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Beyond our daily activities, CHAI Core wants to spread the word about new opportunities in the field of eHealth.
eHealth Digest
Are you making the MOST of your behavior change app?
March 2017, Issue 12.0



We're shaking things up for this year's first eHealth Digest by bringing you some of the MOST trending intervention development strategies, as highlighted in Tombor, et al.'s (2016) Development of SmokeFree Baby: a smoking cessation smartphone app for pregnant smokers.

Tombor and colleagues present their multi-step process for developing a smartphone app to help pregnant women to stop smoking. What's particularly interesting is their use of the Multiphase Optimization Strategy (MOST) framework, which emphasizes using a factorial experiment in the design process to identify the optimum combination of components.

Formative research was first conducted, which involved conducing focus groups to understand the needs of pregnant women and views on how digital interventions can improve smoking cessation efforts. These steps informed both the selection of a smartphone app as the mode of delivery and the selection of intervention components. The intervention also included behavior change techniques (BCTs) that were identified and associated with short-term smoking cessation in evidence based treatment manuals and effective interventions that provided behavioral support to pregnant smokers. They established a set of intervention components, and following MOST guidelines identified which features or functions ("core modules") were likely to be effective and should be tested experimentally. Each core module had a control and full version to provide a basis for testing different component levels. They drew on the BCTs to specify the intervention content in the app. And finally, they designed a prototype intervention, and piloted the app.

The final result is the SmokeFree Baby app that includes general app features and five core modules; each module focuses on a specific topic and includes content based on a unique set of BCTs. To make the MOST of their app, Tombor et al. will be using a 2 by 5 factorial design to evaluate and optimize the combination of the five modules and two different levels of each. They plan to use the findings from this to identify which combination is most effective in influencing smoking behavior in pregnant women, revising and re-evaluating the app accordingly. Their approach shows how feasible it is to design a digital health intervention using the BCT framework and then make "the MOST" of it by testing multiple conditions simultaneously and "systematically screen out ineffective intervention components to keep only those components with the greatest potential to inform better interventions."
eHealth Researcher Spotlight
Carmina Valle, Deb Tate, Brooke Nezami & Julianne Power
March, 2017

Welcome to our first Researcher Spotlight of 2017! This month we've decided to highlight our first app through ResearchKit: Nudge. Dr. Deborah Tate and Dr. Carmina Valle, through funding provided by the UNC Gillings Innovation Labs, are using a smartphone application to determine predictors of young adults' adherence to self-monitoring behaviors, specifically to daily self-weighing and daily use of wearable activity trackers. In a future iteration of the app, they will evaluate the effects of different types of message manipulations on adherence to daily self-weighing or tracker use in young adults. The investigators plan to use the results of this project to guide the development of a behavior-change intervention using adaptive, tailored messaging. CHAI Core developed the native Nudge app using cutting-edge technology that pulls data from a wireless scale, physical activity tracker, and GPS.

The Nudge team is comprised of Co-PIs Carmina Valle and Deb Tate, as well as Postdoctoral Fellow Brooke Nezami and doctoral student Julianne Power.

We had the pleasure of asking the team a few questions.

What attracted you to using a mobile app in your weight research?
Our research is about reaching people in their daily environments to provide weight management support. Cell phones are widely used across the globe and socioeconomic groups, and people generally have their phones with them all of the time. This widespread use of mobile phones means that researchers can reach participants wherever they are, while also collecting data throughout the day to learn about each participant's unique behaviors, barriers, and environments. Using mobile devices allows us to deliver messages at the right time and to learn more about when and where people need more or less support in their behavior change.

What impact do you hope Nudge will have?
One overarching goal of Nudge is to improve the ability of mobile interventions to change behavior by sending support at just the right time. These "just-in-time" adaptive interventions, or JITAIs, collect data from mobile devices such as smartphones and wearable activity trackers, and incorporate it into machine learning algorithms that take into account participants' unique characteristics, contexts, and behaviors to optimize message frequency, timing, and content. We hope that our research will help move the field of intervention research forward by identifying high-reach, low-burden methods to keep participants engaged in research studies and increase their adherence to healthy behaviors.

What are you most excited for in 2017?
Other than the release of "Star Wars Episode VIII: The Last Jedi", we are excited to launch the first study by our Gillings Innovation Lab using the Nudge app. During the study, we will use daily self-weighing with wireless scales and physical activity trackers as a "use case" to examine patterns of adherence to self-monitoring weight and activity. Participants will provide feedback via the Nudge app and offer insights on their reasons for self-monitoring their behavior or not, and times when they are receptive to supportive messages. This will be the first in a series of studies by our lab that will use the app to precisely tailor the timing, dose, and content to the needs and habits of individuals.
eHealth Digest
All I Want for Winter is an Enhanced Alcohol Reduction Intervention
December 2016, Issue 11.0
With winter officially here, it's time to cozy up by the fire, read a nice book, and maybe even indulge in the latest binge-worthy show (Westworld, anyone?)! But before you enjoy our week off, we wanted to review our final eHealth article for 2016: Drinker prototype alteration and cue reminders as strategies in a tailored web-based intervention reducing adults' alcohol consumption: randomized controlled trial.

Published in the Journal of Medical Internet Research, van Lettow and colleagues (2015) examine two strategies, prototype alteration and cue reminders, as potential enhancements to Drinktest, an online tailored alcohol reduction intervention. Once enrolled, participants (n=2634) were randomly assigned to one of four arms: 1) Drinktest only, 2) Drinktest + Prototype Alteration, 3) Drinktest + Cue Reminders, and 4) Drinktest + Prototype Alteration + Cue Reminders. Participants were assessed at baseline, 1 month follow up, and 6 month follow up. The primary outcomes of interest were self-reported drinking behavior, intentions to reduce alcohol consumption, and willingness to drink.

