[This is a preview of some of the exciting mHealth research being presented at the mHealth Summit on December 3-5, 2012. This abstract and others are candidates for the iMedicalApps-mHealth Summit Research Award]
By: Trevor van Mierlo and Rachel Fournier, iMedicalApps-mHealth Summit Research Award Finalist
Healthcare and digital technology are strange bedfellows. While the creation of a health care intervention is cautiously methodological, electronic innovations are developed rapidly. This seemingly mismatched marriage can result in products or services that do not live up to their full potential, or at the very worst, remain stuck inside the laboratory and are never used.
Indeed, when looking back at the history of digital health, there have been more honest attempts than home runs. So how can the gap between digital healthcare and technology innovation be bridged?
What is increasingly clear is that an interdisciplinary, iterative approach is required. An excellent case study is the development of the Canadian Cancer Society (CCS) Quebec Division’s SMAT (Service de Messageire texte pour Arreter le Tabac or “Short Messages against Tobacco”) program.
Smoking is a particular problem in Quebec with a 23% smoking rate. A particular concerns is that smoking is on the rise among young adults, a population hard to reach through traditional public health efforts. Currently, 31% of people age 20-24 smoke.
In order to reach young adult smokers, CCS Quebec recognized the need for a solution that was readily accessible, population-based and cost-effective. Quebecers are well connected electronically and 59% regularly send or receive text messages. Could mobile technology help?
Rather than reinvent the wheel, CCS Quebec reached out to the Ontario division. The Ontario team had already implemented a successful, award winning text-messaging program available in both English and French. Evolution Health, the company that owns the digital health platform, began to work with CCS Quebec on an adaption process.
At project onset, both Evolution and the CCS Quebec recognized that the existing text messaging platform could not be simply “translated” and substantial effort would be required to modify it for Quebec’s unique population. Due to the fast-moving pace of technology, SMAT’s infrastructure would need to be open-ended and phased-based.
The project began with several qualitative studies. An extensive literature review was conducted, focus groups identified the needs of young adult smokers, and a real-world “mini pilot” helped work out the logistics.
The result of this research was Phase I of SMAT, which ran from August 2010 – March 2011. The first phase included two distinct features: an algorithm-based proactive program (targeted messages delivered at specific intervals tailored to the user’s quit date) and a reactive program (the ability for users to text keywords, and immediately receive personalized advice).
In Phase I, 183 registrants sent 1,196 texts to the service. Of these, 697 messages contained specific words (distraction, stress, etc.) but 398 were conversational. The conversational tone of the keyword service surprised Evolution and CCS Quebec. Why would someone engage in a dialogue with an automated service?
Evolution and CCS Quebec decided to explore and exploit the keyword-conversation phenomenon. This resulted in a third component of the SMAT program launched with Phase II – Text and Chat Integrated (TaChI). TaChI enabled smokers to engage in a live text chat with the Quit Specialists who monitored CCS Quebec’s Telephonic Quitline. Participants were able to receive live one-on-one support anytime, anywhere. Trained Quit Specialists were able to manage several conversations simultaneously and refer to client profiles and past conversations, which automatically populated the administrative computer screens.
The study period for Phase II began in December 2011 and ended in June 2012. 994 smokers (51% male, 40.5% between the ages of 18-24, averaging 17 cigarettes per day) were recruited. 42,613 algorithm-based proactive text messages were distributed, and 65% used the reactive keyword service with the most popular keywords being distraction, envie (”craving”) and stress. Quit Specialists engaged in 1,099 TaChI chats, 48% of those being with men.
Phase II Quantitative Results
A three-month month follow-up text survey was distributed to all participants asking the question: “In the last 7 days, have you smoked a cigarette or cigarillo, even just a puff? 1 = yes 2 = no”. 58% (n=546) of participants responded and 31.1% (n=170) indicated cessation. Intent to treat analysis results in a remarkable 17.1% quit rate.
Phase II Qualitative Results
In order to further understand the motivations and needs of study participants CCS Quebec conducted detailed phone and web surveys with 373 participants (39.5%). 71% (n=265) wanted to continue to receive text messages, 62% (n=231) said SMAT was useful in their quit attempt, and 95% (n=354) said they would recommend the SMAT service to other smokers.
The positive results from the Evolution Health and CCS Quebec partnership were achieved though the use of Agile Development. Agile is a software development methodology based on an iterative and incremental process. Due to the unlikely marriage of healthcare and digital technology, Agile allows programs like SMAT to gradually expand in sophistication, and is rooted on identified needs rather than projected outcomes.
It is important to recognize that Agile inherently has two major risks, especially for traditional project mangers running tight budgets. First, because of its iterative nature, Agile development can’t be managed within a tightly structured project plan (Gantt Charts beware). Second, when implementing Agile, the entire development team will embark upon a journey of discovery. This means that specific expectations and/or budgets can only be defined by milestones. Ultimately, Agile development is best managed with vision and leadership.
Phase III of SMAT is currently awaiting funding from Health Canada. Through the analysis of usage patterns and further implementing Agile, the three components of SMAT will also be made available in a mobile app format.
Trevor van Mierlo is the Founder & CEO of Evolution Health. He is currently completing his doctorate at Henley Business School, University of Reading, focusing on the development of cost models to assess digital health interventions.
Rachel Fournier is Evolution Health’s VP of Business Development. She is a graduate of Stanford University’s Program in Science Technology and Society and is responsible for fostering strategic partnerships with researchers, population health and industry.