Novel Technologies for Promoting Behavior Change David Marrero, PhD Saturday, March 5, :45 a.m. 9:30 a.m.

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1 Novel Technologies for Promoting Behavior Change David Marrero, PhD Saturday, March 5, :45 a.m. 9:30 a.m. Advances in technology offer both great promise to improve diabetes care delivery and potentially some interesting threats. Behavioral theory can help us to better understand how technology may improve patient outcomes and what we need to consider as we decide to integrate technology in treatment and care delivery. There are at least 6 ways that integrating technology can make a contribution: 1) enhancing sustainability of health-based behavioral interventions, 2) Obtaining frequent, objective measures of behavior, 3) Identifying the influence of individual treatment components that comprise a treatment package, 4) Enhancing costeffectiveness of treatment, 5) Incorporating behavior analysis in the creation of consumer-based applications (apps) and 6) Reducing barriers to access and health disparities. The advantages and disadvantages of consumer directed apps are discussed and the values of using theoretical models in developing technology supported approaches to therapy are described. References: 1. Asch, D. A., Muller, R. W., & Volpp, K. G. (2012). Automated hovering in health care- - watching over the 5000 hours. The New England Journal of Medicine, 367(1), Bastawrous, A., & Armstrong, M. J. (2013). Mobile health use in low- and high-income countries: An overview of the peer-reviewed literature. Journal of the Royal Society of Medicine, 106(4), Crowley-Koch, B., & Van Houten, R. (2013). Automated measurement in applied behavior analysis: A review. Behavioral Interventions, 28(3), Kaplan, R. M., & Stone, A. A. (2013). Bringing the laboratory and clinic to the community: Mobile technologies for health promotion and disease prevention. Annual Review of Psychology, 64, Raiff, B. R., & Dallery, J. (2010). Internet-based contingency management to improve adherence with blood glucose testing recommendations for teens with type 1 diabetes. Journal of Applied Behavior Analysis, 43(3), Webb TL, Joseph J, Yardley L, Michie S: Using the Internet to Promote Health Behavior Change: A Systematic Review and Meta-analysis of the Impact of Theoretical Basis, Use of Behavior Change Techniques, and Mode of Delivery on Efficacy. J Med Internet Res Feb 17;12(1):e4. doi: /jmir.1376.

2 Novel Technologies for Promoting Behavior Change: What do we need to think about? David G Marrero, PhD Director, Diabetes Translational Research Center Indiana University School of Medicine The Assumption. The leading causes of morbidity and mortality are increasingly modifiable lifestyle factors Behavior analysts have the opportunity to promote health by combining effective behavioral methods with technology The promise of technology Increasing evidence that behaviorists can impact health behavior through the development and implementation of technology-based interventions. Technological innovations: wearable sensors devices to transmit patient data mobile devices for support, education, and training real-time access to therapeutic interventions via information technology The potential of technology. The potential of such technology lies in its ability to permit hovering (i.e., realtime monitoring) of patients behavior during the everyday activities during which choices about health are typically made The potential threat of technology. What can behavioral theory tells us about technology usability? Diabetes is not a potent behavioral paradigm: Positive versus negative reinforcement Personal reinforcers Social reinforcers The role of punishers Moms and hypoglycemia Inability to sense high glucose levels

3 The problem through a behavioral lens A behavior analytic approach to health holds that health behaviors are operant (i.e., voluntary behaviors that are determined primarily by their consequences) Some behaviors offer positive consequences in the short term, but can be harmful if such patterns persist long-term Abstaining from some behaviors may have punishing consequences in the short term, but offer benefits in the future So how do we integrate technology? Enhancing sustainability of health-based behavioral interventions Obtaining frequent, objective measures of behavior Identifying the influence of individual treatment components that comprise a treatment package Enhancing cost-effectiveness of treatment Integrating technology 2 Incorporating behavior analysis in the creation of consumer-based applications apps Reducing barriers to access and health disparities Enhancing Sustainability and Maintaining Treatment Gains Behavioral techniques have been established as an effective approach to promoting behavior change the extent to which new behaviors endure remains a challenge Technology-based behavioral models can be embedded in more sustainable platforms Maintenance of treatment gains may be accomplished by shifting from the delivery of the contrived consequences to more natural consequences (e.g., social reinforcers) An example Enlisting social groups to detect and reinforce health behaviors using technology-based systems Fitbits; uploads automatically-generated data to an individual s computer or smartphone. The individual can then join online communities, with which he or she can share and receive social praise for his or her physical activity data and earn badges or other consequences. Collecting Objective Measures of Behavior A hallmark of behavior analytic treatments is obtaining objective measures of target behaviors These measures may be discrete instances of behavior (e.g., taking a medication) or byproducts of behavior (e.g., A1c) on which reinforcement is contingent Technology offers major advantages in the frequent collection of these measures and protect their integrity

4 A few examples MEMs caps and med adherence Accelerometers and physical activity CGM and memory glucose meters Dietary trackers Patient Portals Identifying the Effectiveness of Individual Treatment Components Most interventions are actually treatment packages, and the extent to which specific components contribute to their efficacy is often unclear. Example: Diet regulation: Food tracking Fat or calorie restriction Prescribed diet vs. adjustment of eating strategy Social linkages Evaluating cost-effectiveness Does the cost justify the potential impact? Example; the case for using genetics to assess risk for developing type 2 diabetes Is there a population in which costs are justified? Women with GDM and their children. Integrating Behavioral Analysis and Consumer-base Apps Lots of Apps out there; more than 8000 health Apps Several that address behavioral health (e.g., anxiety, depression, PTSD, physical activity, diet, alcohol use) Advantages Broad reach through smartphones; fast dissemination (WW example) Provide training support cheaply Flexibility in use: geared to the user s schedule Can address willingness to engage in formal programs Health disparities and specific population reach E.g., Stoops et al. (2009) developed an internet-based smoking cessation intervention that was feasible, efficacious, and well-liked among rural Appalachian smokers. Cost Disadvantages Quality control: Who developed and why? Many are not grounded in empirically supported principles of behavior or reflective of public health recommendations Tailoring and individual responsiveness Need to be connected to a specific technology

5 Value of using theory in building technology The two behavior change techniques that are associated with the greatest changes in behavior are stress management and general communication skills training. Both techniques influence behavior change indirectly via mechanisms such as: facilitating problem-solving promoting self-efficacy diminishing the impact of stressors that may prevent behavior change Value of theory.. Emotional control training was less effective in promoting behavior change. Of the 11 interventions (45%) that incorporated emotional control training, 5 reported negative effect sizes on behavior In many of these interventions they simply included strategies to manage mood or information on... dealing with relationships and feelings. In contrast, stress management training tended to be more intensive Their conclusion The findings suggest that the effectiveness of Internet-based interventions is associated with more extensive use of theory (in particular the use of the theory of planned behavior), inclusion of more behavior change techniques, and use of additional methods of interacting with participants (especially text messages). Ok, so why use technology? Ability to embrace real-time, longitudinal assessment of behavior in naturalistic settings. With technology, the range of populations and behavior problems can be broadened substantially. Using the Internet to Promote Health Behavior Change: A Systematic Review and Meta-analysis of the Impact of Theoretical Basis, Use of Behavior Change Techniques, and Mode of Delivery on Efficacy. J Med Internet Res 2010;12(1):e4 Why technology? Thank You! Technology can produce new environment-behavior relations by arranging virtual communities and social media and/or by capitalizing on powerful observation, recording and feedback technologies.

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