The article goes on to describe the operationalization of both enhancements. According to the authors, "prototypes refer to the mental image of a typical person engaging in a certain behavior, such as a typical drinker." By emphasizing the consequences of certain behaviors (e.g. "Your answers show you'd like to be seen as social and spontaneous. The[se] characteristics correspond best with drinking moderately"), an individual's perception of their prototype can be altered, inspiring behavior change. In contrast, a cue reminder is an object selected by the participant (e.g. silicone bracelet) intended to "help people remember the content of interventions or their personal goals."

At follow up, there was an overall reduction in alcohol consumption (measured as self-reported mean number of drinks/day) across all groups, with larger reductions in the prototype alteration (3.03 drinks/day, p=0.03) and cue reminder (3.04 drinks/day, p=0.03) conditions than Drinktest only (3.10 drinks/day); combining enhancements did not have a synergistic effect. In addition, while intentions to reduce alcohol consumption increased and behavioral willingness to drink decreased, no differences between groups were found.

The authors are careful to put these findings in context. The study was limited by high dropout, with only 1260 participants completing at least one follow up (48% attrition), and only 599 participating in all three assessments (77% attrition). Attrition was higher among participants who were men, non-Western, younger, had lower education, and reported slightly higher alcohol consumption. Interestingly, dropout was significantly higher among those in the Drinktest only condition as compared to the other three. A second limitation was the homogenous nature of the sample, with 94% of Western origin (defined as origin from all European countries except Turkey, North America, Oceania, Japan, and Indonesia).

Van Lettow and colleagues (2015) conclude by advocating for further research to understand how to best optimize the use of prototype alteration and cue reminders as strategies to reduce alcohol consumption. So while we here at CHAI Core wish you a very happy holiday season, we hope this eHealth digest will serve as a cue reminder to enjoy your vacation safely!

See you in 2017!
Internet Interventions

Thinking about where to publish your next e-intervention? Consider the new journal called Internet Interventions

The aim of Internet Interventions is to publish scientific, peer-reviewed, high-impact research on Internet interventions and related areas.
Internet Interventions welcomes papers on the following subjects:
  • Intervention studies targeting the promotion of mental health and featuring the Internet and/or technologies using the Internet as an underlying technology, e.g. computers, smartphone devices, tablets, sensors.
  • Implementation and dissemination of Internet interventions.
  • Integration of Internet interventions into existing systems of care.
  • Descriptions of development and deployment infrastructures.
  • Internet intervention methodology and theory papers
  • Internet-based epidemiology
  • Descriptions of new Internet-based technologies and experiments with clinical applications
  • Economics of internet interventions (cost-effectiveness)
  • Health care policy and Internet interventions
  • The role of culture in Internet intervention
  • Internet psychometrics
  • Ethical issues pertaining to Internet interventions and measurements
  • Human-computer interaction and usability research with clinical implications
  • Systematic reviews and meta-analysis on Internet interventions.
Archive
Christine Rini, PhD
November, 2016
PainCOACH is an automated, Internet-based version of Pain Coping Skills Training. Chris first developed PainCOACH for osteoarthritis, then worked with CHAI Core to investigate how to adapt the program to help cancer patients with bone pain. With the goal to better understand how to coordinate use of the adapted program with patients' clinical care, the pilot study gathered firsthand participant and healthcare provider feedback through in-person interviews and focus groups. CHAI Core conducted and analyzed these qualitative data, integrating patients' entries in program journals completed during the intervention as a way to gather their in-the-moment impressions.

It has gone international! Researchers in Australia have adapted PainCOACH and will begin their study soon.

We had the pleasure of asking Chris a few questions:

What attracted you to eHealth for pain management?
Before I began my training in social/health psychology, I worked in marketing for a computer software company. One of my responsibilities was to develop computer-based demonstrations of the company's software. The demonstrations were given to potential customers to help them understand how the software worked. I enjoyed the challenge of figuring out how to make very complex information meaningful and saw the value in using those demonstrations to reach a large audience in a very cost-effective way. After I completed my PhD and became a researcher, I was offered the chance to collaborate on a grant application proposing to use technology to improve health. The proposal evolved to focus on pain management, and I was fortunate to have the opportunity to take the lead. It was exciting to extend what I had learned in my prior work, applying it to an important public health problem.

What impact do you hope your work will have?
Our goal is to make the PainCOACH program as strong as possible, then find a way to make it freely available to people who could benefit from it. People suffering from persistent pain welcome the opportunity to take a more active role in managing their pain. Learning pain coping skills helps them feel like they have tools beyond those offered by medical pain treatments. I've heard PainCOACH users talk about their positive experiences using the pain coping skills they've learned in the program. It has been incredibly rewarding and motivating.

And on a lighter note, describe your ideal Thanksgiving meal!
Ideally, it includes all the traditional stuff - turkey, stuffing, sweet potatoes, cranberry sauce... That?s my traditional breakfast the next morning, too! And pie, of course!
The Magic Potion for Adherence
October 2016, Issue 11.0
With today being Halloween, we wanted to address one of the scariest issues in public health research: low adherence! As researchers, we invest time, funding, staff, and countless other resources into our interventions; when participants do not receive the intervention as intended, our studies face a major limitation. Zarski et al. (2016) recognized this issue and set out to assess whether different guidance formats for a web-based stress management intervention (GET.ON Stress) would result in different levels of treatment adherence (the number of completed modules).

