LIVING IN THE CLOUD I came from computer science. I ended up in health education. The journey I followed married the two together. The first 25 years… It is important to understand my background in order to get a clear picture of why I chose to pursue the scholarly work in which I have been engaged. It is this past that has driven me in the pursuit of the path I have been following over the past 25 years. In 1984 I graduated from WMU with a bachelor of science in computer science and minors in applied mathematics and finance. I was going to take on the world and prosper from it along the way. I was fortunate enough to land my first job with IBM, which at the time was the largest and most profitable company in the world. IBM ruled the technology landscape. Their systems were the mainstream behind every major corporation. There was a reason why we all wore blue pinstriped suits, yellow ties, and medium-starched white shirts. Not heavy or mild starch mind you, but medium starch. At just under 500,000 employees worldwide, IBM was the king. I was a systems engineer who specialized in supporting mainframe systems and applications for government, education, and healthcare sectors. Of course the PC had not yet been created and introduced to the world. There were no cell phones, social media, Internet, tablets, or any other modern day technology we take for granted. During my third year at IBM my focus took a turn. It was one day after New Year’s in 1987 when I first experienced, what resulted in a an entire year+ of 24/7 high anxiety. A minute didn’t go by where I wasn’t in extreme discomfort with multiple symptoms of intense anxiety. One day in 1988, on my way to work, I felt temporary reprieve from my anxiety symptoms as I realized that if I could only last another 25 years I would qualify for early retirement. I was 25 years old at the time. As I walked into work, smartly dressed in my standard IBM corporate wear, I realized that I just wished away half of my life. It was that day I walked into my boss’ office and told him I could no longer stay at IBM. Whether it was a day, a week, a month, or whatever timeframe he needed to replace me, I was done. So I left IBM, went back to school, and began pursuing a career that would allow me to help others like myself who have fallen victim to environmental constraints that cause poor health and, ultimately, disease and early death. I spent 5 years pursuing master and doctoral degrees in health education, with the intent of moving into a position where I could influence the lives of others. And now, 25 years later, I am a professor of health education at WMU, doing exactly the opposite of what brought me a glimmer of hope that morning when I wished half my life away. The past 25 years… It was 1998 and I was sitting in a session at a national conference listening to the presenter describe how she was using this new technology called the World Wide Web (WWW) to show students how they could mimic a conversation between two people. As I looked around the room there were only about a dozen or so of us, with most wearing remnants of their toil within their version of the IBM world. Prior to this session, I had always seen this new technology as a means for providing access to content and information. To all, the WWW was basically an online “table of contents” for retrieving information. There was no social media, text messaging, advance web design coding, Google, or any other process in place that would make the Internet more than just a tool for searching content. Looking back, I cannot remember when we changed terminology from WWW to “the Internet.” It seems strange now, but at the time WWW was the only descriptor used to refer to the Internet. But as I sat in that session listening to the presenter describe how one could use a series of questions that would drive a predefined webpage response, a light bulb clicked. This is the moment when my scholarly pursuit began. It was when the training of my previous 25 years made sense as to where it would fit into my next 25 years. I sat there and pondered the use of the Internet as a means for creating potential health-related applications that could help individuals take action in moving from poor health behaviors to healthy choices. I saw the potential for using the Internet as not only a tool for retrieving topical information, but as a tool having an intelligent component associated with it that could be used for interactive behavior change. As a nation, we were losing the battle for healthy population growth. Obesity was on the rise, smoking was still allowed in all facets of life, sexuality issues like HIV/AIDS were rampant, and new drug trends, such as crack and date rape drugs, began engulfing previous substance abuse patterns. As a profession, health education and health promotion was unable to keep up. The expanding population health issues exploded beyond the discipline’s capacity to address them. As I sat in that session 25 years ago, I saw a tool that could be used as a means for bridging that gap. TECHNOLOGY CONTRIBUTIONS FOR SOLVING PUBLIC HEALTH ISSUES AND NEEDS eHealth Behavior Management Model When I returned from the above-mentioned conference, I immediately began working on developing a model that could be used to engage the power of the Internet as a means for systematically influencing health behaviors. Over the next year I explored how popular behavior change theories could be combined with an Internet overlay in providing the means for application. The eHealth Behavior Management Model (eHBM) was the resulting product, and became the basis for many of my major contributions. This model essentially took prominent health behavior change theories and models, including the