Spring 2005 Edition

May 2, 2005

The traditional medical and clinical psychology models which have served as the basis for most health behavior change interventions involve participants meeting individually or in groups with a professional once each week, or perhaps less often, for education, reinforcement, goal setting and skills training. However, most of the behaviors we seek to change occur in contexts far removed from our clinics. As the field of e-health continues to develop, we witness rapid advances in technology that provides greater opportunity to take our behavior change interventions out of the “clinic”. Yet these opportunities to reach out and to intervene with participants in their homes and as they live their lives via portable devices, present us with new challenges that require consideration from theoretical and ethical perspectives, as well as questions that point us to new research on how intelligent technologies should optimally be used during the behavior change process.

Until now, Internet interventions for obesity treatment have mimicked clinic-based interventions, yet in an online environment. A standard program includes structured weekly behavioral lessons; monitoring and reporting of diet and exercise; interactions with counselors and peers via email, chat rooms or message boards; etc. Compared to their face-to-face counterparts, these programs offer greater convenience for participants while still providing opportunities for continued contact and maintaining accountability. In fact, most participants in Internet weight loss research programs report that the accountability to a staff member or counselor was “critical” to keeping them “on track.” As our technologies advance, we are able to integrate even more behavioral surveillance into our treatments, thus making participants increasingly accountable. Our current NIH-funded Internet weight loss trial involves self-monitoring with Palm Pilots programmed to transmit monitoring data to e-counselors throughout the day via wireless upload. The opportunity for increased surveillance and accountability allows us greater opportunity to intervene with conceivably less burden for reporting on the part of the participant. Despite these advantages, it raises important questions about what level of surveillance is necessary and even helpful, and what infringes on personal freedom.

Routinely, Internet behavior change interventions track user data such as frequency of logins, use of various web resources, and adherence to self-monitoring. Adherence to self-monitoring has long been the source of face-to-face clinical conversations and is considered a cornerstone of behavioral weight loss. A typical conversation might begin: “Mrs. Smith, I see that you were able to monitor your dietary intake quite well in the beginning of the week but there are fewer and fewer foods recorded in your diary over the weekend. What kinds of things were getting in the way of monitoring?” These exchanges allow for problem solving and attempts to increase motivation for monitoring – a burdensome task. Automated systems with portable monitoring devices can immediately initiate an e-version of this conversation when non-compliance is detected. Thus, we have the ability to detect non-adherence early and we can intervene early. With these procedures we must constantly balance the need for early intervention with infringements of personal control and autonomy. Everyone has experienced an automated prompt that becomes more of an annoyance than help.

Imagine applying home monitoring or home-based telemedicine practices to weight loss. For example, assisted living technologies now exist that are designed to allow the elderly to remain in independent living situations by providing remote surveillance. These systems range from simple “panic” buttons worn around the neck or wrist to complex sensor systems that monitor the individuals’ movement around their house. More elaborate sensor systems monitor whether meals are cooked or not, the number of times elders use the bathroom, whether they sit in various chairs or sleep in their beds at night. Family members can go online and evaluate the daily behavior through easy web interfaces. The systems also learn the behavior patterns of the elder and send an alert via phone, pager or email when deviations from normal behavior are detected (e.g., a fall, or lack of movement in the house). Consider the application of these technologies to situations involving far less risk and safety concern than an elderly parent with early dementia– for example, the overweight person seeking weight loss. Imagine sensors in the fridge to detect how often the vegetable drawer was opened or in athletic shoes to detect adherence or non-adherence to exercise. GPS systems can detect when a participant is entering a fast food restaurant and offer a menu of optimal choices. These devices could be stand-alone interventions with computer-automated feedback or used in conjunction with human interactions via Internet, cell phones etc. Such interventions are part of our future. We have the technology! What’s not clear is how best and for whom we should use these technologies to promote health behavior changes.

Deborah F. Tate, Ph.D.
University of North Carolina -Chapel Hill
Schools of Public Health and Medicine

The views expressed in this article are those of the author and do not imply endorsement by The Robert Wood Johnson Foundation or the Health e-Technologies Initiative.