To assess their hypothesis, Zarski and colleagues conducted a pooled analysis from three RCTs that each compared GET.ON Stress (intervention) to waitlist control. Each study's intervention group varied by guidance format:
  1. Content-focused guidance
    (most intensive, 4 hours/participant) - Participants received personalized written feedback from an eCoach on the exercises they had completed in each module and reminders when participants did not complete a module within 7 days.
  2. Adherence-focused guidance
    (less intensive, 1 hour/participant) - eCoaches regularly checked module completion and sent reminders when participants did not complete at least one module within 7 days. The eCoaches provided individual support and feedback only when participants requested it.
  3. Administrative guidance
    (least intensive) - Did not include eCoaching for participants, only contact information for technical issues.
Zarski et al. (2016) predicted that (1) treatment adherence rates would be higher for both content-focused guidance and adherence-focused guidance compared to administrative guidance and that (2) adherence rates for adherence-focused guidance would be equivalent to those for content-focused guidance.

Eureka! Zarski and colleagues found that their hypothesis was correct. Participants in both the content and adherence guidance formats completed significantly more modules (mean 5.70, SD 2.32 and mean 5.58, SD 2.33, respectively) compared to participants in the administration-focused condition (mean 4.36, SD 2.78; t223=4.53, P<.001; r=.29). In addition, there was not a significant difference in treatment adherence between content and adherence guidance formats (t262=0.42, P=.67; r=.03).

So even though it's Halloween, don't let low adherence frighten you! The article concluded there was no significant difference in adherence between the content and adherence guidance formats, so "by choosing adherence-focused guidance regarding the costs of treatment, substantial savings may be made without a significant reduction in patient adherence."

Can an Insomnia Intervention Help Prevent Depressive Symptoms
August 2016, Issue 10.0
The start of every new semester is an exciting time at UNC: campus is crowded with students, professors are putting the final touches on their syllabi, and there is always something new happening at the Pit. Along with all this excitement and activity, sleep often has a tendency to become a low priority; however, a good night's sleep can go a long way towards mental health. That's why this month we're highlighting the recent publication by Christensen et al. (2016) on the GoodNight Study, a randomized controlled trial of an online insomnia program to prevent depressive symptoms.

Christensen et al. (2016) tested whether a remotely-delivered 6-week intervention to reduce insomnia, called SHUTi, could reduce depression symptoms at 6 months among those with insomnia and mild depression. The program included six modules on insomnia, as well as two behavioral modules emphasizing sleep hygiene, cognitive restructuring, and relapse prevention. The entire intervention was automated, with human contact only occurring during assessments.

At baseline, 1149 participants were randomly assigned to receive SHUTi (n=574) or HealthWatch (n=575), an internet control program with information about a variety of health topics, except sleep or mental health. Although attrition was high at 6-week (n=581, 49% attrition) and 6-month assessments (n=504; 56% attrition), intention-to-treat analyses demonstrated that depression symptoms were significantly reduced among SHUTi participants (p<0.0001 at both time points) compared to control group participants. At both follow-ups, the average score on the Patient Health Questionnaire-9 for participants in the SHUTi group was no longer in the depressed range, while the control group reported mild depression scores.

Despite a high dropout rate over 50%, the findings were still significant, even when controlling for differential attrition. Christensen et al. (2016) concluded that "an internet-based insomnia intervention effectively reduced depressive symptoms in people with insomnia and subclinical depression." They also emphasized that an internet-based insomnia intervention might offer a widespread, non-stigmatized means of preventing depression.

So even with all the excitement of a new semester, remember: prioritizing sleep is essential as it can help reduce your risk of depression. And as always, GO HEELS!

Allison Lazard
July 2016
Our Researcher Spotlight this month is Allison Lazard, PhD, MS, assistant professor in the School of Media and Journalism!

Allison's research focuses on how visual design influences message perception and engagement within the digital environment. CHAI Core provided Allison its qualitative expertise to recruit and organize focus groups consisting of adolescents, young adults, and current users and susceptible non-users of other tobacco products (OTP). Discussing the aesthetics, usability, and content of popular existing tobacco education websites, participants informed the development of a new website to educate adolescents and young adults about OTP risks. This website is designed to most effectively convey the campaign message of UNC Tobacco Center of Regulatory Science (TCORS). Usability testing is now underway.

We had the pleasure of asking Allison a few questions:

What attracted you to utilizing websites for health education?
After working as a commercial food photographer and then a multi-designer in the pharmaceutical industry, I knew I wanted to switch gears and use all the tools I had learned from my experiences in these industries to improve health outcomes and lives. With a firm belief in the power of design, I headed into a career of research that investigates how we can best use all that we know from advertising and marketing for health communication. Utilizing websites for health education is a natural fit in today's media environment.

What impact do you hope your work will have?
I want health communicators to understand that design matters. Design shouldn't be an afterthought. Rather, we should incorporate designers, and the thought process behind design, into our message development much earlier than often happens. Design is scary to some. It is often viewed as something that should be left to the "creative" or the "artsy" types because it requires a different way of thinking or skill set. This is a myth.

And on a lighter note- what is your favorite summertime activity?
After not being on the seat of a bicycle since, oh I don't know, I was 12 or 13, I decided to take up cycling when I moved to Chapel Hill. And what a place to decide to do so! There is nothing more relaxing than riding around Orange County after an eventful day of work.


