In recent posts on Web-based and mobile behavioral intervention programs, we reviewed evidence suggesting that social support, in one form or another, can improve participants’ adherence and engagement with the program. That didn’t always mean however, that participants achieved better outcomes as a result. In one study for example, an online community increased engagement with and utilization of a Web-based activity program, but it did not increase participants’ actual activity levels.
Another study, slightly older than the ones reviewed above, did show that a Web-based program improved outcomes. In this case, the intervention was an online videogame known as Re-Mission. Since I haven’t touched previously on outcome studies for automated lifestyle intervention tools or videogames as an example of such programs, I’ll do that here.
Re-Mission is intended improve medication compliance in teens and young adults with a history of cancer. In the game, players control a nanobot within a 3-dimensional body of a young person that has cancer. Play involves destroying cancer cells and managing chemotherapy-related adverse effects like vomiting and bacterial infections by using antiemetics and antibiotics. The game purports to help users understand their disease and its treatment and improve their sense of self-efficacy: they can take control of their disease.
With the rise of cell phone usage, smart and otherwise, many health care providers, researchers and entrepreneurs alike have assumed that this ubiquitous technology can be used to improve health and wellbeing. Entrepreneurs have led the charge and so the common catch phrase “there’s an app for that” underscores the fact that nearly 17, 000 health related apps are available either for free or a small charge for Android or Apple users. Young people in the US are perhaps the best targets of our mhealth efforts because they are eager users of mobile technology. However two questions arise naturally: 1) does data show that these apps lead to improved outcomes? 2) is there a theory of how we might use cell phones to improve health outcomes?
In a series of studies, we found that simply responding to text messages over a 3-month period led to improved quality of life and pulmonary function in pediatric asthma patients. In both studies, the researchers randomly assigned 30 asthmatic children, 10 to 17 years old, into three groups – a control group that did not receive any SMS messages; a group that received text messages on alternate days and a group that received texts every day. The children that received messages everyday between two scheduled appointments had the improved psychological and physical outcomes. Thus, our data does indicate that cell phones can be used effectively to improve health outcomes.
Perhaps more compelling is that we may have evidence of a possible mechanism that can lead to improved outcomes. The Health Belief Model is a cognitive theory of behavior change that espouses the notion that a critical pillar of behavior modification is that the individual must make the connection between the severity of the symptoms and the disease itself. In the case of asthmatic patients, we found that many times they attributed their symptoms to other causes. For example, they would say that they couldn’t exercise in the afternoon because they had a heavy lunch or that they couldn’t sleep the night before because they had seen a movie that had made them anxious— rather than attributing these symptoms (inability to exercise or sleep) to their asthma. The Health Belief Model also places value on acquiring knowledge about the disease. Thus, we sent patients texts messages that either asked about symptoms they had experienced or about asthma myths. Thus, our studies also indicate that improving symptom awareness and knowledge about their disease led them to have better medication adherence which in turn led to improved health outcomes.
“Why aren’t you taking your cholesterol medication?” I asked the woman.
With the coronary disease I diagnosed a year ago, my discovery that she had not taken her medication was very troubling.
“It made me tired,” she replied matter-of-factly. ”And besides, the cardiologist said the stress test was negative, so my heart is fine!”
I ordered the stress test after her heart calcium score was significantly elevated, revealing significant atherosclerosis. She totally misunderstood the results, and I needed to fix that problem. So I pulled out my secret weapon: a good analogy.
“The purpose of the calcium score test was to see if you had termites in your home” I explained. ”I found them. The negative stress test just said that the termites hadn’t eaten through your walls. It’s good news that your walls aren’t falling down, but they will if we don’t stop the termites.”
Her eyes opened wide comprehension: the termites were eating her walls. She was living on borrowed time.
“Would you take a medication if it didn’t have side effects?” I asked.
She quickly nodded. Of course she would. From now on she would be a compliant patient.
Compliance is good. Noncompliance is bad. It’s something I learned very early in my training: patients who do what their doctors say are compliant (good), and those who don’t follow instructions are noncompliant (bad). If you are lucky as a doctor, you have compliant patients. They are the best kind. They obey their doctors. They are submissive. Noncompliant patients are bad; they are a bunch of deadbeats.
Please hold your nasty comments; I don’t really believe my patients should obey or submit to me.*