How can tools like the Internet support changing complicated and complex behaviours like cigarette smoking? This presentation outlines the way an eHealth promotion strategy can help people quit smoking and prevent others from starting using illustrations from the Smoking Zine program developed by the Youth Voices Research Group at the University of Toronto

1. Public
eHealth:
Promo1ng
personal
and
popula1on
health
through
ICT's
Cameron
D.
Norman
PhD
Assistant
Professor
Dalla
Lana
School
of
Public
Health
University
of
Toronto

2. Public
eHealth
&
Behaviour
Change
If
you
want
to
understand
something,
try
to
change
it
– Kurt
Lewin
(1951)

3. Ten
Great
Public
Health
Achievements
-­‐-­‐
United
States,
1900-­‐1999
• VaccinaNon
• Motor-­‐vehicle
safety
• Safer
workplaces
• Control
of
infecNous
diseases
• Decline
in
deaths
from
coronary
heart
disease
and
stroke
• Safer
and
healthier
foods
• Healthier
mothers
and
babies
• Family
planning
• FluoridaNon
of
drinking
water
• RecogniNon
of
tobacco
use
as
a
health
hazard
Centers
for
Disease
Control
(1999).
Morbidity
&
Mortality
Weekly
Report,
48
(12),
241-­‐243.

4. Cancer
• In
the
United
States,
the
overall
cancer
death
rate
decreased
by
12%
between
1991
and
2003.
• A
significant
proporNon
of
this
decline
(40%)
is
not
due
to
breakthroughs
in
molecular
medicine,
gene
therapy,
or
other
highly
technical
treatments,
but
to
a
behavioral
intervenNon:
smoking
cessa1on
• Thun,
M.
J.
et
al.(2006).
Tobacco
Control,
15,
345-­‐347.

5. Obesity
Overweight
(BMI
=
25-­‐29.9)
associated
with
a
loss
of
>
3
years;
BMI
>
30
associated
with
loss
of
7
years

6. Cardiac
RehabilitaNon
• “Although
the
efficacy
of
stand-­‐alone
psychosocial
intervenNons
remains
unclear,
both
exercise
and
mulNfactorial
cardiac
rehabilitaNon
with
psychosocial
intervenNons
have
dem-­‐
onstrated
a
reducNon
in
cardiac
events.”
Rozanski,
Blumenthal,
Davidson,
Saab
&
Kubansky
(2005).
Journal
of
the
American
College
of
Cardiology,
45
(5),
637-­‐651.

7. HIV
/
AIDS
• “Interpersonal,
structured
adherence
support
was
associated
with
improved
long-­‐
term
medicaNon
adherence
and
virologic
and
immunologic
HIV
outcomes”
Mannheimer,
S.B.
et
al.
(2006).
JAIDS,
43,
S41-­‐S47

8. Chronic
Disease
Management
• “Chronic
disease
self-­‐
management
programs
probably
have
a
beneficial
effect
on
some
(but
not
all)
physiologic
outcomes
that
have
been
assessed
in
controlled
trials”
Chodosh,
J.
et
al.
(2005).
Annals
of
Internal
Medicine,
143,
427-­‐438.

9. Tobacco
Use
• Tobacco
was
responsible
for
more
than
100
million
deaths
worldwide
in
the
20th
century
and
is
forecast
to
kill
at
least
one
billion
more
in
the
century
to
come
[1]
– 80%
of
such
deaths
are
projected
to
occur
in
the
developing
world
[2]
• Half
of
the
current
smokers
today
(about
650
million
people)
will
die
as
a
result
of
tobacco
use,
with
tobacco
use
accounNng
for
the
premature
death
of
4.9
million
people
worldwide
[3].
1. World
Health
OrganizaNon:
WHO
Report
on
the
global
tobacco
epidemic,
2008:
The
MPOWER
Package.
Geneva,
CH:
World
Health
OrganizaNon;
2008.
2. Sabrie
E,
Glantz
SA:
The
tobacco
industry
in
developing
countries.
BriJsh
Medical
Journal
2006,
332:313-­‐314.
3. Shafey
O,
Dolwick
S,
Guindon
GE
(Eds.):
Tobacco
Control
Country
Profiles
2003.
Atlanta,
GA:
American
Cancer
Society;
2003.