Let the Sunshine in...
Your Phone Will Tell You When It's Time for Some Shade
June 2016, Issue 9.0
The solstice has come and gone, which means hot summery days and sunny blue skies are upon us. So, too, are sunburns. It can be hard to keep up with all the necessary precautions of sun protection and skin cancer prevention, especially while you're enjoying the great outdoors. Turns out, there's an app for that.

Solar Cell, a mobile app developed by researchers at Klein Buendel, in partnership with the National Cancer Institute, provides real-time, personalized sun protection advice based on UV Index forecasts, time and location from your phone, and personal information like skin tone and use of sunscreen. In addition to having access to educational information, the app will send a visual and audio alert if you need to reapply sunscreen, are at risk for a sunburn, or have reached your daily dose of vitamin D.

Researchers evaluated the effects of Solar Cell in two randomized control trials. In their first study, Buller, D. B., Berwick, M., Lantz, K., Buller, M. K., Shane, J., Kane, I., & Liu, X. (2015a) randomized a sample of 604 adults into an intervention group (Solar Cell app, n=305) and a no treatment control group (n=299), to assess the app's effect on sun protection at 10 weeks. Participants in the intervention group reported using the shade more than those in the control group (average percent of days spent in the shade in the past 3 months, 41% vs. 33.7%; p=.03) but used sunscreen less (average percent days wearing sunscreen in the past 3 months, 28.6% vs. 34.5%; p=.048). No significant difference in the number of sunburns in the past three months was found. Although use of the app was associated with increased sun protection, only 41 percent of the intervention sample (n=125) used the app at least once.

With a goal of improving use of the app, Buller, D. B., Berwick, M., Lantz, K., Buller, M. K., Shane, J., Kane, I., & Liu, X. (2015b) conducted a second evaluation of the app at 12 weeks with a sample of 202 adults. To encourage use of the app, an iPhone version was made available and participants were screened more extensively and sent routine reminders. Of the 96 participants randomized to the intervention/Solar Cell group, 74 (77%) used the app at least once. Of the 74 individuals who used the app, 24 (32%) used the app 1 to 5 times, 17 (23%) used it 6 to 10 times, and 33 (45%) used the app 11 or more times.

Use of the app was associated with more sun protection, particularly among women. Women users of the app reported more use of all sun protection practices combined than men who used the app (average percent of days using all sun protection practices in the past 3 months, 46.4% vs. 43.3%; F = 1.49; p=.04), and men who used the app reported less use of lip balm with sunscreen than women users of the app (average percent of days wearing sunscreen in the past 3 months, 32.7% vs. 35.5%; F = 5.36; p=.02).

Solar Cell is set to hit the virtual shelves this year, hopefully in time for the beach. While evidence has shown that the app's personalized, real-time information can help people who use the app to practice better sun protection behaviors, the research also highlights utilization as a continued problem for the field.

Gail Henderson
GeneScreen
May 2016
This month?s featured researcher is Gail Henderson, PhD, Professor in the Department of Social Medicine and Director of the Center for Genomics and Society!

GeneScreen, the Center for Genomics and Society?s flagship project, is studying the best ways to offer targeted genetic screening to the general adult population. Saliva samples sent in by participants are tested for genetic mutations that can cause one of 11 rare but highly preventable or treatable conditions, including certain types of cancer and heart disease. Additionally, participant surveys and telephone interviews are used to assess opinions of genetic screening and to understand the decisional factors behind joining the study and non-participation.

CHAI Core is proud to be involved with GeneScreen-- assisting in formative data collection, conducting usability testing, and developing and designing the web-based participant platform. Beginning with recruitment for 100 participants from the UNC General Internal Medicine Clinic in March, GeneScreen will scale up to recruit 1,000 participants this fall.

We asked Dr. Henderson some questions about herself and her work:

What attracted you to using technology in your research?
Explaining difficult concepts ("genomics," "gene variants") online is challenging. Our website, designed by CHAI Core, is terrific; and most important, using web-based recruitment standardizes education materials and allows us to test online consent.

What impact do you hope your work will have?
While the GeneScreen conditions are rare, we predict that the impact of identifying individuals who unknowingly harbor these mutations would have a significant impact on morbidity and mortality. If that is proven true, then we might envision GeneScreen (with perhaps more than the original 11 conditions) as a tool available in primary care, as common as cholesterol screening.

And on a lighter note- what is your ideal summer vacation?
Always the North Carolina beach!


Check it Off, Check It Off!
April 2016, Issue 8.0
Here at CHAI we love many things, but two of our favorites are our fellow Tarheels and mHealth. So naturally this month's eHealth Digest highlights the recent contribution to the mHealth literature by UNC Gillings' own Dr. Smisha Agarwal, PhD student in the department of Maternal & Child Health. Featured last month in the British Medical Journal, Agarwal, LeFerve, Lee, L'Engle, Mehl, Sinha, and Labrique (2016) describes in detail the development of a new checklist for reporting mHealth interventions. Sponsored by the World Health Organization (WHO), the result was the mHealth Evidence Reporting and Assessment (mERA), a 16-item checklist for the reporting of mHealth interventions.

What is noteworthy about yet another checklist for researchers? As stated by Agarwal and colleagues (2016), the quality of mHealth reporting was inhibited by a variety of factors, including the multidisciplinary nature of mHealth and the pace at which technology changes relative to the speed at which research is conducted and disseminated. mERA seeks to reduce these challenges by providing a set of criteria that authors across disciplines can use when reporting their interventions, including information about the intervention (content), where it was implemented (context), and how it was delivered (technical features).

