed through the phone!  This is a growing industry and there is a  lot of research needed but we are finding many successful programs including the most successful being text messaging programs, which we will talk more about in a minute.
 

Slide 3.  Generational experiences with Technology (7-9 minutes) (This slide can be skipped if time does not allow)

What are the generational experiences with Technology? Most of you have seen this type of continuum previously, but have you seen an updated one that includes the now dubbed Generation Alpha? Let’s take a look at this….but before we do think about this:

Pick a significant moment in your life – maybe the time you got married or the time your first child was born….what was the most advanced technology in your house that you owned?  What was the most advanced technology that your parents owned when you were born? Now think today?  How many communication technology tools do you own? How many friends or family members do you know that do NOT have a cell phone, or computer or tablet?  Do your parents use text messaging?  SO just reviewing this slide quickly let’s take a look at the last two generations born…..Generation Z and Generation Alpha (refer to the slide)

Slide 4.  Digits & Demos (5 minutes)

Who is using Cell Phones and Mobile Phones?

Ask any one of these following questions depending on the pace of the group and the interaction level. Recall the first time you bought a smartphone?   

How did you use it? How do you use it now? How often do you get on the internet?

Do you use apps regularly?  The majority of people who use Social Media – use it to connect to people.  Technology is the tool for connection!! It’s the relationship not the tool!  Refer to the slide and discuss how Latinos are leading the way in phone usage and the digital divide is closing fast!

Slide 5. Health Information and ICT (3 minutes)

So what is ICT and what does it have to do with Health information?  Simply put,

•       ICT – is defined as Information Communication Technology.  The name doesn’t really matter, because the technology is almost interchangeable now….tablets are getting smaller and smart phones are getting larger.  Tablets were just introduced in 2010, how many of you have a tablet?  Newer technology gets introduced and it takes less and less time for it to become adopted by the majority.   Did you know most people use their tablets at night, after work in front of the TV?  We have some opportunities waiting for us just in that one moment! 

Review the data on the slide.

•       72% of Americans  say they have looked for health information online

•       2/3 start with a search engine

•       Most common research topics

•       Specific diseases

•       Treatment or Procedures

•       Physicians or other

       Healthcare professionals

  

Slide 6.  It’s not the technology it’s the experience (5 minutes)

Text messaging is considered social media by the CDC

Text Messaging offers many unique benefits that are conducive to social cognitive theory and the theory of planned behavior.

•       Of cell phone users 81% send and receive text messages

•       79% of Medicaid beneficiaries use text messaging

•       90% Text messages are read within 3 minutes

•       99% Text messages are read

These data make the use of text messaging even more appealing for health educators.

Slide 7. Tailoring (10 minutes)

So what are the important factors if you are going to use Text messaging as a part of your health promotion program?

Tailoring, Timing and Multi-modal.  Let’s talk about tailoring first.

•       Content Strategy is Important (Must be basic and brief)

•       Balance novelty with redundancy This is a key concept.  We want to have as many impressions as possible without boring people.  So the idea is to keep the messages engaging, smart, quick and brief, but the same each time.

•       Tailor to Zip Code – the message can be segmented by geography

•       Audience - the message can be segmented by audience – perhaps you want to target young gay Latinos (they use their smartphones more than any other group according to the PEW Research center).  Send them testing information, and tell them to bring a friend.

•       Stage of Change – you can target stage of change by the opting in process – you will be asking people if they want to opt in for text message information sent via text messages – you must always tell them how many they will get and they can stop anytime.

•       Messages must be

•       Accurate, timely, meaningful

•       Action Oriented

•       Visual if possible

  

Slide 8. Content is King Er…Queen! (3 minutes)

Content of messages is extremely important!

A picture is worth a 1000 words, these two message campaigns tell us a lot about the culture and the values of the time, doesn’t it?  This demonstrates very effectively why we must make sure it is the right message, it is active oriented and also only provide 3 or less messages in easy to understand language.  Which these posters do provide a quick easy message…..hmmm…

Slide 9.  Timing (5-10 minutes)

Timing of the message is important not only for delivery but for theory related behaviors we know produce change:

such as self-pacing – the receiver can read it multiple times if needed and at the right time for them

Cognitive rehearsal – is tent of SCT (Bandura, 1977) this allows the practice of the behavior

Increased choice of control – again allowing the user to control the timing and pace

Situational context is connected with choice of control and perceived control will increases learning

Attention creates opportunity – getting someone's attention gives the perfect opening to provide a message – but it must be quick and to the point!

Slide 10. Multi-Modal (3 minutes)

A key is to utilize multiple tools, such as videos embedded or polls and questionnaires, along with pictures if possible Make sure your message is formatted to all devices. Remember we have been talking about how people are accessing the same messages and data on multiple devices.

People use their cell phone, their tablet and their computer to access information.  Nowadays, this is achievable, it’s called multi-modal usage and it keeps the message redundant but novel too!

