Design & Evaluation of Mobile Technology for
Health Behavior Change
Greg Norman, PhD
Department of Family & Preventive Medicine
University of California, San Diego
1
Center for Wireless &
Population Health Systems
2
Center for Wireless &
Population Health Systems
•
•
•
•
•
•
•
•
•
•
Kevin Patrick, MD
Greg Norman, PhD
Jacqueline Kerr, PhD
Linda Hill, MD
Jeannie Huang, MD
Simon Marshall, PhD
Cheryl Rock, PhD
James Fowler, PhD
Karen Calfas, PhD
Bill Griswald, PhD
3
Center for Wireless and Population Health Systems
Research on systems of wireless, clinical, and
home technologies to measure and improve lifestyle
and other health-related behaviors in:
-- Healthy adolescents
-- Overweight and obese children and adults
-- Depressed adults
-- Adolescents risk for type 2 diabetes
-- Adolescents with chronic disease
-- Older adults to promote successful aging
-- Adolescents recovering from leukemia
-- Young adults to prevent weight gain
-- Adults with schizophrenia
-- Exposure biology research
-- Cancer comparative effectiveness research
CWPHS.UCSD.EDU
4
Intervention & Methodology
• Expert Systems
• Kiosks
• Interactive Websites
• SMS Mobile Phones
• Exergames
• Mobile Apps
• Measure Development
• Classification
• Longitudinal Data
Analysis
• Randomized Controlled
Trials
• Mediation &
Moderation
• Geographic Information
Systems (GIS)
mHealth = Integrates intervention & measurement systems
5
Overview:
SMS Text Messaging
Intervention for Weight Loss
SMART: Social/Mobile Approach to
Reduce WeighT
6
Problem
• Trend of increasing obesity.
• Behaviors that can impact obesity
include physical activity, sedentary
behavior, and dietary behaviors.
• Need for effective approaches to
obesity prevention and treatment.
7
Obesity Trends* Among U.S. Adults
BRFSS, 1990, 1999, 2009
(*BMI 30, or about 30 lbs. overweight for 5’4” person)
1999
1990
2009
No Data
<10%
10%–14%
15%–19%
20%–24%
Behavioral Risk Factor Surveillance System, CDC.
25%–29%
≥30%
8
Rational for Mobile Interventions
moderate to vigorous activities:
0.7 hours/day
light-intensity activities:
6.5 hours/day
sedentary time: 9.3
hours/day
1.
2.
3.
4.
5.
6.
Context relevant
Point of decision
Just in time
On the go
Convenient
Unobtrusive
Wireless
Technologies
Data Analytics
*
Persuasive Design
9
Body Sensor Network
10
Social Networks
11
Geographic Information Systems
(GIS) & GPS data
• Parks
• Distance & density & acreage
• Schools
• Distance & density
• Recreation Facilities
• Distance & density
• 2010 Census data
• Housing unit density
• Parcel & Land Use
• Commercial, industrial, institutional,
residential, office, open space, vacant
• Retail parcel count
• CoStar / SD County Tax Assessor
• Retail floor area ratio
• Coastline
• Distance to coast
• Local & Major Roads
• Intersection & cul-de-sac counts
12
13
mDIET & ConTxt
Mobile Diet Intervention through Electronic Technology
PURPOSE
Randomized Clinical Trials to evaluate the use of Text Messages (SMS) to
improve dietary behaviors and weight outcomes in obese men and women.
mDIET:
mobile
Dietary
Intervention
through
Electronic
Technology
Funded by the National
Cancer Institute
R21 CA115615-01A1
Resulted in the
first report in the literature
of an RCT evaluating
SMS/MMS for weight loss
14
mDIET: Study Design & Sample
Randomized Controlled Trial:
Participants were randomized to either an Intervention (mDIET) or Control
group (usual care).
Completed 3 in-office measurement visits over a 4 month period
• Sample N = 63
• 81% Women
• Mean age 45.9 years
• Women ranged 26 – 55 yrs.
• Men ranged 33 – 55 yrs.