10. Knowledge
TranslaNon
• Volume
of
informaNon
and
knowledge
is
currently
greater
than
ever
before,
yet
relaNvely
linle
is
being
translated
into
pracNce
across
the
spectrum
of
discovery
and
pracNce
• Hyan,
Best
&
Norman
(2008).
Knowledge
integraNon:
Conceptualizing
communicaNons
in
cancer
control
systems.
PaJent
EducaJon
&
Counseling,
71,
319-­‐327.
• EsNmates
that
it
is
taking
up
to
17
years
to
translate
innovaNons
into
everyday
clinical
pracNce
• Balas
EA,
Boren
SA.
(2000).
Managing
clinical
knowledge
for
health
care
improvement.
In:
Yearbook
of
medical
informaNcs.
p.
65–70.

11. Looking
Forward
to
Change
• The
only
people
who
truly
welcome
change
are
wet
babies

12. HOW
WE
CHANGE:
THEORIES
&
MODELS
OF
CHANGE

13. Some
Wisdom
from
Kurt
Lewin
(1890-­‐1947)
“There
is
nothing
so
pracNcal
as
a
good
theory”

14. Likelihood
of
AcNon
Scale
A
person
more
likely
to
act
if…
• View
themselves
as
personally
suscepNble
• Sees
the
(potenNal)
problem
as
serious
• Believes
change
will
reduce
risk
• Assesses
pros
as
outweighing
cons
of
change
• Believes
that
others
endorse
change
• Is
moNvated
to
comply
with
others’
wishes

15. Likelihood
of
AcNon
Scale
A
person
more
likely
to
act
if…
• Environment
is
supporNve
of
acNon
• Person
has
necessary
knowledge
and
skills
• Confident
that
they
can
carry
out
acNon
• Intrinsically
moNvated
to
change
Skinner,
H.A.
Promo1ng
Health
Through
Organiza1onal
Change.
San
Francisco:
Benjamin
Cummings
Publishers,
2002.;
Norman,
C.D.,
Maley,
O.,
Li,
X.,
&
Skinner,
H.A.
Using
the
Internet
to
iniNate
and
assist
smoking
prevenNon
in
schools:
A
randomized
controlled
trial.
Health
Psychology,
2008,
27,
799-­‐810.

16. Health
Belief
Model

17. Theory
of
Reasoned
AcNon/Planned
Behaviour

18. Social
CogniNve
Theory
• Emphasizes
the
reciprocal
role
of
environment
(physical,
social,
cultural)
and
behaviour
– Social
learning
• EvaluaNng
expectaNons
and
capabiliNes
-­‐-­‐
focus
on
skill
development
and
self-­‐efficacy
(confidence)

19. Self-­‐DeterminaNon
Theory
• People
are
more
likely
to
change
if
they
genuinely
want
to
change
– “want
to
change”
vs.
“have
to
change”
• RelaNng
goals
of
change
to
personal
values,
preferences
&
aspiraNons
• Emphasis
on
supporNng
an
individual’s
autonomy
(freedom)
to
make
decisions
about
their
life

20. TranstheoreNcal
Model
&
Stages
of
Change
• Precontempla1on
– No
desire
to
change
within
6
months
• Contempla1on
– Considering
change
within
6
months
• Prepara1on
– Considering
change
within
30
days
• Ac1on
– AcNvely
engaged
in
change
behaviours
• Maintenance
– Maintaining
changed
state

21. Why
InformaNon
Technology?
• Allows
for
tailoring
and
customized
programming
for
diverse
audiences
• 24/7
&
“always
on”
• Easily
modifiable
• AnracNve
and
interacNve
• Scalable
&
portable
• Permits
a
conversaNon
on
health
behaviour
at
a
populaNon
level
(Web
2.0)

22. WEB-­‐ASSISTED
TOBACCO
INTERVENTIONS
A
Case
Study

23. First
Order
Web-­‐Assisted
Tobacco
IntervenNon
(WATI)

24. Second
Order
WATI

25. Third
Order
WATI
• Website
• Dowloadable
curriculum
guide
• Integrated
tools
for
student
collaboraNon
&
dialogue
within
and
between
classes