According to the authors, mERA "is intended to improve transparency in reporting, promote a critical assessment of mHealth research evidence, and help improve the rigour of future reporting of research findings."

The article goes on to provide an in-depth description of each of the 16 checklist criteria, which include infrastructure, technology platform, intervention content, user feedback, cost assessment, replicability, and data security. For instance, the technology platform criteria prompts researchers to "describe, in sufficient detail to allow replication of the work, the software and hardware combinations used in the programme implementation."

The article concludes by proposing that widespread use of mERA will not only improve the quality of reporting, but also indirectly improve the quality of mHealth evidence. So the next time you are documenting your latest mHeath achievement, make Dr. Argawal, WHO, and Taylor Swift proud: just check it off, check it off using mERA!

That Fitb[it] Factor
Leap Day 2016, Issue 7.0

Wearable activity trackers are intriguing and seemingly advantageous behavior change tools for physical activity (PA) that can provide enhanced self-monitoring through personal feedback. But what happens when text message prompts are added alongside this technology?

An activity tracker plus SMS-based PA prompts was hypothesized to show a greater increase in PA levels than the activity tracker alone. Wang et al. (2015) randomized 67 overweight and obese adults (91% women) into two groups: Fitbit One plus SMS text messaging (intervention) and Fitbit One only (comparison). All participants were instructed to wear the Fitbits throughout the 6-week study. For those in the intervention group, a typical reminder prompt was delivered three times a day at participants' preferred times and resembled, "Good morning [name]! This is your 9AM reminder to do at least a 10-minute bout of moderate-to-vigorous intensity physical activity."

Changes in PA were not significantly different between groups at 6 weeks.* However, significant between-group differences were found from baseline to Week 1 with the intervention group increasing PA levels while the comparison group had no significant change for steps (p=0.01), fairly/very active minutes (p<0.01), and total active minutes (p=0.02).

The follow-up questionnaire helped to shed some light on these unanticipated results. The comparison group appeared to have higher engagement levels; a greater percentage of participants in the comparison group reported using their tracker "very often" or "often" to see how many steps they took (90% v. 71%) and how much distance they traveled (70% v. 55%). In regards to the text messages, researchers suggest the frequency and lack of tailoring might be to blame. About half of participants said the three daily texts were "too many." Participants also noted that the texts were "impersonal," "annoying," and "inconvenient," and commonly reported the messages were ignored once recognized as "automated."

If the text messages were more adaptive and tailored, would PA increase more than with a Fitbit alone? Or is the Fitbit enough? As wearables grow increasingly popular, it?s important to continue researching the effects this technology may have on behavioral interventions. If you are interested in reading more about the Fitbit, further studies by Cadmus-Bertram et al. (2015) suggest this tool can be effective and people will adhere to using it.

*The accelerometer Actigraph GT3X+ was used as the primary measure for PA steps and minutes at baseline and week 6, and the Fitbit One was used as the secondary measure of PA steps and minutes at baseline and weeks 1, 2, 3, 4, 5 and 6

Delesha Carpenter & Adam Sage
Asthma App
January 2016

Our Researcher Spotlight this month is Delesha Carpenter, PhD, MSPH, Assistant Professor in the Division of Pharmaceutical Outcomes and Policy and her Research Assistant, PhD candidate Adam Sage!

The researchers teamed up with CHAI Core to collect formative data from adolescents diagnosed with asthma and members of their support network (parents, friends, and health care providers) to determine what ideal components to include in an asthma self-management mobile application. These qualitative interviews provided feedback on two existing asthma apps and informed the development by the research team and CHAI Core of an interactive prototype, now in usability testing. The aim of this app is to prevent, monitor, and manage asthmatic symptoms by incorporating goal setting, encouraging self-observation, judgment and reaction, and engaging caregivers to further encourage self-management.

We had the pleasure of asking Delesha and Adam a few questions about themselves and their work.

What attracted you to using an app-based intervention?
"Over 75% of adolescents have access to a smartphone and this is their medium. It?s how they engage with their social network members and their surroundings. It seemed important to introduce an asthma self-management app into this space where they spend so much of their time."

What impact do you hope your work will have?
"I hope our user-centered approach helps us develop an app that adolescents will use to better manage their asthma and to communicate their asthma successes and setbacks with their providers and caregivers."

And on a lighter note- if you could be any other profession in the world, what would you choose?
"Carpenter: A writer for Saturday Night Live.
Sage: A musician! The PhD was my original backup plan in case I didn't become famous. I didn't become famous."


Smartphone Apps & Physical Activity:
A Few of Our Favorite Things!
December 2015, Issue 6.0

As the semester comes to a close, CHAI Core wanted to publish one more eHealth Digest for you to ponder over hot cocoa by the fire, festive meals with friends and family, or however else you spend your winter break! This month, we've decided to highlight research by Dr. Abby King and Dr. Eric Hekler, the latter of whom presented at Gillings last month on precision behavior change.

What separates King et al. (2013) from other studies is the use of behavioral science-informed user experience design (BSUED). As described by the authors, the "BSUED process draws from behavioral science theory in delineating motivational ?drivers' of behavior change and constructing intervention strategies to reflect those motivational drivers." Using this process, the authors developed three distinct smartphone apps, all of which aimed to increase physical activity; each also included an accelerometer that provided feedback on physical activity and sedentary behavior.

