Ebook: Information Technology Based Methods for Health Behaviours

Understanding and modifying health behaviours is a significant area of activity in health care innovation. The need to change behaviour effectively applies across a range of health contexts ranging from individual-led interventions for addressing wellbeing and prevention through to clinically-delivered management of chronic diseases and rehabilitation. There is considerable contemporary research interest in emerging Information Technology (IT) based methods for monitoring health behaviours and delivering health behaviour change interventions remotely, as a new form of telehealth or virtual care. Health technology offers numerous practical advantages including cost-efficiency, scalability, personalization, and automated high volume data collection and analysis. However, the success factors for design, implementation and deployment of IT-based methods in this domain have not yet been fully codified, and typically bespoke choices are made in developing the underlying IT systems.

This edition of the Global Telehealth series of papers, Global Telehealth 2019 (GT2019), was initiated by a National Symposium on the topic of “IT-based Approaches in Health Behaviours” convened at Flinders University in Adelaide, Australia by Flinders Digital Health Research Centre on 5th July 2019. The meeting was held in conjunction with a series of Health Behaviours workshops and graduate students masterclass, and an Adelaide Public Lecture within the Caring Futures Institute programme, delivered by Professor Richard Rosenkranz of Kansas State University under a Flinders University International Visiting Fellowship and further supported by the South Australian Premier’s Research Industry Fund.

The series of papers from the Symposium was supplemented by contributions solicited from other delegates attending the event and by an open call for submissions with the facilitation of the International Medical Informatics Association (IMIA) Telehealth Working Group. This step enabled the topic to be enhanced with some broader contextual offerings which are pertinent to IT-based implementation of health behaviour tools. Contributions were invited for any area of health behaviour applicability and covered a variety of health targets (e.g. physical activity, nutrition, sleep), demographic targets (e.g. ageing, youth, clinical conditions), behaviour change elements (e.g. design, reward, social motivation) and delivery mechanisms (mobile, web, online learning).

The papers selected for inclusion here are intended to establish some common themes for success factors from case study descriptions and evaluations of recent successful IT-based health behaviour projects, as well as perspectives from clinical, health technologies, and health services domains. The scope of coverage for this Global Telehealth volume therefore continues to follow the Series intention, to provide a record of both presented and contributed papers for the year, with a broad focus on the chosen theme. The book comprises only full-paper blinded peer-reviewed contributions received for the Symposium and the subsequent call for further contributions, as judged by the international expert review panel. Most papers were reviewed by three independent reviewers and approximately 70% of the total submissions received were accepted for publication.

The editors wish to acknowledge the generous support of the host institution Flinders University in supporting the lengthy process of receiving and handling papers submitted for consideration, and correspondence with the authors. We also express our gratitude to members of the international review committee for their considered comments and helpful recommendations to authors, which ensured a high level of integrity in the selection of papers and improvement of their contents.

Anthony Maeder, Stephanie Champion, Carly Moores and Rebecca Golley

Co-Editors

As technological innovations continue to be developed and introduced within healthcare, public health, and our daily lives, human beings now have access to sophisticated and powerful tools that could be used in a variety of ways to change health behaviours. Information and communications technology (ICT) features prominently among 21st century innovations, and we must consider how they may be used to help or hinder our efforts to address population health challenges. There are numerous relevant challenges that need to be addressed within healthcare, public health, and other areas relevant to population health. The Australian population is aging (increasing in both the absolute number, and also proportion of older adults), along with having greater levels of obesity, diabetes, cardiovascular diseases, cancers, and other chronic diseases that will take a large toll on Australia. There are many lifestyle determinants of chronic disease that could potentially be addressed through ICT-based intervention efforts to improve diet, physical activity, alcohol, tobacco, sleep, and sexual behaviour. Challenges also include better delivery of what innovations or interventions have been shown to work, how we can best help those who need help the most, and how to implement policy, systems, or environmental interventions that can help to make healthy behaviours more convenient, attractive, and normative. As the name suggests, ICT involves any technology that allows us to store, retrieve, manipulate, transmit, or receive information electronically in a digital form. Although such technologies may allow us to reach more people than we could without them, and to do so in more rapid manner, with better geographic reach than ever before, ICT does not automatically provide any advantage in addressing the key drivers of health behaviour. Information itself could be useful—but is almost never sufficient—to facilitate health behaviour change; rather, information must instead be placed within the context of the key drivers of behaviour change. These drivers can be described most simply as factors that enhance people’s capability, opportunity, and motivation to engage in health promoting behaviour, or their obverse, behaviours that undermine health. Beyond the storage, retrieval, manipulation, transmission, or receipt of information, we must ensure that key drivers of behaviour are built into ICT approaches. Understanding, predicting, and influencing human behaviour is crucially important if we aim to address relevant population health challenges, and to achieve better health and wellness within populations. In other words, if we want to be well, we need to be “well behaved.” Illustrative examples will be shared from the author’s research studies, primarily focused on motivating and building the capability of adult leaders to provide better opportunities for children to be physically active, eat healthfully, and to establish health promoting habits. These studies range from interventions set in girl scouts, schools, and whole communities, with a variety of ICT approaches.