• Race/Ethnicity
• 76.2% Caucasian or White
• 15.9% African American or Black
• 3.2% Asian American/Pacific Islander/Native Hawaiian
• 4.8% Prefer not to state
• 22.2% Hispanic
15
mDIET Components
•
Daily Text & Picture Messages
– Participant could choose the # of messages to receive & times to receive the messages
(2-5 messages per day)
– Daily messages are statements or questions
•
Printed Materials for recommended weekly reading
– Behavioral Skills, Nutrition, and PA topics (e.g. Self-monitoring, Portion Control, Routine
Physical Activity) First half provided in Binder at baseline; Second half provided at midpoint measurement visit; participants were given a pedometer
•
Monthly Brief Counseling Calls (5-10 minutes)
– Progress and counseling calls from their Health Coach addressing strategies,
social support, problem solving, etc.
•
Goals
– Primary: Daily 500 calorie deficit (through calorie reduction and an increase in calories
burned by reaching and maintaining a 12,000 steps/day goal)
•
Self-Monitoring
– Weekly weigh in (text weight) and daily food & exercise journal
16
Types of mDIET Messages
Type of Text or Picture Message
Example
Motivational Sayings
Never say never, you can do it! Keep up the good work!)
Nutrition & Physical Activity Tips
Try 10 baby carrots and a tablespoon of fat-free dressing for
a 100 calorie snack; Want extra steps? Take the stairs today
Nutrition & Physical Activity Reminders
Remember to move more today to reach your 12,000 step
goal; Be sure to practice portion control strategies at your
next meal
Short-Term Goal Reminders
Think about what you can do in the next 4 hours to be
healthy
Behavior Questions
Have you practiced portion control strategies today? Have
you reached your 12,000 step goal today?
Weekly Weight Questions
What is your weight?
Weekly Weight Graphs
Chart of weekly weights
Portion Control Picture Messages
Pictures of portion sizes
17
Personalized Text Messages
• Eating Behaviors
– 4 items on the EBI were emphasized (based on our own logic rules)
• Name
– Some text messages included their first name (e.g. Congrats, Maria!
You continue to improve. You're clearly working hard and it shows).
• Grocery Store
– Participants were asked to identify the grocery store that they most
frequently visit (e.g. Did you buy fruits and vegetables from Trader Joes
this week?)
• Social Supporter
– Participants were asked to identify someone in their personal life
(family member, friend, co-worker) that could part of their social
support system (e.g. Have you been telling Mark about your weight
loss success?)
18
Message Activity
19
How mDIET Works…
3000
Messages
1500 Intervention Rules
Time of Day
Client
Management
System
Time of Day / Day of Week ?
User’s Week in Program ?
Previous Messages ?
Previous Replies ?
User EBI ?
......
...
Sender
SMS Out
Receiver
SMS In
User
Database
20
ASP Web-pages
MS/SQL Database
Java Application
Mail Gateway
mDIET: Results
Mobile Diet Intervention through Electronic Technology
21
Participant Feedback on mDIET
•
•
•
•
•
“Steady reminder – keeping health on my mind”
“Felt commitment every day – could not let myself forget my goals”
“They served as an excellent reminder to watch what I ate”
“Keeps me focused”
“Constant reminders to believe in myself and make the right
choices”
• “I found that texting your weight every week was extremely helpful”
• “I miss my 6am message!”
Overall satisfaction with mDIET program for weight loss 95.6% of
participants would recommend mDIET to friends/family
22
23
ConTxt
PURPOSE
• To develop and test the efficacy of a SMS intervention for
weight loss among overweight and moderately obese (BMI
27-39.9) men and women ages 21–60.
• The ConTxt study builds upon our work with pilot SMS weight
loss study mDIET.
• The ConTxt study aims to expand the logic of the SMS
messages and ecological components for over 300 Englishspeaking participants and Spanish-speaking participants.
