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There is a growing recognition of the importance of lifestyle behavior change for health promotion and disease prevention, as well as the concomitant influence of patient–physician communication on effective behavior change. Mobile technology is increasingly being recognized as an important and efficient tool to collect patients’ health behavior data and facilitate patient–physician communication.
The aim of this study was to assess the feasibility of an iPod touch-based health behavior assessment (HBA) tool in enhancing patient–physician collaborative goal-setting for health promotion in primary care.
A total of 109 patients from three primary care clinics in central Texas completed a brief HBA, which was programmed on an iPod touch device. An instant feedback report was generated for the patient and their physician simultaneously to facilitate collaborative goal-setting. Within approximately 7 days of the HBA, the patients were phoned for a follow-up survey for their feedback on the iPod touch–based HBA and resultant patient–physician communication.
Patients were able to complete an HBA on the iPod touch with ease. Among those who completed the follow-up survey (n=83), 30% (25/83) reported that their physicians discussed the HBA report with them, while 29% (24/83) established behavior change goals with them. More than 90% (75/83) of the patients reported positive experiences with the iPod touch–based HBA.
It is feasible to use mobile tools for HBA in the primary care setting. The HBA also facilitated patient–physician communication on behavior change. However, more research is needed on the effectiveness of large scale dissemination of mobile-based HBA technology on health communication and behavior change for preventing or managing lifestyle-related chronic conditions, such as obesity, diabetes, cancer, or heart diseases.
Unhealthy behaviors such as physical inactivity, smoking, and unhealthy diets are major contributors to costly chronic health conditions, for instance cancer and other chronic diseases, including diabetes, obesity, and heart diseases [
Planned health behavior changes are widely recognized as among the most cost-effective interventions for achieving positive health outcomes for prevention and control of chronic diseases [
While there are clearly health outcomes and care delivery benefits associated with systematically collecting health behavior data and initiating patient-physician conversation about behavior change, there are practical challenges. Many clinics are understaffed and underresourced and struggle to meet all of the current competing demands they face [
Interactive behavior change technology (IBCT) has been recognized as a potential resource for improving the effectiveness of health behavior change in health care systems [
Therefore, the goal of the current study was to assess the feasibility, including usability, acceptability, uptake, and perceived value of using the iPod touch in a health behavior assessment (HBA) in the primary care setting. The reason for choosing the iPod touch was its perceived ease of use, relatively low cost, and adaptability with other mobile devices.
We conducted a cross-sectional study with data collection at two time periods of approximately 7-days apart in 2011. The study setting was three conveniently selected primary care clinics of a large university-affiliated, multisite specialty health care system in central Texas. The participants were adult patients who had scheduled a routine office visit with their primary care provider in the participating clinics. The criteria for participation included: (1) being at least 18- years old, (2) the ability to speak and read English, (3) having scheduled an appointment for nonurgent care, and (4) arriving at the clinics at least 15 minutes before their scheduled appointments. The study protocol was reviewed and approved by the Scott & White Healthcare institutional review board with no written consent required from subjects.
Our information technology specialists programmed the iPod touch device to collect participants’ demographic, general health status, and anthropometric data, along with data on health beliefs and involvement with their health, as well as HBA drawn from North Carolina Health Partners “Starting the Conversation” Series [
Sample screen shots of iPod Touch HBA.
Sample generated HBA summary reports.
We collected the following information using the iPod touch device: (1) demographic data, including gender, age group, and race/ethnicity, (2) health status data, including general health, physical health, and mental health, (3) anthropometric data, including height and weight, (4) data on participant activation or involvement with their own health using 12 questions about health beliefs, such as taking responsibility for their health condition and understanding the nature and causes of their health conditions, and (5) data on health behaviors using seven questions about dietary behaviors, six questions about physical activity behaviors, and six questions about smoking behaviors.
Given our interest in a pragmatic set of measures to assess lifestyle behaviors in primary care settings, we chose to employ questions from the Starting the Conversation Toolkit developed by researchers at the University of North Carolina as a brief tool for rapid lifestyle assessment, behavioral counseling, and monitoring behavioral change in a variety of health care settings [
The follow-up phone survey comprised 15 items, including 12 questions on their experiences with using the iPod touch on a 5-point Likert scale from strongly agree to strongly disagree, two “Yes-No” questions on their communication with their physicians, and one open-ended question on any other information or feedback they liked to share with us.
Health behavior assessment questions on the iPod touch.