The 10,000 Steps program originated from a landmark whole-of-community multi-strategy intervention to increase physical activity (PA) in Rockhampton, Australia in 2001-2003. It used a social ecological framework to promote physical activity at the individual, population, environmental and policy level. Two of the fundamental aspects of the original program were goal setting (10,000 steps per day) and self-monitoring (use of a pedometer for daily step counts). A project website (www.10000steps.org.au) allowed registered participants to record their physical activity. Over time the program morphed into an e- & mHealth intervention without face-to-face elements. The program is now delivered via website and smartphone apps and employs activity trackers (pedometers, Fitbit, Garmin).

To date the project has signed-up over 425,000 members who have logged 221 billion steps (∼43 million a day) on the website or app. More than 14,000 workplaces and community organisations have been involved with the program. A central element of the program, the ‘Workplace Challenge’ has been used by ∼65% of 10,000 Steps members, which on average increases physical activity by 159 min/week for those who participate in it. In 2011, the Queensland Government designated the 10,000 Steps program as their key physical activity workplace health promotion strategy.

Multiple factors underpin the success of the program. The message is simple and clear: the project name, with its distinctive logo and tagline (‘Every Step Counts’) provides a clear and prescriptive target for the physical activity ‘dose’. Using effective behaviour change techniques: goal setting (the 10,000 Steps concept), self-monitoring (steps are tracked), social support (participants organise as ‘teams’ to reach certain step goals) and gamification (teams competing against each other creating ‘friendly competition’). Ongoing redevelopment: since inception, there have been three complete redesigns of the website (including a branding redesign), and new smartphone apps. More recently, the website was modified to allow syncing of steps using popular activity trackers. Resources to support implementation: the program provides resources (e.g. ‘Active Workplace Guide’) and has dedicated staff to respond to queries from workplaces and individuals to help overcome implementation barriers. Project staff continuously promote the program via media interviews, attendance at events, social media and marketing, advertising, and networking and collaboration.

Ongoing evaluation has contributed to continuous funding: to ensure the program remains successful in a fast-changing technology environment, continuous evaluation has been necessary. These evaluation strategies, the success of the original project and the strong partnership with the program funder (Queensland Health) have all contributed to the long-term (19 years) support for the project.

Health behaviour change programs that utilise IT-based delivery have great potential to improve health. Whilst more static Web 1.0 technologies have been somewhat effective, they often failed to promote longer-term user engagement required for greater health promotion impact. With Web 2.0 technologies, however, there is potential for greater engagement and retention, through allowing individuals to determine how information is generated, modified, and shared collaboratively.

The WALK 2.0 study utilised a Web 2.0-based platform to engage participants in health behaviour change aimed at increasing physical activity levels. The program included two trials: (1) a three-arm randomised controlled trial (RCT) that compared the effectiveness of Web 2.0, Web 1.0, and paper-based logbook interventions; and (2) a real-world randomised ecological trial (RET) that compared a Web 2.0 and Web 1.0 intervention. The aim of this paper is not to focus on the research trial results per se, but rather the success factors and challenges in both the RCT and RET.

Both the RCT and RET demonstrated successful outcomes, with greater improvements in physical activity for the Web 2.0 groups. A range of challenges, however, were identified in designing, implementing, and evaluating such interventions. These include IT-based intervention development within a research context, the ability to establish a self-sustaining online community, the rapid pace of change in web-based technology and implications for trial design, the selection of best outcome measures for ecological trials, and managing engagement, non-usage and study attrition in real-world trials.

Future research and developments in this area must look to broader research designs that allow for the ever-changing IT-user landscape and behaviour, and greater reliance on development and testing in real-world settings.

Accurate assessment of postural balance is necessary to identify and measure falls risk, inform clinical practice, determine efficacy of treatment and ultimately falls prevention. The aim of this scoping review was to identify gaps and inform practice, research and policy. There are a multitude of technologies available for assessing balance and no one that meets the requirements of every situation. Force plates had provided the gold standard technology for measuring centre of pressure variables as the cornerstone of balance assessment. Inertial measurements units are now considered as valid and reliable, however inertial sensors in smartphone require further refinement to measure with the same degree of accuracy. Fusion systems combine wearable and non-wearable technology in formal gait labs but also gaming. The flexibility provided choice of wearable, non-wearable and fusion systems meets most clinical and research requirements.

This chapter presents two case studies where the dominant narrative was subverted, one by citizen participants and one by researchers. Subversion, as a questioning and challenging stance, in the context of co-creation supports the discovery of new pathways for healthy behaviours even in modest projects. We also illustrate how emotion-led and interest-based design is used to increase adoption by end-users. Here we explore the development of an active ageing portal for a local council and the use of ‘Kira’ the robot to promote social interaction between older adults living with dementia.