ConTxt Team & Support Staff
Investigators
Staff
Students
Principal Investigator
Kevin Patrick
Study Coordinator
Lindsay Dillon
Ph.D. Student
Julie Kolodziejczyk
Co-Investigators
Greg Norman
Simon Marshall
Cheryl Rock
Bill Griswold
Elva Arredondo
Measurement
CarlynInvestigators
Peterson
Recruitment/
Intervention
Angelica Barrera-Ng
Tech Development
Mark Sullivan
Fred Raab
CMS/Data
Allison Flick
Graduate
Preeti Baweja
Misty Lacks
Undergrad Interns
Erika Gonzalez
Megan Alcalay
Karen Yeung
Kanchi Kejriwal
Helen Shea
Dianne Valenciano
25
RCT Study Design
309 Subjects, 21-60 years old male & female,
Weight: 27 < BMI < 39.9
English & Spanish speaking
Text Messages Users (or willing to learn)
n = 103
SMS Only
n = 103
SMS Only +
Counseling
• RCT ERNROLLMENT BEGAN:
October 2011
• Community Recruitment:
Email listservs, flyers,
community events, print
and/or radio advertisements
n = 103
Comparison
Control/Comparison
• Standard of Care Information via printed materials:
• Diet/Nutrition
• Physical Activity
• General Health
• Monthly mailings
• 4-Month opportunity to “cross-over” and receive 4months of the ConTxt intervention AFTER completion of
12-month assessment.
Intervention Components
• Weekly printed materials on core behavioral and weight loss
strategies
• Daily SMS messages:
• TAILORED MESSAGES: weight loss/management strategies; goal
setting; behavioral barriers; weight monitoring; skill mastery;
physical activity; and location
• PERSONALIZED MESSAGES: name; location; social supporter;
grocery store; children/pets
• STANDARD MESSAGES: weight loss strategies; self monitoring
SMS + COUNSELING CALLS
Receive bi-weekly and monthly counseling calls to assess progress, skill
development, and barriers
28
ConTxt: 16-Week Cycle Topics
• 1. Self-monitoring &
Goal Setting
• 2. Calories
• 3. Meal Planning
• 4. Pedometers & CV
Exercise
• 5. Portion Control
• 6. Sedentary Time
• 7. Barriers
• 8. Routine PA
• 9. Eating Out
• 10. Managing Social
Situations
• 11. Vigorous PA
• 12. Substitution
• 13. Healthy on a
Budget
• 14. Strength &
Stretching
• 15. Body Image
• 16. Sticking with It
Weight Behavior Inventory (WBI)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Shopped when I was not hungry.
Shopped from a list.
Stored food in containers where it was not
readily visible or in a closed cabinet.
Kept healthy ready-to-eat or portion
controlled snacks for myself.
Removed high calorie foods from my home,
office or room.
If I was served too much, I left food on my
plate.
Only ate when I was hungry.
Decided ahead of time what I would eat for
meals and snacks.
Reduced portion sizes.
Changed food preparation techniques.
Left a few bites of food on my plate.
Followed a structured meal plan.
Recorded or wrote down the type and
quantity of food eaten.
Avoided eating while watching TV.
Reduced my calorie intake.
Cut out/reduced sweets or junk food.
Cut out/reduced between meal snacks.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
Cut out/reduced late night snacking.
Ate less meat.
Ate less fat.
Drank less alcohol or changed type of drink
to reduce calories.
Increased fruits and vegetables.
Used frozen entrees such as Lean Cuisine or
Smart Ones.
Decreased frequency or portion sizes of
desserts.
Altered my daily routine to get more
lifestyle physical activity.
Used the stairs instead of the elevator.
Wore a pedometer.
Reduced the amount of time spent
watching TV.
Used home exercise equipment.
Exercised at a gym or participated in an
exercise class.
Worked out with a personal trainer.
Exercised for period of 30 minutes or more.
Recorded or graphed my physical activity.
Weighed myself regularly or daily.
Recorded or graphed my weight. 29
Types of Text Messages
ID
1
MESSAGE “TYPE”
Weight Messages
2
Weekly Content Messages
these messages relate to the corresponding printed materials
3
Self-Monitoring Messages
these messages relate to self-monitoring tips, facts, reminders
4
Physical Activity Messages
these are messages that are “tailored” based on a participants preferred physical activity:
run/walk, swim, bike, gym activities, or generic. The preferred physical activity will be set at the
baseline visit.