Patient involvement | Eating behavior | Physical activity | Tobacco use |
1. I am responsible for managing my health condition | 1. Eat food that is fried or high in fat | 1. Go out or a brisk walk per week | 1. To perk me up or give me a lift |
2. Taking active role in my health is most important factor | 2. Servings of fruits or vegetables eaten | 2. Hours spent watching TV or on the computer | 2. When I am with friends or drinking socially |
3. I can take actions to prevent problems with my health | 3. Regular sodas and glasses of sweet tea or juice drunk | 3. Walk, ride a bike or bus vs. driving | 3. Helps me feel comfortable and relaxed |
4. I know what my prescribed medications do | 4. Eat beans (eg, black beans) chicken or fish | 4. Do gardening or intense housework | 4. When I’m anxious, worried, depressed or angry |
5. I can tell when I need medical care | 5. Eat regular (not low-fat) chips or crackers | 5. Participate in sports or exercise program per week | 5. Within half an hour after I wake up |
6. I can tell my provider concerns I have when not asked | 6. Eat desserts or other sweets | 6. Think of ways to move more vs. less | 6. Without really thinking about it |
7. I can follow through on medical Rx I need to do at home | 7. Margarine, butter, or meat fat use on bread |
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8. I understand nature and causes of my health conditions |
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9. I know the medical treatment options available |
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10. I know how to prevent further problems |
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11. I can figure solutions when new problems arise |
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12. I can maintain healthy lifestyle changes like diet and exercise |
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Data management, including data entry and coding, recoding, as well as analysis were done using SPSS. As a pilot study focused on feasibility and initial efficacy assessment, data analyses were limited to descriptive statistics. We first computed survey response and follow-up rates. We then performed descriptive statistics on the health behavior measures, participants’ interactions with their physicians, and their experiences and perceptions of the iPod touch device as an assessment tool, including means and standard deviations. Exemplary quotes from participant feedback are included as illustrations.
Of 293 subjects who were approached by the research staff for participation, 27.6% (81/293) were ineligible, 15.4% (45/293) were not interested, and 57.0% (167/293) expressed interest. Of these, 16.2% (27/293) refused verbal consent, while 83.8% (140/293) consented to participate. However, 31 subjects could not complete the HBA survey before being called to the exam room for their physician appointment resulting in a total of 109 subjects who completed the HBA. The mean time needed for participant instruction on navigating the iPod touch device was 43.5 (SD 29.9) seconds.
Of the 109 participants who completed the HBA survey in the clinic, 76.1% (83/109) were successfully contacted for the follow-up phone survey within 7 days of their clinic visit after up to four phone call attempts.
As shown in
Participants generally reported a high involvement with their own health, with the vast majority of them reporting strong agreement or agreement with being responsible for managing their health conditions (107/109, 98.2%), taking an active role in their own health (109/109, 100%), being confident in taking actions that will help prevent or minimize some symptoms (106/109, 97.2%), and having the confidence to tell their health care provider concerns they have when not asked (105/109, 96.3%). While they reported less tobacco use (mean score 1.9, SD 3.7), they reported average behaviors regarding healthy eating (mean score 6.1, SD 2.4) and physical activity (mean score 7.6, SD 2.7).
Demographics and general health information of participants (n=109).
Characteristic | n (%) | |
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18-30 | 31 (28.4) |
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31-45 | 33 (30.3) |
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46-64 | 34 (31.2) |
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64+ | 11 (10.1) |
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Male | 34 (31.2) |
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Female | 75 (68.8) |
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African American | 17 (15.6) |
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Asian/Pacific Islander | 4 (3.7) |
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Hispanic/Latino | 18 (16.5) |
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White | 69 (63.3) |
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Other | 1 (0.9) |
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Underweight | 1 (0.9) |
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Normal weight | 24 (22.0) |
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Overweight | 26 (23.9) |
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Obese | 58 (53.2) |
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Excellent | 6 (5.5) |
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Very good | 21 (19.3) |
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Good | 56 (51.4) |
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Fair | 22 (20.2) |
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Poor | 4 (3.7) |
Health status and health behavior assessment of participants (n=109).
Characteristic | Mean (SD) |
Body mass index | 30.9 (6.6) |
Number of days physical health not good in the past 1 month | 6.3 (8.5) |
Number of days mental health not good in the past 1 month | 7.1 (8.8) |
Number of days unable to do ADLsa | 5.4 (8.6) |
Dietary behavior (0-14) | 6.1 (2.4) |
Physical activity (0-12) | 7.6 (2.7) |
Tobacco use (0-12) | 1.9 (3.7) |
aActivities of daily living
Of the 83 participants who successfully completed the follow-up phone survey, 30% (25/83) reported that their physicians discussed the HBA report with them, while 29% (24/83) established behavior goals related to the HBA report with them.