Transtheorectical model of stages of change, behavioral intent, and persuasive communication, and superimposed them on the Internet as a means for delivering web-based behavior change interventions. In essence, it was one of the first such model developed that combined effective health behavior change theories with the capability of the Internet, and served as a basis for other scholar’s work in advancing health behavior interventions using the Internet. It was highlighted as a “special topic in public health” article published in the inaugural year of CDC’s Preventing Chronic Disease journal (Bensley, et al., 2004). In 1999 I was presenting this model at a state public health conference. Being an application of the Internet coupled with the lack of use of the Internet—beyond simple content searching—as a tool for health promotion, there were relatively few people in attendance. At the conclusion of the session, a county health department worker came up to me and asked if it was possible to apply this model as a means for helping women with parent-child feeding behaviors who were associated with the U.S. Department of Agriculture’s Women, Infants, and Children (WIC) program. She gave me the name of a state employee who worked with WIC. I sat down and drafted an algorithm, based on eHBM, showing how a series of automated web pages could be used to mimic the behavioral counseling role of a WIC dietitian. The State of Michigan saw value in my model and asked if I could develop a web prototype that could be piloted. The resulting wichealth.org was born, which has become my most important scholarly achievement (A demo video of wichealth.org is available at: wichealth.org demo. To preview the actual website login into wichealth.org with userid and password both: wichealth). Being a previous computer programmer, I designed and coded the interactive website and launched it in August, 2002. That first iteration was comprised of three behavior change lessons and reached over 5,800 clients during the next 12 months, in the six Midwest region states. Midyear and annual evaluation indicated an overwhelming success in both the process being easy-touse and helpful to the client, and the impact in terms of progressing toward active behavior change. This success led to the first major grant I received, at $48,000, to continue expanding into additional behaviors and redesigning it in a more professional manner. The expansion and growth of this system over the past 12 years has been immense. It has been adopted for use as a primary nutrition education and behavior change system in 26 states. It is completely bilingual in English and Spanish and has served nearly 1.8 million WIC client lessons across 25 parent-child feeding behaviors, for an effective cost per client ratio of $2.02. The system has undergone midterm and annual evaluations since inception and consistently shows tremendous impact of the educational intervention, where 90-95% of WIC clients indicated (1) they believe they can make change based on their experience, (2) found the system both helpful and useful, and (3) found the system easy to use (Bensley, et al., 2006). Over 80% of clients responded they preferred this form of behavior change education to any other offering existing within their WIC clinic, including 1-on-1 counseling. Critical to the growth of the project has been the infusion of data collection points that have become the basis for understanding user interaction and needs. We collect every user click that occurs on the site, with measurements of time on page, number of links visited, pattern of links visited, and many others, which provides important usability data used to improve the experience. In addition, numerous data points provide for direct client feedback and comments, again which serve as mechanisms for continued validity and reliability that the user experience is sound. In essence, the system interaction itself is not only an intervention, but also a means for enhancing a greater understanding of the means in which the client uses the system. And this robust system is built is such a way that it actual grows based on better understanding user needs and patterns. Since inception, this project has received over $5.1 million from 71 grants and contracts across the country, and impacted nearly 1.8 million client behavior change efforts. wichealth.org is considered the national model for online WIC behavior change. It has received a Merit Award from the Health Information Resource Center sponsored Health Web Awards competition, considered a best practice program in outreach and nutrition education for multi-cultural communities by the Food Research Action Center, identified as 1 of 12 participant-centered nutrition education materials within the national Participant Centered Nutrition Education Resource Guide prepared by the Altarum Institute, and was the basis for USDA development of Criteria for the Development and Evaluation of Electronic-Based Nutrition Education for WIC Participants. A USDA funded study of wichealth.org vs. traditional education (group education at the clinic) found traditional education needed follow up 1-on-1 counseling to achieve the same level of behavior change as using wichealth.org alone (Bensley et al., 2011). The growth of wichealth.org has been enormous (view a short video depicting evolution and growth from 2002-2012 at wichealth.org growth). Being Internet based, the need for expansion to meet growing user needs occurs on a continual basis. The grant team I manage and direct, which consists of 4 fulltime and 3 part-time employees, is in a continual process of researching and revising the system to maximize the ever-growing usability needs of clients, as well as the ability