Current legislation aims to enable older Australians to age in place, and puts public healthcare within the remit of local governments. As Australia’s population ages, local governments will need to explore new methods of service delivery in order to meet the increasing need for services that promote healthy ageing. Information technology (IT) may provide one such solution, however older Australian adults are reported to have low levels of technology use. In this simple descriptive qualitative study, focus groups with local government staff and community-dwelling older adults explored their perspectives regarding: a) IT solutions that councils could use to promote community-based healthy ageing, and (b) the enablers and challenges for adopting such solutions. Twenty-four adults participated in focus groups, and eleven of these adults also provided written data in response to visual prompts. Field notes were recorded by attending researchers. These three data sources were combined through narrative synthesis. Local government staff and community-dwellers alike perceived the utility of IT solutions in connecting community members, and connecting people to services (such as transport and providers of health information). While local government staff identified that IT solutions could provide benefits to the council when implemented in conjunction with existing services (e.g., to track data and identify information about community engagement and needs), community-dwellers placed stronger emphasis on adopting technology which had a clear purpose for its use. Due to limited digital literacy and some ambivalence towards embracing technology, IT solutions should be implemented with support to increase digital literacy, be widely advertised, and be centered in community needs. Personas have been generated and provided as possible case studies for technology adoption.

In health and behavioural sciences, there has been a shift towards use of mobile, wearable and IoT based frequent granular data collection strategies to capture temporal patterns and environmental changes. There are a wide range of free and easy-to-use services that allow researchers to design and deploy intermittent assessments and surveys. However, there is a lack of tools suitable for frequent or real-time data collection. This paper outlines DROPS (Flinders Data Repository for Open Science) software infrastructure, that provides an easy-to-use web-based service for researchers to upload real-time research study data gathered from study participants devices into cloud storage as well as coordinate sharing of data with other researchers for secondary research. The infrastructure developed by Flinders University as part of a collaboration project with the Australian National Data Service, runs on a server, receives the data through an API interface, and stores in a no-SQL database. The solution eliminates the barriers of setting up back-end infrastructure to manage the reception and storage of research data assessed in real-time environments.

Maintain Your Brain (MYB)i is a randomised controlled trial (RCT) of multiple online interventions designed to target modifiable risk factors for Alzheimer’s disease and dementia. Traditional clinical trial management systems (CTMS) requirements consist of features such as management of the study, site, subject (participant), clinical outcomes, external and internal requests, education, data extraction and reporting, security, and privacy. In addition to fulfilling these traditional requirements, MYB has a specific set of features that needs to be fulfilled. These specific requirements include: (i) support for multiple interventions within a study, (ii) flexible interoperability options with third-party software providers, (iii) study participants being able to engage in online activities via web-based interfaces throughout the trial (from screening to follow-up), (iv) ability to algorithmically personalize trial activities based on the needs of the participant, and (v) the ability to handle large volumes of data over a long period. This paper outlines how the existing CTMSs fall short in meeting these specific requirements. The presented system architecture, development approach and lessons learned in the implementation of the MYB digital platform will inform researchers attempting to implement CTMSs for trials comparable to MYB in the future.

The way health care is delivered changes continuously and is increasingly supported by digital technologies, such as telemedicine. Many terms in that context exist, which are not defined consistently and therefore used ambiguously. This makes it difficult to assess the evidence base. Ontologies bring structure and clarity to the discourse around telemedicine and related terms. We use this tool to provide definitions of relevant terms and show their interrelations. The results provided will be applied to different case studies to show their applicability. We aim to provide a more evidence-based understanding of relevant terms in digital health.

Behaviour change can refer to any transformation or modification of human behaviour. Within healthcare it refers to a broad range of activities and approaches that focus on the individual, community, or environmental influences on health-related behaviour. For e-Health (or digital health) it refers to behavioural impacts mediated through a specific e-Health intervention. However, there are also other health-related behaviour changes being quietly imposed upon both the populace and the healthcare professions broadly, by use of information and communications technologies for health.

To better understand these deliberate or incidental impacts on the behaviour of healthcare consumers and providers alike, a scoping narrative review was performed using peer-reviewed and grey literature resources. Qualitative information was charted from the selected literature. This created an objective analysis of both contemporary and less commonly appreciated aspects of behaviour change in our ‘digital’ age.

Many contemporary examples exist. The Internet and www brought alternate approaches moving from face-to-face or paper-based to websites, electronic diaries, and now mobile phones (particularly smartphones) to personalize health-related behaviour change in a myriad of diseases and conditions. Segments of the population have also exhibited health-related behaviour change through their growing www-based health-information seeking. More recent examples include ‘spontaneous telemedicine’ where physicians have changed the behaviour of themselves and colleagues through use of Instant Messaging, e.g., WhatsApp. Patients are also changing their behaviour spontaneously through taking and providing ‘medical selfies’. However, the recent and rapid growth in accessibility and popularity of social media has markedly impacted behaviour change through the speed with which information can be spread, by both legitimate users and socialbots. Insidious examples include spread of health-related ‘misinformation’ (e.g., vaginal cleansing,), and now ‘disinformation’ (e.g., the ‘anti-vaccination’ movement, now resulting in recurrence of once eradicated diseases).

These, and other examples, represent the broader, sometimes incidental, impact of some current e-health approaches on health-related behaviour change and should be identified and acknowledged as such. Doing so may fundamentally change opinion and efforts to redirect elements of behaviour change and aspects of behaviour change theory in unexpected ways.