Awesome, very easy to read, very quick. Good for people who haven’t used iPod.
Another participant suggested,
I wish they would do everything like that (iPod) because I think it is a lot better than reading and writing. I was able to see the text better on the iPod than on paper.
Participants’ responses to the follow-up phone survey (n=83)a.
Characteristic | Strongly agree/Agree (%) | Not sure (%) | Strongly disagree/Disagree (%) |
1. iPod touch device was easy to use | 99 | 1 | - |
2. Words on the iPod touch easy to see | 100 | - | - |
3. Questions were easy to understand | 98 | 1 | 1 |
4. Felt rushed to answer the questions | 10 | 1 | 89 |
5. Report was easy to understand | 94 | 4 | 2 |
6. Will use information to better health | 94 | 5 | 1 |
7. Report makes me want to change | 83 | 11 | 6 |
8. Will like to use device more in clinic | 94 | 2 | 4 |
9. Report helped to talk to doctor | 76 | 9 | 15 |
10. iPod touch negatively affected interaction | 4 | 1 | 95 |
11. iPod touch positively contributed to health | 86 | 7 | 7 |
12. Overall experience with iPod positive | 99 | 1 | - |
a
This pilot study assessed the feasibility of using a common mobile tool for HBA and counseling in a primary care setting. Our data suggest that the iPod touch device may be a feasible device to assess lifestyle behaviors. Nearly all participants reported a positive experience overall, finding the words on the iPod touch screen easy to see. The vast majority of patients found the device very easy to use and the questions easy to understand. In addition to its user-friendliness from a participant perspective, as seen in other studies, the iPod touch also offers ease from researchers’ perspective. For example, it minimizes survey response error, it is reliable in eliciting sensitive data in a private and confidential manner, and it is advantageous in terms of easy data storage and transportation.
In addition to being an easy-to-use HBA tool, we also found that the iPod touch was a promising device to assist behavior change in a diverse population of varying age groups, genders, ethnicities, and health status. The generated HBA reports triggered patient-physician collaborative goal-setting for one-third of our patients. This finding corroborates a call to use mobile health technologies or IBCT to promote health behavior change in the primary care setting [
Several limitations of the study should be noted. First, we had a small and convenient sample recruited from one health care system from one geographical region. Thus, the findings may not be generalizable to other patients in primary care setting. In addition, we did not include children or non-English speaking patients. While promising, further research with a larger sample is needed for better understanding on how different populations may use mobile technology for both HBA and health communication messaging. Second, our follow-up rate was 76.1% (83/109) and we had a short follow-up time (7 days) in the study. Given that this was a pilot study to assess feasibility of using mobile tool for HBA in primary care setting, such a response rate was expected. However, better compliance may have resulted if participants had been compensated after completing all phases of the study instead of only after the iPod touch survey. Further studies are needed to enhance follow-up and better observe how mobile technology might impact long-term behavior change in patients. Third, our study was focused on using the iPod touch device for HBA. Training on how to use the printed HBA reports for better patient–physician communication and goal-setting for behavior change was not included as part of this study. We also did not collect any data on participant technological expertise, or physician’s feedback on using printed HBA reports in their communication with patients, which is needed in future studies. Future research must also include such training for both patients and physicians, so the proportion of patients receiving counseling on behavior change can be increased as well as the assumed effectiveness of such behavioral counseling. Fourth, we used an iPod touch platform for conducting the HBA. In future studies, a comparison of the benefits and costs of iPod touch devices with other mobile devices would be instructive.
Despite these limitations, the current study suggests that it is highly feasible to use mobile tools for HBA and counseling in primary care settings for the prevention or management of obesity, diabetes, cancer, or heart disease, which are heavily influenced by lifestyle behaviors. Recognizing the magnitude of the prevalence of unhealthy behaviors in Americans, but limited health care resources, Congress passed the Health Information Technology for Economic and Clinical Health Act, which emphasizes the use of electronic health records [
body mass index
health behavior assessment
interactive behavior change technology
The study was supported by a Scott & White Healthcare Institutional Research Fund (#08182, PI: SNF). Publication support was provided by the Central Texas Cancer Awareness Research Education and Services (CTxCARES) funded by the Centers for Disease Control and Prevention (CDC) and the National Cancer Institute (NCI) through cooperative agreement number 1U48DP0010924. The opinions are the sole responsibilities of the authors and do not represent those of the funding agencies. We thank Dawn Begaye for study coordination, Bradley Bartels and Kristin Hamilton for data collection, and Phyllis Davis for administrative assistance. We also thank Tom Peck and Anita DuBose for the design of the iPod touch software system.
Conflicts of Interest: None declared.