to capitalize on new web-based features and opportunities. Over the past decade wichealth.org has expanded by incorporating video hosts (vs. static images) as behavioral counselors, social media interfaces such as Twitter and Facebook, a responsive mobile design that works on tablets and smart phones, and an even more smart system technology, so that the system learns from users experiences and becomes a predictor for other like users. For instance, the system knows the type of user I am based on my profile and the user interaction I have with the site (what I click on, what I access, etc.). In essence, the system learns from its users so that when a new user accesses a lesson, the system can provide an individual and tailored experience based on what other users with similar web behavior patterns found to be effective in their behavior change process. With 1.8 million users, it is then possible to predict with a high degree of accuracy the best path of intervention that will result in the greatest likelihood of successful behavior change. In addition, the system “remembers” return users and can then continue, and alter if need be, in the behavior change process from where they previously exited the system. That’s what I envisioned this system evolving into back in the late 1990s when I first started thinking about it. The capability of the Internet to do this wasn’t quite there in the 1990s, but I knew it would only be a matter of time before the technology caught up. Behavior Intelligence Framework More recently, an expansive content management system (Behavior Intelligence Framework, or “BIF”) was developed that is based on the eHBM and incorporates the ability for my staff to rapidly develop behavior change lessons and manage educational content without the need for engaging in expensive programming. This system is a unique application of web capabilities, with a patent pending application submitted in the fall of 2013. BIF has served as the basis for additional public health sectors, beyond that which is connected with WIC. In 2011, I received funding from the state of North Carolina to develop a nutrition education and behavior change system for state daycare providers and the parents of children attending daycare, as a nationally funded online intervention Kids Eat Smart Move More (to preview the actual website login into nccacfp.org with userid and password both: wichealth). The resulting website was built using BIF and implemented across North Carolina. In addition to the behavioral lessons inherent within the system, new features were added for addressing growing public health needs. A Location Finder tool was created for the purpose of reducing obesity through improved physical activity by providing parents and providers with the ability to search for—filtered on a variety of amenities—local parks in North Carolina. This project is a prime example of the adaptability of my scholarly work into other settings and populations as a means for improving public health. Another example of adaptation is with Bronco Health Advisor, a web-based system focused on improving health behaviors among college students. This initiative uses the same algorithm-driven approach that is used with other iterations of eHBM, but is adapted so that users of the system are provided with access to resources existing on campus as part of their counseling session. In essence, it shows the adaptability of the system in terms of how it can be used. Whereas previous applications of eHBM focused on direct client behavior change through presenting new skills and materials to the client, Bronco Health Advisor focuses on engaging behavior change by bringing existing organizational owned resources to the user. As with other applications of eHBM evaluation results have shown Bronco Health Advisor to be an effective tool for moving students toward positive action with health behaviors. As the systems I developed continued to expand and grow across the country, so did the need to develop additional features to meet ongoing client needs. Evaluation results and feedback from clients and users directed the need to continue focusing on building and implementing additional technology solutions. The complexity of human behavior requires multiple avenues for influencing change, as it has been clearly found that single approaches alone do not necessarily create the best opportunity for long-term behavior change. In essence, it takes more than just a knife to turn a potato into a plate of mashed potatoes. The same is true with health behavior change. So began a quest to continue expanding the use of technology to create a better likelihood of successful health behavior change. As a result, a number of additional technology solutions were developed as supplemental behavior change tools associated with web-related systems. These “features” exist as add-on applications designed to assist the user solidify intended behavior change that resulted from their experience with BIF-related interventions (e.g., wichealth.org, Kids Eat Smart Move More, Bronco Health Advisor). These include Table Talk, Health eKitchen, Online Peer Counseling, and Location Finder. Each of these tools is a complex system in its own right that can be integrated into my web systems. Each of these is described below. Table Talk is a tailored text messaging system that delivers messages tailored to any number of predefined user characteristics, such as age, stage of readiness to change behavior, number of children, income level, etc. and consists of a automated message scheduler. It was designed to serve as a follow up to previous client behavior change. In essence, it harnesses the power of fingertip messaging associated with cell phones for