Participants (n=68) were sedentary adults, 45 years and older, who did not have smartphones. The study gave every participant a smartphone and randomly assigned them to one of the three apps (analytic=22, social=23, affective=23). The first app used an "analytic" approach, which included the behavior change techniques of goal-setting, behavioral feedback, problem-solving, and informational advice for behavior change. The second app relied on a "social" approach, entailing social comparison, modeling, social support, and normative feedback. The final app applied an "affective" frame, using positive reinforcement, an avatar for modeling, feedback on progress, and rewards for behavior change achievements.

So what did they find? Across all three groups, users increased weekly minutes of moderate to vigorous physical activity between baseline and 8 weeks posttest (paired t[60]= 4.5, p,0.0001), as well as weekly minutes of brisk walking (paired t[60]= 5.3, p,0.0001). There was no significant difference between the groups for either measure. The study also found that participants experienced a significant decrease in discretionary television sitting time across the intervention (paired t[58]= 2.5, p,0.02). Again, no significant differences across groups were found for this measure, but the decreases in minutes of television sitting time for the analytic and social were larger than the affect app (mean for analytic = 48.9681.7; social = 34.9695.1; affect = 6.5674.3).

We chose to highlight King et al. (2013) as our final eHealth Digest of 2015 because the study compared distinct behavior change techniques across three technology-based interventions. Our wish for 2016 is that more studies in eHealth continue to build on this principle: focus on the active ingredients of behavior change when designing, testing, and evaluating interventions.

Happy Holidays from CHAI Core! We look forward to seeing you in 2016!
Temitope Erinosho
THRIVE for Health
November 2015

Taking center stage this month is the wonderful Dr. Temitope Erinosho, Research Assistant Professor of Nutrition at UNC, and her innovative approach to obesity and cancer risk prevention in children from low-income families. Currently, she is developing a family-based life skills intervention (THRIVE for Health) to help low-income parents develop psychosocial skills to better navigate their daily challenges and promote healthy weight behaviors in their preschool aged children.

Dr. Erinosho has been working with CHAI Core to complete the formative phase of her study, Understanding concerns, needs, and challenges of low-income parents of preschool children aged 3-5 years old. CHAI Core conducted and analyzed the results of 10 in-depth interviews and 4 focus groups with low-income parents in rural and urban areas of North Carolina to assess their needs, concerns, and challenges as parents of young children, as well as ways to engage them in a life skills intervention. Five key stakeholders who are leaders of community organizations that serve low-income families were also interviewed to understand their perspective on how to engage families in a life skills intervention.

The second phase of the study will use these findings to develop and implement the intervention.

We asked Dr. Erinosho a few questions about herself and her work
Avatars and Tailoring and Coaches - Oh My!
October 2015, Issue 5.0

Exactly one year ago today, CHAI Core was hosting our spooktacular eIntervention Workshop, focused on highlighting the "active ingredients" of technology-based interventions. Using an additive design, A Randomized Trial of an Avatar-Hosted Multiple Behavior Change Intervention for Young Adult Smokers (2013), An and colleagues were able to examine their own intervention's active ingredients. The authors explored whether online tailored messages with and without online peer support increased smoking abstinence. Their program consisted of three groups: 1) website with untailored general interest messages (control/Tx1; n=567), 2) website with tailored health messages (Tx2; n=566), 3) website with tailored health messages plus online peer coaching (Tx3, n=565).

The control website included six sessions of non-health related content such as music, finances, and relationships. Both intervention group websites (Tx2 and Tx3) were presented as an online personal health makeover show, hosted by an avatar of participants? choosing. Each of the six weekly sessions focused on a theme (e.g. social support), or one of four behaviors: smoking, alcohol use, experience, and eating breakfast.

Participants in the intervention groups set, tracked, and received tailored feedback on their goals, which included motivational messages tailored to individual outcome expectancies, self-efficacy, social support, and perceived barriers for the targeted behavior in each session. The avatar host also delivered tailored dialogue to users, held signs with tailored text, and made gestures to highlight tailored content.

The Tx3 group had one additional feature: online peer coaches who uploaded personal video messages on the website for users that provided feedback on their health goal from the previous week and encouragement to meet their current goals. Coaches followed up with a brief phone call to participants a couple days after the video was uploaded.

The results show that an avatar-hosted website with tailored messaging was successful in increasing rates of smoking abstinence among young adult smokers, and that peer coaches provided an additional benefit. Smoking abstinence rates were significantly higher for both intervention groups compared to control at 12 weeks (Tx1: 11%, Tx2: 23%, Tx3: 31%, p<.001), and in the group with peer coaches compared to the group without peer coaches (p=.0058). Participants in the intervention groups were also more likely to improve in at least three of the four targeted behaviors compared to control (Tx1=19%, Tx2=39%, Tx3=41%, p<.001).

So what should we as researchers take away from this study? Not only did An et al. (2013) show that peer coaching via video and telephone enhanced the effect of tailored health messages on smoking abstinence, it also demonstrated the importance of study design. By using an additive design, the authors were able to isolate the effects of their intervention's active ingredients: tailored health messages and peer coaching.
Joan Cates
Protect Them
September 2015

CHAI Core is happy to highlight health communication extraordinaire and Senior Lecturer in the School of Media and Journalism, Dr. Joan Cates!

This summer, Dr. Cates and her team launched their intervention website, Protect Them. The website, designed and developed by CHAI Core, has three portals for (1) health care providers, (2) parents, and (3) preteens. Each portal includes interactive education materials like an online training for providers to improve communication about HPV vaccination and a video game for preteens to increase awareness and knowledge about HPV.