5
Motivational Messages
6
Daily Pedometer Messages
7
User Initiated Messages
8
Urge/Food Craving Messages
9
WBI Willingness Question
includes weekly weight question and responses, weight milestone messages, and weight
“competitive messages.”
these are inspirational or motivational messages
includes daily pedometer tracking question, potential responses, pedometer milestone
messages, and pedometer “competitive messages.”
includes Restaurants, Meals, Food Cravings, Physical Activity, and Location
these are messages that are “tailored” based on a participants “guilty” food craving: chocolate,
sweets, salty, comfort foods or generic. The food craving will be set at the baseline visit.
includes the willingness question & response.
Note: these also fall under the general WBI category of 15
Types of Text Messages
ID
10
MESSAGE “TYPE”
WBI Knowledge Messages
11
WBI Barrier Questions
(includes the barrier question and goal)
12
WBI Barrier Messages
(these messages are messages that are sent to participants that answer Y or No Response to
the willingness question and are tailored based on the response to the barrier question).
13
WBI Assessment Questions
14
messages that are sent to participants that answer N to the willingness question
(includes the assessment question and response)
WBI Maintenance Messages (these are messages that are sent if a participant scores a 4 or 5 on the assessment question)
15
GENREAL WBI Messages
includes ALL the WBI messages above: Message type 9 – 14
16
Appointment Reminder
Messages
FUTURE Messages
(includes messages that will be sent based on certain dispositions in CMS)
17
18
Physical Activity Location
Messages
messages that can be used for the “User Preference” messages based on tagging, like/unlike)
Note: The logic for these are not in place
these are messages that are “tailored” based on a participants preferred physical activity
location: home, gym, office, outside. The preferred physical activity location will be set at the
baseline visit.
SMS Logic & Flow
Sunday
Weekly WBI Messages
Willingness
Barrier SMS Messages
Send SMS: “Are you willing to
set goals for [WBI] this week?
(y/n)”
(M, T, W, TH, SA)
NO
Knowledge
Text
Messages
Weekly Mastery
Assessment (Friday)
Send SMS:
“On a scale of 1 (never) to
5 (always), how often did
you [insert WBI] in the
past week?”
Mastery = Weekly
Average (after 3
weeks) >/= to 4
YES
Skills/ Tips
Text
Messages
Answer
Answer
1, 2, or 3
4 or 5
Send Multiple
Choice
Barrier
Question
WBI Maintenance
Messages
a) Barrier 1
(M, T, W, TH, SA)
b) Barrier 2
c) Barrier 3
d) Barrier 4
32
Tagging Text Messages
Subject Matter
Core Strategies
Reminder, Tip, Fact,
Question/Assessment
1 Calories
15 Intention Formation
22 Reminder
2 Organization
16 Self-Monitoring
23 Tip/Hint/Strategy
3 Meal Planning
17 Goal Setting:
24 Fact/Information
4 Cardiovascular Exercise
18
5 Portion Control
19
6 Volumetrics
20
7 Sedentary Behavior
8 Eating Out
9 Social Situations
10 Vigorous Intensity PA
21
40
Goal Review:
Participating in
25 Question/Assessment
reviewing their goals statement or question
Positive Feedback
26 Response
Problem
Solving/Overcoming
Barriers
"Surf the urge"
Negative Feedback
Personalized on set
categories?
27 Social Supporter 1
Social Supporter 2 (i.e. kids
28
name)
Social Supporter 3 (pet
30
name)
31 Physical Activity Type
32 Physical Activity Location #1
33 Park
34
35
36
37
Activity Location 2
Restaurant #1
Restaurant #2
Food Craving/Food Urge
11 Substitution/Replacement
39 First Name
12 Healthy on a Budget
13 Strength Training
14 Stretching
41 Grocery Store
Does it
relate to
location?
38 Yes
Tagging Text Messages Examples
Message
Tags
Tag Type
1. Confidence is feeling satisfied
with who and what we are.
24
Fact, Information
2. Your goal this week is to sit
down and plan your weekly
meals. You can do it, Diane.
2, 3, 15, 23,
26, 39
Organization, meal planning,
intention formation, strategy,
response, first name
3. You can send us a text with the
word chocolate, sweets, salty, or
comfort if you are craving one of
those foods and need help!
15, 21, 23
Intention formation, hint, strategy
User Ratings of Messages
58 randomized to SMS have been in the program for 0 to 17 weeks. 36
rated at least one message. Number of messages an individual rated
ranged from 0 to 144, mean 13.8, sd = 23.6, median = 4.