26. Suppor1ng
Smoking
Preven1on
&
Cessa1on
with
Youth

29. 1.
Makin’
Cents
 ParNcipants
input
the
number
of
cigarene
packs
they
smoke
in
one
month;
market
value
is
calculated
into
annual
total
 ParNcipants
spend
this
amount
in
virtual
shopping
mall
 Helps
users
recognize
consumer
opNons,
the
value
of
a
dollar
relaNve
to
purchasing
power
 Promotes
understanding
of
the
economic
impact
of
decision
to
smoke
and
economic
challenges
of
those
who
are
nicoNne
dependent

31. Makin’
Cents:
Process/Concept
• This
stage
is
designed
to
raise
consciousness
of
the
cost
of
cigarene
purchases
relaNve
to
other
consumer
goods

32. 2.
It’s
Your
Life
 ParNcipants
complete
short
assessment
about
their
smoking
behaviour
(frequency,
amount)
 Program
tailored
to
whether
person
is
a
smoker,
non-­‐
smoker,
experimental/social
smoker
 ParNcipants
become
aware
of
why
they
smoke,
smoking
panerns,
smoking
triggers
and
urges

34. It’s
Your
Life:
Process/Concept
• This
stage
is
both
an
assessment
of
smoking
status
and
provides
personalized
feedback
on
the
level
of
relaNve
risk
based
on
the
results
of
the
assessment

35. 3.
To
Change
or
Not
to
Change
• Allows
parNcipant
to
assess
readiness
to
change
(quit
or
reduce
smoking)
• ParNcipants
assess
importance
of
change
• ParNcipants
assess
their
confidence
in
being
able
to
change
• Quiz
is
tailored
to
user’s
smoking
status
idenNfied
in
previous
stage

37. To
Change
or
Not
to
Change:
Process/
Concept
 This
component
assesses:
 Readiness
to
change
(stage
of
change)
 Confidence
(self-­‐efficacy)
 Importance
for
change
(self-­‐determina7on)

38. 4.
It’s
Your
Decision
• Creates
a
decision
balance
displaying
pros
and
cons
of
smoking/being
smoke
free
• ParNcipants
can
clearly
see
their
thoughts
about
smoking
and
reasons
to
quit,
cut
down,
or
remain
the
same
• May
help
the
parNcipant
to
advance
their
readiness
to
change

40. It’s
Your
Decision:
Process/Concept
 This
stage
examines
the
pros
and
cons
of:
 Being
a
non-­‐smoker
versus
 Being
a
smoker
 Decision
Balance

41. 5.
What
Now?
• This
secNon
brings
together
the
results
from
the
previous
stages
• If
idenNfied
as
a
smoker,
the
Smoking
Zine
will
guide
them
in
creaNng
a
personalized
quit
programme
• If
not
ready
to
quit,
then
parNcipant
is
guided
to
the
Personal
Forecast
quiz
secNon

43. What
Now?
Process/Change
 IdenNficaNon
of
readiness
 Helps
to
develop
quit
plan
 Date
 Method
of
cessaNon
 Support
mechanisms
 Relapse
prevenNon
strategies
 Outcome
rewards
 Produces
a
cogniNve
behaviour
change
plan
and
a
cue
to
acJon

44. Arabic
AdaptaNon

45. Hebrew
AdaptaNon

46. Chinese
AdaptaNon

47. IntegraNng
the
Smoking
Zine
into
the
Classroom

48. Virtual
Classroom
on
Tobacco
Control
 Developed
in
partnership
with
TakingITGlobal,
youth-­‐driven
acNvism
and
educaNon
network
 Goals:
 To
posiNvely
influence
behavioural
intenNons
and
resistance
to
smoking
iniNaNon
among
young
people
 To
inform
youth
about
global
tobacco
issues
and
understand
the
impact
of
their
choices
 To
increase
the
number
of
youth
involved
in
tobacco
control

49. Virtual
Classroom
on
Tobacco
Control
 Features
four
interrelated
units
 Facts
and
Figures
examines
the
health
effects
of
tobacco,
both
first-­‐hand
and
second-­‐hand
 The
Smoking
Zine
allows
students
to
explore
their
smoking
behaviours
and
intenNons
 Denormaliza1on
invesNgates
how
the
tobacco
industry
targets
youth
 Global
and
Social
Jus1ce
focuses
on
the
tobacco
industry’s
exploitaNve
pracNces
in
the
developing
world

