# Presentation: 409445

## Momentary Health Interventions: Concepts and Future Directions

**Momentary Health Interventions: Concepts and Future Directions**

**Paul M. Cinciripini, Ph.D.**
**Brian Carter, Ph.D.**
**David Wetter, Ph.D**
**Department of Behavioral Science**

**Notes:**
Acknowledge grant and collaborators

## Areas of Intervention 

**Improvement of  health and well being **
**Life style changes **
**Smoking, exercise, alcohol, diet, stress**
**Health outcome may be distal to intervention (risk reduction) and/or immediate (reduced blood pressure, cholesterol)**
**Quality of life**
**Depression, fatigue, pain management, sleep**
**Enhancement of current well being**
**May mediate success of another health intervention, with immediate and/or distal health outcome (e.g., Smoking cessation)**

**Notes:**
What are we trying to accomplish? Two types of intervention: those with direct health outcomes and those that might meditate a success of another intervention. QOL is an objective in and of itself but may also facilitate an individual making other life style changes.

## Challenges to Health Interventions

**Implementing an effective intervention**
**Compliance**
**Maintaining interest and motivation**
**Dynamic problem solving**
**Counselor or healthcare provider-not typically “in the moment” with the patient**
**Hand held interventions can contribute to all**
**Include both self-report and objective assessments (physiological) done in real time**
**Identify antecedents & consequences more easily and apply corrective measures (e.g., intervene as early in the chain as possible)**

**Notes:**
We have many interventions which if followed can be quite effective. But the challenge is to get people to “just do it”. Compliance always an issue. Behavior change is not easy and motivation waxes and wanes-how do we keep them interested? But importantly, how do we solve problems dynamically? In the typical therapeutic setting even if we saw some one every day-which is not really practical, we aren’t “in the moment” with the participant and that may be where the action really is. Old behavioral adage to intervene as early in the chain as possible

## Why Use Handheld Computers ?

**Small, lightweight, easy to carry & use-**_**always there**_
**Multiple functions (e.g., appointment book, games) make them easy to integrate into daily living**
**Deliver significant amounts of information **_**on demand**_** and simplify user access**
**Prompt user for interaction with alarms **
**Provide program initiated health information**
**Use complex, interactive programming to implement planned health interventions in real time**
**Can be integrated with other electronic forms of assessment or physiological monitoring devices **

## Conceptualizing Momentary Health Interventions  

**Three levels of momentary intervention**
**Differ in primary approach to behavior change**
**Education**
**Monitoring & feedback**
**Delivery of specific intervention strategies **
**Different strategies to increase a behavior (physical activity) vs. those to decrease one (smoking) **
**Differ in user vs. device initiated assessments/prompts**
**Differ in complexity of algorithms for delivering intervention content**

**Notes:**
Arbitrary scheme and may be overlap-just a start at conceptualization 

## Levels of User and Program Assessment and Intervention 

## Level 1-Education Approach

**Convey knowledge about an at risk behavior, etiology, relationship with other factors **
**General recommendations for improving health and/or reducing risk**
**Not typically individualized**
**Immediate access to therapeutic content**

## Level 1 Example Content

**Print material using simple or complex search strategies**
**E-books, treatment manuals, self-help books, selected readings for motivation (i.e, quotes), healthy menus,nutrition information, calories burned, etc.**
**Large volume of information more easily accessed**
**ability to bookmark, set favorites**

**Notes:**
The electronic advantage is access to large volume of information with sophisticated search strategies

## Levels of User and Program Assessment and Intervention 

## Level 2-Monitoring & Feedback Approach

**Increase awareness of patterns and circumstances surrounding a target behavior **
**Assess progress of an ongoing intervention, achievement of goals**
**motivate and reinforce behavior change through feedback**

## Level 2 Treatment Approach

**User initiated assessment **
**frequency, intensity, duration and possibly context of the target behavior**
**Device provides simple feedback**
**Computer compiles & formats information **
**Categories, reports, tables, graphic images**
**Document progress associated with different intervention techniques**
**Present over daily, cumulative or unique time periods**
**Present contextual information**
**Simplifies complex information **
**Calories, fats and other nutrient information, duration of exercise, anxiety level in certain situations**

**Notes:**
Consistent with behavioral approaches to “self-regulation” 
Telling patients “how often”, “how much”, “when” and under “what circumstances”, a target behavior occurs may increase awareness, motivate and reinforce behavior change
Document progress associated with different intervention techniques
Facilitate stimulus control strategies  by providing contextual information about the target behavior and the environment (i.e. how many cigarettes are smoked in specific situations, or how often one has increased anxiety in connection with specific cognitions.