327 messages have been rated 1
to 16 times
User Ratings of Text Messages
Message
Tags
Likes
Tag Type
1. There's no limit to the
20, 15,
number of chances you get to 4, 23
start exercising again. If you
give up or skip a week, try
again.
11/11
Problem solving, intention
formation, exercise, hint, tip
2. Do you LIKE these
22
messages? Remember to text
LIKE or L after any messages
you LIKE.
16/16
Reminder
3. Check out the restaurant's
website and look at their
menu to plan what you're
going to eat before you go.
8/10
Eating out, organization, Intention
formation, hint, strategy
8, 2, 3,
23, 15
37
SMART: Social/Mobile Approach to
Reduce WeighT
PURPOSE
To leverage mobile phones, social networks, and the web for weight
loss among 18-35 year old young adults.
Funded with a 5-year grant from NHLBI/NIH.
| Slide 39
SMART Study Team
Investigators
Staff
Students
Principal
Investigator
Kevin Patrick
Study Coordinator
Anjali Kansagara
Ph.D. Student
Ernesto Ramirez
Laura Pina
Co-Investigators
Greg Norman
Simon Marshall
Cheryl Rock
Karen Calfas
James Fowler
Bill Griswold
Jeannie Huang
Tom Robinson
BJ Fogg
Measurement
Melanie Epstein
Intervention
Christina Servetas
Tech Development
Evan Cook
Fred Raab
CMS/Data
Allison Flick
Undergrad Interns
Annie Phan-huy
Alexis Leon
Cathy Calinisan
Arek Hiridisah
Lauren Friend
39
SMART Study Design
400 Subjects, 18-35 years old male & female,
Weight: 25 < BMI < 34.9
University students
at three colleges in the San Diego area
n = 200
Comparison
n = 200
 Owns a personal
computer
 Owns a mobile phone
and uses text
messaging
 Facebook user /
willing to start using
Facebook
ENROLLMENT Began:
June 2011
Treatment
40
PRIMARY AIM:
At least 5-10% weight loss at 24 months
Study Population: College Students
Campus
SDSU
UCSD
CSUSM
Total
RCT N
160
160
80
400
41
Study Outcomes
Primary outcome - Weight status at 24 months
Secondary outcomes • Weight status at other time points
• PA/Diet/Sedentary/Sleep
• Quality of life
• Depression
• Use of technologies & relationship to outcomes
42
SMART| Slide 43
Group A vs Group B
Group A -InteractiveTechnology vs. Group B -“Self-guided”
Group A
Group B
Interactive Weight-loss Program
Self-guided Weight-loss Program
•
•
•
•
•
•
•
•
•
Tools: Binder with introductory program materials,
scale, pedometer
15-min “greeter session”
30-min in-person kick-off session
10 “lifelines” cashed in for virtual (Skype) face time
or phone calls over a 24-month period
–
•
•
•
•
•
Decrease daily calorie intake by 500-1000 cal/day
Increased PA by 10% until at 60min/day and 80% of target HR
Knowledge – Content on TTM website
–
•
Problem solving around barriers
Mobiles apps
Social support via Facebook
Email
Text messaging
Behavioral recommendations
–
–
•
Binder with introductory “program” materials
Monthly website topics
Weekly health tips
Weekly online polls
Paid incentive.
Focus on five core behaviors
Paid incentive for measurement visits
43
Comparison Condition
• Standard of Care information via a static website:
www.smarthealthtools.com
• Weekly emails:
–
–
–
–
introduction to monthly health-related topic first week of
each month
a health tip every second week
a health events calendar every third week
a poll question on website every fourth week
• Consent via Facebook but no further interaction on
Facebook
44
SMART
Social Mobile Approaches to Reduce Weight
Facebook an
intact social
network
SMART Study
1 - Participant
2 - Friend of Participant
3 - Friend of Friend
45
A “User-centered” Intervention
Web
Smartphone
Apps
Mobile Txt Msgs
Email
Other Tools
Bathroom Scale
Pedometer
Be sure to check
your email for
this this week’s
topic from
ThreeTwoMe
46
| Slide 47
Intervention: Health Coach Session
SMART: Social Mobile Approaches to Reduce Weight
t=0 mo
15-min
greeter
session
•
•
30-min
in-person
health
coach visit
t=12 mo
t=18 mo
t=24 mo
10 “lifelines”
Up to 15-min each
Can be used from month 2 through month 24
Before the visit: send questionnaire for “getting to know you”
30-minute Health Coach focus:
–
–
–
–
–
•
t=6 mo
Communicating SMART study goals: 5-10% weight loss; 500-1000 calorie deficit per day; increase physical activity: 0  10%
gradually  moderate to vigorous intensity exercise for 60 min/day (calculate target HR)
Set personal goals for subject. How much weight loss do they want to achieve?