Protect Them is part of an NIH-funded R01 study to use and evaluate communication strategies among healthcare providers, parents, and preteens to normalize discussions about HPV prevention and encourage preteens to get the HPV vaccine. These strategies include materials on the website as well as printed posters and brochures, also designed by CHAI, for participating health clinics. With the research study?s adaptive design, the website will be assessed and refined at intervals over the course of the 4-year study period.

We asked Dr. Cates a few questions about herself and her work
What impact do you hope your work will have?
"Our hope is that healthcare providers, parents and preteens will become comfortable talking about and deciding on vaccination against a sexually transmitted infection, HPV, at the ages of 11-12 when the vaccine is most effective."

What other areas (e.g. schools, departments, people) on campus would you hope to collaborate with in the future?
"The interdisciplinary study team already includes media and journalism, medicine, public health, and nursing, in addition to community and family medicine at Duke. Future collaborators could offer insight on the psychology of video games, which we are using to empower preteens to understand issues about sexual health."

If you could have any other profession in the world, what would it be?
"I would be a healthcare provider with the training and expertise to deliver health care to pre-adolescents, a uniquely magical age!"
To Tailor Text or To Tailor Video?
August 2015, Issue 4.0
That is the question in Stanczyk et al.'s 2014 study Comparison of Text and Video Computer-Tailored Interventions for Smoking Cessation: Randomized Control Trial.

To test the effectiveness of web-delivered text and video on smoking cessation at 6 months, Stanczyk et al. randomized smokers into three groups: 1) text-based computer-tailored smoking cessation intervention (n=708), 2) video-based computer-tailored smoking cessation intervention, (n=670), and 3) generic short text advice (n=721). They also examined whether the effect of tailored text or tailored video varied based on participant education (high or low) and readiness to quit (high or low).

Groups 1 and 2 differed only in terms of mode of delivery. All content was the same and based on the I-Change model, which integrates various health behavior theories such as social cognitive theory and the transtheoretical model. Those in the text group read their tailored content on the program's website, while those in the video group viewed their tailored advice in an online video, presented by adults in a TV news format. In both groups, participants who indicated a desire to quit smoking within one month received tailored text or video to increase self-efficacy and action planning. Those who did not indicate a desire to quite within one month received tailored text or video to increase their motivation to quit.

Among all randomly assigned respondents who completed the first session of the intervention, only video was significantly more effective for smoking cessation (based on 7-day smoking abstinence) than the control group (OR 1.45, 95% CI 1.09-1.94, P=.01). In an analysis of those who completed at least two intervention sessions, both tailored video and tailored text were significantly more effective for smoking cessation compared to controls (OR 2.29, CI 1.64-3.20, p<.001 and OR 1.57, 95% CI 1.57, 1.15-2.15, p=.005, respectively). Additionally, tailored video was especially effective for prolonged smoking abstinence among smokers with low readiness to quit, compared to controls (OR 5.13, 95% CI 1.75-14.92, p=.003). No significant differences in quit rates between smokers with low and high educational levels were found.

So, to tailor text or to tailor video? Both can be useful, but as video becomes an increasingly popular way to deliver information online, Stanczyk et al.'s study shows that using tailored video content to get people to quit smoking may come in handy, particularly for those who are not quite ready to take the plunge.
Can text messages help to prevent skin cancer?
April 2015, Issue 3.0
The beginning of spring finals can only mean one thing: summer is almost here! While many of us have waited eagerly to greet the sunshine and beach weather, enjoying the sun responsibly is one of the best ways to prevent skin cancer. Knowing this, researchers in Australia and New Zealand designed a randomized controlled trial?to test the effects of different theory-based text messages among 18-42 year olds. Youl et al. (2015) utilized three arms, focused on three behaviors: sun protection (intervention), skin self-examination (intervention), and physical activity (attention control group). Across all arms, participants received weekly text messages for the first three months, followed by nine months of monthly messages.

What is particularly notable was that the text messages were designed to address constructs of social cognitive theory for each of the three targeted behaviors. One sample text highlighted in the article was designed to build self-efficacy for skin self-examination: "Participant Name, melanoma rarely has symptoms so look out for the AC rule when checking your moles ASYMMETRY (halves that differ) and more than one COLOR." Messages were also personalized to each participant's name, gender, sunburn history, and skin cancer risk factors (e.g. hair and skin color).

At the 12 month follow up, both the sun protection and skin self-examination groups improved their sun protection more than the attention control (sun protection p=0.03; skin self-examination p=0.035). In addition, the proportion of participants in the skin self-examination group who reported any skin self-examination increased by 26.4% (p<0.001) at 12 month follow up, while the proportion of those in the attention control group did not increase. No significant changes were seen at 12 months for whole-body self-examination, sunburn behaviors, or suntanning.

Bottom line: theory-based text messages showed promise for increasing sun protection behaviors. The authors advocated that future research consider using multimedia text messages, as visuals of sunburn or self-examination practices might further increase protective behaviors.

Wizdom Powell
M.A.N.H.O.O.D.S.

This month, CHAI Core is highlighting Wizdom Powell, Assistant Professor of Health Behavior and faculty member of Lineberger's Cancer Prevention and Control Program. Dr. Powell describes her current research as "a 5-year project funded by NIDA to investigate the role of neighborhoods, daily stress (e.g., racial profiling), stress hormones, and substance use among young adult Black males in Durham County. My project, M.A.N.H.O.O.D.S., relies on Ecological Momentary Assessment (EMA) to capture risk behavior and affect measurements in real time."