51. MAKING
EHEALTH
ACCESSIBLE:
THE
ROLE
OF
LITERACY

52. Approaches
to
EvaluaNng
InformaNon
Third
Party
Verifica1on
Cri1cal
Appraisal
• “Seals
of
approval”
• “Informed
Consumer”
• Expert-­‐reviewed
content
• Individuals
are
approved
for
use
responsible
for
learning
how
to
evaluate
• Centralized,
informaNon
straighyorward
process
• EvoluNonary,
responsive
• Slow,
resource-­‐intensive
and
can
be
tailored
to
and
subject
to
fraud
individual
needs
• Complex
skill
set

53. Literacy
as
a
Tool
for
CommunicaNon
• Literacy
refers
to
a
person’s
ability
to
communicate
at
a
level
that
allows
them
to
understand
the
world
around
them
[interpret
the
signals
coming
in]
and
to
contribute
to
that
world
through
personal
expression
that
is
meaningful
to
others
[sending
useful
signals
out]

54. Literacy
is
about
Content
• For
online
content
to
adequately
inform
it
must
be:
– Accessible
– Complete
– Accurate
– Timely
– Evidence-­‐based
&
verifiable
– Balanced
• Many
media
messages
to
consumers
address
none
of
these
points!
See:
Eysenbach,
G.
(2002).
Infodemiology:
The
epidemiology
of
(mis)informaNon.
American
Journal
of
Medicine,
113
(0),
763-­‐765

55. The
Role
of
Networks
in
Decision
Making
"In
a
world
where
individuals
make
decisions
based
not
only
on
their
own
judgments
but
also
on
the
judgments
of
others,
quality
is
not
enough”
WaXs,
D
(2003).
Six
Degrees:
The
science
of
a
connected
age.
New
York:
Norton,
p.250

56. Bearman,
P.S.,
Moody,
J.
&
Stovel,
K.
(2004).
Chains
of
affecNon:
The
structure
of
adolescent
romanNc
and
sexual
networks.
American
Journal
of
Sociology,
110
(1).

57. Viewing
Literacy
as
A
ConNnuum
• Literacy
levels
are
not
dichotomous
(literate
/
illiterate)
• Literacy
levels
ebb
and
flow
over
Nme
as
new
knowledge
is
formed,
new
experiences
take
place,
and
new
technologies
and
tools
are
introduced
• What
passes
as
high
literacy
today
may
not
be
the
same
tomorrow
because
the
content
and
context
in
which
those
skills
are
applied
changes

58. eHealth
Literacy
• “the ability to seek, find, understand,
and appraise health information from
electronic sources and apply the
knowledge gained to addressing or
solving a health problem.”
• Norman & Skinner (2006). Journal of
Medical Internet Research 8(2) e9.

59. Traditional
Literacy
In Lite
fo r
rm ac
at y
io
n
Li t al t h
cy
e ra
He
eHealth
Literacy
Co terac
Lite dia
y
Li
rac
mp y
Me
ute
r
Science
Literacy
Norman
&
Skinner
(2006a).
JMIR,
8
(2)
e9

60. General
Skills
Traditional
Literacy
C ite
om r a
L
pu c y
te
r
Lit alth
cy
e ra
He
eHealth
Literacy
Inf itera
Lit dia
cy
or
L
ma cy
era
Me
tio
n
Science
Literacy

Traditional
(Basic)
Literacy
&
Numeracy

Media
Literacy

Information
Literacy

61. Specific
Skills
Traditional
Literacy
C ite
om r
L
pu cy
te
a
r
Lit alth
cy
e ra
He
eHealth
Literacy
Inf itera
Lite dia
y
orm cy
rac
L
Me
ati
on
Science

Computer
Literacy
Literacy

Science
Literacy

Health
Literacy

62. Resources
 Youth
Voices
Research
 hnp://www.youthvoices.ca
 The
Smoking
Zine
 hnp://www.smokingzine.org
 Taking
IT
Global
 hnp://www.takingitglobal.org
Cameron
Norman
cameron.norman@utoronto.ca

63. Contact
InformaNon
Cameron
D.
Norman
PhD
Dalla
Lana
School
of
Public
Health
5th
Floor
Office
586,
Health
Sciences
Building
416.978.1242
cameron.norman@utoronto.ca