the purpose of continuing to engage clients toward positive behavior change. The extensive web-based program that drives Table Talk is the basis behind the proposed intervention. It consists of a robust backend content management system that organizes and controls the delivery of predefined text messages. The system consists of a text messaging manager, a text scheduling manager, and a text report manager. The text messaging manager provides the ability to create and enter texts into the system and organize them in various ways, including type of text and program defined subject characteristics (e.g., child age, language, etc.). Text messages are no longer than 160 characters in length (so that all mobile phones can receive them) and consist of a variety of messages types, including informational, tips, reminders, journaling, and data collection. The first three types are one-way delivered texts, meaning no response is requested from the subject. These text types are meant to educate subjects on topics or provide tips and triggers for encouraging behavioral action. Journaling texts request a qualitative response from subjects pertaining to pertinent questions relevant to the program. These types of texts can be used to garner subjects’ comments, reactions, and other data relevant to the program. Data collection texts request a quantitative response to relevant texts. For instance, a subject may receive a text asking how many vegetables she served her child that day. The system has the capability of engaging in a dialogue with the subject based on the texted response. So, if the client replied “3” the system could send a follow up empowering statement (e.g., “That’s wonderful. Veggies grow healthy children”), or a second level question that encourages the subject to continue engaging in dialogue (e.g., “That’s wonderful. How many of those were dark green in color?”). The system is designed so that endless dialogue can occur, limited only by the number of predefined dialogue questions and answers already entered into the system. The scheduling manager provides the ability to indicate when each individual text is delivered to subjects. This manager includes a calendaring system that allows for text delivery to be determined by day of week, time of day, or as follow-up in dialogue-driven data collection type of text messages. Texts can also be organized seasonally or by specific days, such as holidays. Health eKitchen is a video resource management system with a robust filtering mechanism for finding and displaying video clips. The application of this system as an add-on feature provides the capability to utilize existing web videos as part of the ongoing behavior change process. For instance, with wichealth.org the filter mechanism allows the ability to identify video associated with shopping, preparing, cooking, and storing WIC approved foods tailored to child age and specific food. The system that drives this application can be tailored to address any number of behaviors and filters that relate to that behavior. For instance, an application of Health eKitchen could be tailored to focus on physical activity, filtered by type of activity, age, season, expense, and any other filters deem important to that application. To preview the actual website login into wichealth.org with userid and password both: wichealth and select “Health eKitchen” within the “Health eLiving” section of the site’s dashboard. Online Peer Counseling is a feature that provides the ability to schedule and engage in 1-on-1 video conferencing. The system consist of a frontend where the client selects a counselor and schedules a meeting and a counselor application where the counselor can set and review schedules, access client profile information, and select and share resources (e.g., videos, documents, web links) with their clients. In essence, this system provides the ability to engage in a counseled behavior change any hour of the day and any day of the week. The system also contains an administrative reporting application that provides the ability to generate reports on counselors and the clients they serve. Location Finder utilizes filtering and mapping to identify and provide information about desired places of interest. At present, this feature consists of three finder applications: Park Finder, Clinic Finder, and Market Finder. Each of these three finder applications utilizes the robust filtering and mapping capability inherent within the system to identify and filter on places of interest. For instance, the Park Finder provides the ability to search for parks and filter the results based on distance and park amenities, such as playground, dog area, swimming pool, picnic areas, etc. A mapping feature provides results, along with information regarding the park, including pictures, description, hours of operation, park website, and user comments. The finder applications allow the ability for users to provide comments or share on social media platforms, such as Facebook. Clinic and market finder applications operate in a similar fashion, albeit the focus is on office clinic and food markets. Other Technology Solutions I have had the opportunity to create a number of additional technologies designed to meet the needs of a variety of other health behavior issues. A brief discussion of these projects is included below. Refresh a Life was a competitive grant totaling over $640,000 awarded to build, implement, and evaluation the impact of four CPR refresher training modalities on long-term CPR selfefficacy and skill. As one of four Co-Principal Investigators, I spearheaded the development of the interventions, which included a web-based training, a text messaging training, an email intervention, and a