Focus on: motivation, readiness, current behaviors, lifestyle, current knowledge of WL behaviors, practices, issues, problems,
behaviors
Focus on orienting them to the study; how to use the study and the study tools (apps, FB, social support)
Convey key messages:
• We want to hear from you whether you’re losing or gaining weight. We’re here to help you.
• We know from other studies that people who interact with study tools tend to be more successful.
• In order for you to be in the study, you must be willing to do this.
• You have to interact everyday. Some things will work for you; others won’t.
• We have many tools. Find the tools that work for you.
• If you’re not losing weight, use your ‘lifeline’ and contact your health coach.
10 Lifelines for “emergencies” or if they “fall off the wagon”.
47
| Slide 48
Intervention: Web
SMART: Social Mobile Approaches to Reduce Weight
ThreeTwoMe
Term for the SMART intervention
Developed as a unique “brand”
www.threetwome.com
• 16 weekly topics in
blocks of six
• Deeper dive on each topic
• “Homework” for each topic
via “Practice it”.
48
| Slide 49
Intervention: Web
SMART: Social Mobile Approaches to Reduce Weight
ThreeTwoMe
Term for the SMART intervention
Developed as a unique “brand”
www.threetwome.com
Users can set
their own
profile settings
on:
Email
SMS
Cell phone
And,
update/change
as frequently
as they like.
| Slide 52
Intervention: Blog
SMART: Social Mobile Approaches to Reduce Weight
• Blog posts in
conjunction with
real-time events
(e.g. holidays,
academic
schedules, etc.)
• Cross-reference
to Facebook
• Launching pad
for campaigns
• Christina, our
Health Coach,
posts these with
occasional
“guest posts”
| Slide 53
Intervention: Facebook Page
SMART: Social Mobile Approaches to Reduce Weight
• Christina – “The Health
Coach”
• # of “Likes” overall
• # of “Likes” per post
• # of Impressions
• % feedback on the post
• Video on National Food
Day
ThreeTwoMe : Suite of Apps
Mobile Apps
TARGET BEHAVIORS & STRATEGIES
APP
SelfIntention
Monitoring Formation
Be Healthy
TrendSetter
X
X
Goal Getter
Facts &
Quizzes
All apps accessible via
 Mobile
 Web
 Facebook
GoalSetting
Goal
Review
X
X
X
X
X
Feedback
Knowledge
X
X
X
X
X
Facts & Quizzes
A knowledge app to help learn
and recall key facts.
Goal Getter
Your friends motivate you to reach your goals through secret messages, surprise, and rewards
Be Healthy
A healthy tip a day keeps the doctor away.
Healthy Tips that are acted upon can be shared with others…
Reminders are strategies based on
the “WBI” or weight behavior
inventory
Others developed by SMART.
Tracking based on keyword
associations will serve as triggers
| Slide 61
Coming Soon
SMART: Social Mobile Approaches to Reduce Weight
• ThreeTwoMe is a continuously evolving intervention.
• ThreeTwoMe continues to build, enhance, replace as popular culture and
trends change with time, preferences, and behaviors.
• Coming Soon:
o “Adopt a Chicken” app from Stanford
o App contest
o TTM API
New Architecture
All apps integrate with an API for additional
features.