Slide 11. Tools (3 minutes)

Tools from the CDC and an opt-in current operating Text messaging program for multiple behavior changes.  Try it yourself, but first let’s discuss these CDC tools.  The CDC TV website has hundreds of short videos which can be easily embedded in your email or text message, just copy the links.  This keeps your messages novel but simple and on topic.  CDC Health E-cards are like online greeting cards, you click on them an they open up to one page that is a quick and simple message. Again, this keeps your message new, and the same but different too!  Remember balancing novelty with redundancy!

Slide 12.  More Tools (measurement)  (3 minutes)

Pollit is an instant polling application you can use to measure just about anything!  It’s another way to gather data, but also it engages people in the message.  Perhaps you are trying to encourage people to wash their hands because it’s flu season.  Ask 2 or 3 simple questions that have the message embedded in the question!  Or perhaps you want to know who has gotten their flu vaccine in the last 2 weeks?  A simple reminder in the form of a poll via technology, easy and data driven! We will be using it at the end of this class for our evaluation.  You will get to have a real life experience!

Slide 13. ThinkLink.com  (5-7 minutes)

Thinglink.com is the most exciting interactive messaging tool I have found.  This free online application allows you use any picture you want to upload and then to attach pop up text information blocks with your tailored message!  Or you can add a video to the pop up box or even a link to your blog!.  Let’s say you want to encourage eating healthy vegetables and fruits, you could use the food pyramid and tailor the message for 3 of the target levels with suggested foods or even suggested recipes or videos to make the recipe!  This type of messaging is interactive and allows for self-pacing at the utmost level.   A really big benefit is you can get metrics of how many views you have had and how long people hover over each target message, this allows you to determine your impact and process objectives!

IF TIME ALLOWS HERE: (15 -20 minutes)

So remember when I first said I wanted you to have access to the internet and your email?  Now is the time!  I would like for you to go to your email and access the email I sent you today.  Click on the link. This link will take them to the Thinglink message created just for this lesson describing the topic of mHealth as an educational tool. Process the user experience.  Observe reactions and engagement. Probe for more information about the process if the participant’s engagement and reaction appear low; however it is likely to be high. Be sure to keep control and redirect back to the presentation if needed.

Slide 14.  It’s not the Technology (2 minutes)

Remember – it’s not the technology itself but the relationship to the technology – who is using it, how can you tailor a message in a multi-modal fashion to have the biggest impact with redundancy while maintaining novelty.  This is the balance that provides us with the best case learning opportunities using technology for health education and promotion.

In closing: What questions do you have that we haven’t already answered?

Take questions and if you don’t know the answer, ask the group if they have feedback and also indicate you will get them an answer.  At this time ask the participants to log into their email if possible.  They will have two emails; the second one is titled Technology Tools evaluation. (They should have already opened the ThinkgLink email) Ask them to open this email and participate in this online evaluation by following the directions and answering the 5 questions.

Evaluation (10 pts)

An online evaluation will be used with Pollit.com  This evaluation form will be emailed to participants just prior to the presentation.  The data will then be analyzed to determine level of achievement of objectives outlined above.

In addition, a second email will also be sent that includes a link for the interactive ThingLink message which is feature on slide 13 and inquiry about signing up for Healthtxts.com as a personal choice. These two email and interactive activities will allow for evaluation of active psychomotor participation, and attitudinal changes.  It also allows for process evaluation of observation of participation and engagement of learners, with the understanding that engagement increases learning, as does perceived control (Street, Gold, & Manning, 2013).  Lastly, a follow up email will be sent at the end of the semester asking if the participant has used a technology tool in an appropriate assignment, it will also inquire about perceived ease of use.

       

Anticipated Problem(s) and Solution(s) (5 pts)

      1.     Lack of internet access could be an issue – however the power point does not require internet access and has pictures of all internet usage needed.

      2.     Participants may not bring technology to access their email.  In this case, they could watch a peer or the instructor can demonstrate using the overhead projector if needed.

Ajzen, I. (1991). The theory of planned behavior. Organizational behavior and human decision processes, 50(2), 179-211.

Davis, F. D., Bagozzi, R. P., & Warshaw, P. R. (1989). User acceptance of computer technology: a comparison of two theoretical models. Management science, 35(8), 982-1003.

Centers for Disease Control and Prevention (CDC). (2012). The health communicator’s social media toolkit.

Gilbert, G. G., Sawyer, R. G., & McNeill, E. B. (2010). Health education: Creating strategies for school & community health. Jones & Bartlett Publishers.

Lopez, M. H., Gonzalez-Barrera, A., & Patten, E. (2013). Closing the digital divide:    Latinos and Technology adoption. Pew Hispanic Center.

PewResearch Internet Project (2014) Retrieved from http://www.pewinternet.org/fact-sheets/health-fact-sheet/

Street, R. L., Gold, W. R., & Manning, T. R. (Eds.). (2013). Health promotion and interactive technology: Theoretical applications and future directions. Routledge.