standard print material approach. The innovation in this study was the three technology interventions. Results of this study were published in BMC Emergency Medicine. My Healthy Weight Action Plan. The Heart and Stroke Foundation of Ontario (HFSO) submitted a competitive bid to lead development of a weight management system that could be used as a model for Canadian populations. Receiving this $250,000+ grant was an achievement, as the proposal I submitted was selected over one that was also submitted by Health Media, which at the time was centered at the University of Michigan, has since been commercialized and sold to Johnson and Johnson Corporation, and is considered the leading technology-based health behavior change organization in the country. The 3-year project resulted in the establishment of the first widely accepted Internet-based weight management system in Canada, which has since been redesigned and reconstructed by HFSO. My Blood Pressure Action Plan. The HFSO also contracted with my group to design an Internet-based approach for blood pressure reduction, eventually resulting in My Blood Pressure Action Plan, which has since been redesigned and reconstructed by HFSO. wichealthsupport.org was built as a training and support site for WIC staff in states implementing wichealth.org. Included in this site are evaluation reports, a robust real time usage stat feature, resource materials, and videos and webinars associated with various implementation aspects of the main wichealth.org site. This site is supported by grant funds received from wichealth.org partner states. A 9-minute demo of this site is available at: wichealth.org demo Joinwichealth.org. This website was developed as a marketing and resource site for WIC state directors and decision makers. Included are wichealth.org newsworthy items, state usage stats, a cost estimate calculator, and technology system solutions. Client-Centered Counseling Training. In 2003 the state of Michigan funded $48,000 for the development of a CD-ROM and website-based training associated with WIC nutritional counseling. Included were video scenarios and educational learning that progressed the selfdirected learner through stages of change and motivational negotiation counseling skills. The CD-ROM was made available to all WIC agencies in Michigan, while the website became a national training for all partner wichealth.org states. The site also was included as the training component in a competitively funded $450,000+ USDA grant on the use of technology as a means for improving fruit and vegetable consumption among WIC clients. The site and CDROM are no longer operational, due to the length of time since inception. Within the technology environment, solutions have shortened life spans due to the ever increasing changes and innovations. Asthma Management Demonstration Project was one of the first applications of the eHBM and served as a project at WMU for improving asthma management among students and staff. Although it served as an important venture into disease management, the lack of available WMU healthcare funding resulted its demise within two years. However, it should be noted that the implementation of this project was vital to the expanding utility of the eHBM as a means for building future systems for impacting health related behaviors. Resource Matrix focused on developing a resource management website to be used as part of the WIC follow-up counseling process. The site provided WIC counselors with the ability to easily access resources existing in a web-based form or as hard copies within their own or other WIC agencies within their state. The site concept did not gain tremendous use, but served as the basis for future technology solutions development inherent within the algorithms that drive the Online Peer Counseling and Bronco Health Advisor systems. FUTURE RESEARCH DIRECTIONS If I have learned anything along this journey, it’s that technology is ever changing. And to be in this field, one must always be a step ahead of it. That doesn’t mean every idea will come to fruition, as it is impossible to truly predict the next evolution that will surface, but the key is to have enough ideas in place so that when the next iteration arrives it can be immediately utilized. As a scholar, I am continually in the process of thinking of the next technology breakthrough and how best to position myself for garnering external funding to implement solutions. I keep an ongoing list of ideas I continually share with my grant funders. It’s a “wish list” of technology systems we desire to build to meet the ongoing public health needs. This $500,000 to $1 million funding list consists of a variety of technologies that could be built and implemented to impact behavior issues. Sometimes the funders bite on this, but many times they are not yet ready to dive in headfirst. A sound example of the success of this wish list was in 2011, when the Michigan WIC Director contacted me and basically said “Bob, I need you to pick 3-4 items on your wish list that you think would make the greatest impact in parent-child feeding behaviors. Let me know what they are and what they will cost and I will find the funding.” That conversation resulted in nearly $700,00 in additional grant funding and led to the expanded development of the Location Finder, Table Talk, a mobile design, and other smart-system components that make up the current BIF-driven system. As a grant writer and scholar, I truly believe that is a prime example of when you have reached the top. What is in store for the future is yet to be seen, as the technology is not yet necessarily here. However, some of what I anticipate and what I am positioning my team for are both new technology solutions