• Extracting common features (e.g.
goals, notifications, sharing) and
packaging them into an API service
• Avoid repetition of code in each
app (problematic in current architecture)
• Open doors for third-party
developers
(possibly a developer app challenge)
• Simplify the start-up development
time required to get a new app
functional
(test new ideas faster, with less investment)
• Create new apps without
modifying the Three Two Me
infrastructure
The New App
The benefits for a new application, and how
the user will use Three Two Me to enhance
their experience.
• Apps can target specific behaviors
• A basic “Push Up Counter” app
can compliment its simple and
unique features with our core
features
• User’s are informed and required
to approve all app connections with
TTM
• Provide the UI for creating goals,
managing trends, and creating /
displaying incentives, social sharing
• New apps can still work great
standalone
(Store information locally using HTML5 Local Storage)
Intervention: Dosage/Participant Engagement
EQUIVALENT GLOBAL
MINIMUM ENGAGEMENT
TIME UNIT / ENGAGEMENT
(Range)
DOSE RECEIVED ENGAGEMENT SCORE
# ITEM & CHANNEL
REQ
?
DOSE DELIVERED
1 Health Coach In-person
Y
1 meeting/2 years 1 meeting/2 years
0-1
30 minute
0,1
2 Weight TXT
Y
1 message/week
1 reply (0 to 7)
0-7
1 minute
0,1
3 Sunday Email
Y
1 email/week
0-1
1 minute
0,1
4 Facebook
Y
7 posts/week
1 read/week
1 (post/comment/like) /
week
0 to N
1 minute
0,1
5 Website
Y
Constant
1 pageview/week
0 to N
1 minute
0,1
6 Knowledge area
Y
7 Blog
No 1 blog post/week
1 minute
0,1
8 Lifelines -Virtual
No 0 to 10
10 minute
0,1
9 BH App
No 7 BH/week
1 (0 to 7)
1 minute
0,1
10 GG App
No 0 to N
1 (0 to N)
1 minute
0,1
11 TS App
No 0 to N
1 (0 to N)
1 minute
0,1
1 blog read / week
0
Intervention: Dosage/Participant Engagement
Summary of Average Weekly Engagement
Goal getter
week
Trend setter
week
76
106
106
82
19
30
0
0
24
21.3569
5.1281
1.9532
1.4497
4.1561
1.1232
21.79927
6.14461
2.49827
2.65809
7.16594
1.19342
Minimum
.27
.06
.10
.00
.17
.07
Maximum
104.00
36.00
11.86
15.67
53.00
5.06
25
6.0357
.7778
.4167
.0000
.6667
.2500
50
12.7143
2.6923
1.0000
.4093
1.7802
.6667
75
28.4643
7.3571
2.1227
1.6875
5.0000
1.5877
N
Valid
Missing
Mean
Std. Deviation
Percentiles
TTM page
views week
Knowledge
week
105
87
1
Blog week
Be healthy
week
SMART| Slide 66
Recruitment
SMART: Social Mobile Approaches to Reduce Weight
Co-branded poster
Quarter-sheet fliers w/QR codes
Magnets
Bookmarks
Stickers
Recruitment
Challenge 1
• Challenge – Intervention will change over time
• Downside – different participants will get different
apps, new apps & features introduced
• Upside – more engaging experience over 2 years of
program
• The Plan – always have tools for the 5 core change
strategies
Challenge 2
• Challenge – Controls participants could get access to
apps.
• Downside – Study contamination, internal validity
threatened.
• Upside – would be an indicator of success.
• The Plan – try to control, measure extent of
contamination.
Challenge 3
• Challenge – Participants could become friends
through program.
• Downside – clustering of participants, lose
independence of observations.
• Upside – could help people achieve goals.
• The Plan – will measure extent of clustering, can
anticipate some clustering, can incorporate in
statistical models.
Challenge 4
• Challenge – Facebook changes over time.
• Downside – could have negative impact nature of
intervention and what we can learn.
• Upside – could improve delivery of intervention and
what we can learn.
• The Plan – roll with the changes.
Conclusions
• Mobile phone is a viable platform for health behavior
change.
• SMS & apps for delivering interactive intervention
content.
• Requires new ways to evaluate engagement.
• Advantages of just in time, when and where needed,
convenient, simple.
• Adaptive interventions to the individual and to groups.
• Expect ‘small’ changes in weight loss that accumulate
over time.
73