CHAI Core is thrilled to be working on M.A.N.H.O.O.D.S. with Dr. Powell. Our programmers are designing a responsive website for study participants, with a password-protected researcher interface for downloading participant data. In addition, our graphic designer has created the study?s logo, color palette, and website graphics.

We asked Wizdom Powell a few questions about herself and her work
What attracted you to using technology in your research?
"Most existing studies assess stress-response and environmental exposures retrospectively. As a result, it is more difficult to establish temporal linkages between exposure, response, and health behavioral outcomes. EMA capitalizes on mobile technology and allows us to get a better understanding of how the stress response process unfolds. Understanding this process is critical to identifying and intervening upon putative triggers of problematic substance use among Black males."

What other areas (e.g. schools, departments, people) on campus would you hope to collaborate with in the future?
"I am interested in seeing whether this technology can be applied to examinations of other stress-related health disparities (e.g., cancer and cardiovascular disease). I can envision collaborating with researchers at Lineberger Comprehensive Cancer Center, as well as, those in Cardiology."

If you could have any other profession in the world, what would it be?
"My real desire is to someday be on So You Think You Can Dance. Except, we would have to rename the show So You Think You Can Dance (LOL). But, in all seriousness, I am really drawn to the methods and epistemological traditions of Medical Anthropology. I could definitely see myself working in this profession."


Do People Get More Active When Goals and Behavior Meet Halfway?
February 2015, Issue 2.0
Ever had a nasty cold or an urgent deadline that prevented you from meeting your physical activity goal for the day? If you have, participants in our health behavior interventions probably have too.

Behavior is inherently variable, so what if participants' goals and feedback were adapted to their performance, and changed accordingly? Would this result in more goals being met and greater physical activity when compared to an intervention with a static goal?

This is what Adams et al. (2013) asked in their pilot study, An Adaptive Physical Activity Intervention for Overweight Adults: A Randomized Controlled Trial. The authors compared adaptive (AI) vs. static (SI) technology-based physical activity interventions, which varied with respect to how physical activity behavior was promoted through goal setting and feedback.

Both groups (n=20) tracked their physical activity using a pedometer and received motivational messages (email or text message) at the same time to encourage physical activity. However, AI participants were emailed a different goal (based on participants' previous steps) each day, whereas SI participants' goal (based on the public health recommendation of 10,000 steps/day) remained the same throughout the intervention. When AI participants met their goal they received an encouraging message and one point worth one dollar. SI participants received encouraging feedback and a gift card that increased in value each month when they uploaded their steps to a website.

Results showed that AI participants increased their daily steps more than SI participants and were more likely to meet their goals (58.2% of days) than SI participants (22.5% of days); a significant difference of 1,130 steps/day (Cohen's d=.74). Many AI participants also showed less variability in daily steps and a steadier increase in daily steps throughout the intervention than SI participants.

Despite their small sample size, Adams et al. (2013) begin to investigate the potential of adaptive goal setting and shaping in eHealth physical activity interventions. They explore whether reinforcing behavior by adapting participants' daily goals and feedback according to their performance can slowly advance participants to achieving recommended levels of physical activity. Perhaps, meeting goals and behavior halfway can lead to the initiation and maintenance of behavior change.

CARE: Caring and Reaching for Health
A Worksite Wellness Program for Child Care Staff
UNC Gillings School of Global Public earners's dynamic duo, Dianne Ward, Professor of Nutrition, and Laura Linnan, Professor of Health Behavior, have teamed up on a worksite wellness study called CARE: Caring and Reaching for Health. The 5-year NIH funded study (Co-PIs Ward and Linnan) will enroll ~100 child care centers and over 400 workers to evaluate the efficacy of a 6-month intervention to increase workers' physical activity and other health related behaviors (Healthy Lifestyles) compared to a control arm (Healthy Finances), which will receive a parallel intervention to improve workers' financial health.

CHAI Core is developing and testing a responsive website for the intervention, which will launch in March 2015. CARE participants will complete three 2-month wellness campaigns and will use the website to set behavioral goals and receive tailored weekly feedback. The website also provides seamless access to the behavioral intervention assessment and feedback tool, CHART.

We asked the duo a few questions about themselves and their work?

What impact do you hope your work will have?
"We are very interested in developing and testing an intervention designed especially for child care workers, as they are considered among a group of 'low-wage earners'. In our pilot studies, we observed that these individuals have poor health (low physical activity, high rates of obesity, smoking, high stress), but are expected to be healthy role models for children in their care. We needed an e-health intervention because child care workers have little time to attend group meetings and need support and motivation to engage in health-promoting activities. Laura and I are excited for this work and to be partnering with the experts at the CHAI Core!"

What words of wisdom or suggestions do you have for people who are just venturing into eHealth research?
"Technology of any kind, like eHealth or mHealth, is a another tool in our toolkit of behavior change methods or strategies. We need these tools so that we are adapting our best behavior change messages and activities using the most updated tools that are available. People who work with participants with low literacy or numeracy, low resources, or other limitations will need to be mindful of the ways in which eHealth tools can/should be used. That said, I am very enthusiastic about the use of eHealth technology in many of the community-based interventions we have delivered to address health disparities."

In other news, don't miss out on visiting faculty speakers from UVA! Dr. Lee Ritterband and Dr. Frances Thorndike will be presenting on Moving Internet-delivered interventions from RCT to real-world dissemination: Challenges, lessons learned, and plans for the future.
Where: 2308 McGavran-Greenberg Hall
UNC Gillings School of Global Public Health
When: January 26, 2015 from 10:00am to 11:15am
(Co-Sponsored by Cancer Prevention and Control and the Cancer Control Education Program)




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