and expanding existing systems to integrate more advanced features. Although there are many ideas and pathways to follow, the next 3-5 years will likely focus on the following major projects: Expanding eHBM. We are now ready to introduce and operationalize into eHBM 2.0. This advanced version of the model will incorporate more recent theory developed by social psychologists that surround tagging resources and intervention experiences not only by stage and process of change, but by taxonomies that pertain to capability (ability), opportunity (triggers) and motivation. The two major models driving these are COM-B and B-MAT, both of which further define intervention resources in terms of these three factors. These models fit perfectly into a system already developed that stages users with regard to readiness to change. Within our existing model, links and resources are provided to the client based on stage of change, process of change, and smart system tailoring techniques. We want to incorporate these newer theories into the smart system architecture, which will provide an even greater likelihood of ensuring the intervention components provide the best potential for behavior change. Further expansion of smart system technology. Through our algorithm development, we have positioned our systems to predict and tailor intervention delivery based on the collective action of patterns of similar users. Our next phase is to create an artificial intelligence where the system itself begins to create new algorithms and pathways that didn’t necessarily exist before in an effort to continue moving users toward tailored behavior change interventions. In essence, the rules will exist that provide the system with the ability to actually “decide” how best to move a user through the change process, given the freedom to logically combine and expand the rules so that the greatest potential for success can be achieved. In essence, this honing in on artificial intelligence is a way to recreate the human experience; one of the key principles of Internet-based solutions. Development of apps designed to monitor and influence health behaviors. Mobile technology is the future. Actually, for those of us in technology, mobile solutions are the present. As such, all technology interventions need to be able to harness the power of and operate within the confines of small mobile spaces. This means apps for automatically recording health behaviors and selecting interventions based on patterns, text and photo-based interventions, and other mobile options. For instance within weight management, food diary and recall is important for successful long-term behavior change. However, this action is one of the most difficult for clients to do. Mobile systems that harness camera and recording technology need to be developed that can use a photo of a meal to be consumed to automatically determine food content, calories, and portion sizes. This alleviates the burden of self-recording, which is problematic in many health behavior change topics. Disease management applications. The models and systems we developed are applicable to a wide variety of additional health behaviors and disease management issues. The expansion into these healthcare fields is ripe, with the current preventative focus inherent within the Affordable Care and Expanded Medicaid Acts. In fact, the BIF system is currently in a patent pending state, with efforts underway through the WMU Office of the Vice President and Research for the commercialization of my systems. Continued WIC-related enhancements. A number of planned enhancements, pending funding, are also part of the current focus of my team, including: A Mobile Authorized Food feature would be available on our mobile version of the site. It would provide the ability for WIC clients to use their smart phones during grocery shopping and could tie in directly with the Market Finder feature of wichealth.org. The client could look up foods that are part of the state food package and view nutrition information, pictures, ideas for how to use in recipes, and videos of how to use it. Food benefits balance could also be determined if connected through state system. Incorporating Tracking Mechanisms into Health eLiving Dashboard of wichealth.org. Part of continued behavior change focuses on tracking of behaviors. Tracking behaviors could consist of physical activity, daily menus, fruits and vegetables offered, BMI, etc. Building this within wichealth.org provides the capability for wichealth.org to expand beyond an education and behavior resource system to be a portal for healthy nutrition and living. Many trackers can be tied into automatically (e.g., exercise activity, fruit and vegetable consumption data collected via text messaging program), whereas others are kept up-to-date by the client. This feature is especially pertinent to the mobile environment where healthy behavior decisions are made based on triggers delivered real time. Expanding Health eKitchen to Include Health eRecipe Finder. Incorporating into the Health eKitchen feature the ability to store and maintain healthy recipes based on food benefits and linking these recipes to existing Health eKitchen video resources pertaining to shopping, preparing, and cooking meals and snacks. FINAL THOUGHTS… The journey I have followed over the past 25 years has been wrought with excitement, humility, success, and innovation. I feel fortunate to have been able to marry my professional passions together. As a computer programmer, health educator, and entrepreneur, I have been able to develop a track record of funding success, obtain wide national recognition, and, most importantly, develop systems that have improved the lives of millions of people.