Notable advantage over paper diaries

## “Pocket Diet Tracker”

## Vivonic Fitness Planner

- Check off your plannedexercises for the day as yougo, or simply add new ones.

- 

- Record your daily nutritionalintake using the extensivefoods database.

- 

- Easy-to-view nutritional breakoutsdetail what you've consumed.

## “Handy Health Care”

## “Universal Tracker System”

## PACE Exercise Adherence Intervention for Breast Cancer Patients with Fatigue

**Handheld intervention used as an adjunct to telephone counseling to increase adherence to walking program**
**Participants can set goals, schedule walks, receive feedback on goals**
**Application prompts walks, records data on length and intensity of walk; participant enters data on fatigue, pain, and mood before and after walk**

- Basen-Engquist, K., Feasibility of a Physical Activity Intervention to Reduce Fatigue in Ovarian Cancer Survivors (P50 CA83639)

## Levels of User and Program Assessment and Intervention 

## Level 3 Education, Monitoring, Feedback & Intervention Delivery Approach

**Computer algorithms used to make treatment recommendations (e.g., “digital therapist”)**
**May follow a treatment plan (e.g progressive exercise program)**
**Recommendations specific to the individual &/or circumstance**
**The program “coaches” with prompts, tips, and in the moment intervention strategies**
**(e.g., “You haven’t been keeping to your exercise program in the  past few days, let’s trouble shoot the problem....”)**
**Monitor possible high risk events that may reduce compliance**
**Poor sleep, fatigue, stress, TV viewing**

**Notes:**
What is a computer algorithm. Can vary in complexity. Current Programs have some but not all of these elements and vary in complexity

Computer guides the individual through a specific treatment plan (e.g., smoking reduction)
Adjusts feedback messages according to level of compliance
Anticipates important events or milestones (e.g., target quit date)
The program “coaches” with prompts, tips, and coping strategies 
Computer provides suggestions for corrective action when needed (e.g., relapse)

## Health Information Tracking System: 

**No level 3 programs identified in search**
**HITS being used in schools combined with health education counseling**
**Developed by researchers at the National Institute of Education, Singapore ****(Wang, Chia, et. Al, 2002)**
**Sold by ADE, a spin-off company**
**Program allows for age and gender specific recommendations, for body weight, food intake & energy expenditure.**
**Takes into account current health status**
**Monitors mood state over time**
**Would need further development to be a level 3 application**

## Meal/food planner: plan  meals based on the nutrients Nutrient/caloric status: information nutrients & calories consumed in comparison to recommended daily amounts.

**Meal/food planner**: plan  meals based on the nutrients **Nutrient/caloric status**: information nutrients & calories consumed in comparison to recommended daily amounts.
**Activity/exercise planner**: plan physical activity based on the caloric expenditure of the activity or exercise.
**Weight loss/gain calculator**: computes time required for safe weight loss/gain

## Project Cassi

## Level 3 Examples & Future Applications

**“****Smart” devices **
**Digital camera to estimate meal portion sizes**
**Integrate with physiological monitoring**
**“****Wearable” computers provide intensity of exercise information and context specific data **
**Heart rate, pressure sensors, steps**
**Use voice to deliver information and enhance motivational messages**
**Alarms, positive feedback, reminders, visualizations and supportive messages**
**Record in therapist or patient’s own voice**
**Live video contact**
**Hand held camera**

**Notes:**
Smart devices that learn from user input. “Neural network” or AI type applications. Can provide even more specific treatment advice based on current and past assessment data and user preferences
Computer repertoire of treatment recommendations (e.g., coping skills)
User self-tailored statements

## Practical Challenges

**Devices are sophisticated and new. Requires excellent and experienced  programmer**
**They know code you know behavior. Invest in up-front planning, specifications and anticipate future needs**
**Balance flexibility of function with costs and time**
**More features means more can go wrong. **
**Locking participants out of built in device functions is more challenging with sophisticated units**
**Develop reliable testing protocols and test under many conditions**
**Software development for new features (i.e., cell phone integration) or add on devices (camera) is presently limited**

## Links

**Diet Tracker http://www.handango.com**
**Handy Health Care http://www.handango.com**
**Universal Tracker http://www.utracksys.com**
**Vivonic Fitness Planner http://www.vivonic.com**