Transcript Telephone helplines - Home - Effectiveness of computer

Can we involve smokers
who are unmotivated to
quit in quitting activity?
Hazel Gilbert
Research Department of Primary Care and Population
Health
UCL Medical School
Overview
1) Principles of tailoring
2) Escape study
3) Baseline characteristics and
follow-up assessment
Self-help Materials
 Generic leaflets and manuals
 Personalised generic
 Targeted materials to particular groups
 Individually Tailored Feedback
Definition: ‘intended to reach one specific
person, based on characteristics unique to that
person, related to the outcome of interest, and
derived from an individual assessment’
(Kreuter et al 1999)
Individually Tailored Feedback
Personally relevant information:
greater attention
central route processing (deeper processing)
greater cognitive and behavioural change
→
→
→
(Elaboration Likelihood Model. Petty and Cacioppo, 1981)
Evidence of effectiveness
‘evidence of the effectiveness of tailoring health
behaviour change messages’ (Noar, Benac and Harris 2007)
(meta-analysis of 57 studies)
‘material tailored for the individual increases quit rates
over and above standard materials and untailored
materials’ (Lancaster and Stead 2005) 17 trials (OR 1.42)
Phases of development
1) Understand determinants of the behaviour
Tailoring process ideally informed by established models of
behaviour change
2) Develop a framework of intervention
objectives
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motivation and readiness to quit
reason for quitting
dependence and self-image
cognitive expectations of the outcomes of quitting
perceived self-efficacy
offer skills and strategies to cope
social environment
encourage finding support
3) Develop tailoring assessment
Design questionnaire to assess the relevant
individual characteristics
4) Create the content of the feedback
Compose a message for each possible answer
5) Design template
Style and Format
• Font
• Graphics
• Colour
• Tone
• Reading and comprehension level
Process
Individual assessment
Computer system
Input
Decision rules
Individualised output
Dijkstra 2008
Message library of
persuasive texts
Applications of Tailored Feedback
in Primary Care
E
ffectiveness
of computer-tailored
S
A Randomised Controlled Trial
moking
C
essation
A
Aim:
To examine the effect of computer
generated individually tailored
feedback reports designed to help and
encourage smokers to quit, on quit
rates and quitting activity, when sent to
smokers with varying levels of
motivation and reading ability, identified
from GP lists
dvice in
P
E
rimary car
General
Practice
Research
Framework
NHS Smoking Cessation Service
Clinical approach:
Intensive face-to-face
Relatively high quit rates
Low participation rates
Unrepresentative
 3-6% of smokers use the services per year
Challenge for Primary Care services:
 to reach the smokers who do not use clinics
Proactive recruitment
 Contact individuals directly offering a service
 Higher participation
 More demographically representative
 Can target specific population groups
• Smokers not motivated to quit
• Areas of high deprivation where smoking
prevalence is higher
123 general practices recruited from the MRC GPRF
• Practices identified current cigarette smokers (18 to 65) from patient
records using the computer system
• Random sample of 500 screened by GP, and sent Smoking Behaviour
Questionnaire (SBQ), together with a covering letter from GP (n=60,000)
• Smokers willing to take part returned the SBQ to research team at UCL
• Randomised to Intervention or Control Group
Control Group
Standard NHS booklet
Intervention Group
• Standard NHS booklet
• Computer-tailored feedback report
adapted to reading level and readiness
to quit
• Additional assessment and feedback
report one month after baseline
6-month follow-up: postal questionnaire to assess smoking status, cognitive
change, perception of the feedback, economic issues
Baseline characteristics
N=6900
Demographics:
Female 56.5%
Withdrawn=69
Mean age 44.72 (17-83)
White 96%
Response rate=11.75%
Qualifications <=GCSE 62.1%
Married/living with partner 58.8%
Intervention=3404(49.8%)
Control=3427(50.2%)
In paid employment 65.2%
Live with smoker 50.2%
Children under 10 18.9%
Children 10-18 24.4%
Pregnant 1.2%
Dependence:
I
C
Non-daily smokers
5.0%
5.4%
Smoke <30 minutes of waking
62.3%
62.1%
Previously quit >3 months
49.1%
48.7%
Mean age started smoking
16.19
16.24
Mean cigarettes per day
17.82
17.7
How much do you want to quit
(scale 1-5)
3.33
3.25**
How determined are you to quit for
good (scale 1-5)
3.26
3.19*
Think of self as addicted (scale 1-5)
4.03
4.03
Image (scale 1-5):
smoking is part of who I am
see self as non-smoker
2.5
3.04
2.48
3.02
**p=.006 * p=.016
Respondents by readiness to quit
50%
46.90%
40%
40.10%
30%
20%
10%
5.70%
7.80%
0%
w ithin 2 w eeks
w ithin 30 days
w ithin 6 months
not w ithin 6 months
planning to quit
Of those planning to quit within the next 30 days (n=890): 339 (38.1%) set a quit date
Of those not planning to quit within the next 6 months (n=3203):
too difficult - 45.3% / want to smoke - 44.8% / both - 4.3%
Readiness to quit by motivation
5
w ant to quit
mean score
4
determined to quit
3
think self addicted
image 'w ho I am'
2
image 'non-smoker'
1
w ithin 2 w eeks
w ithin 30 day s
w ithin 6 months
Planning to quit
not planning
Follow-up Assessment Response
Intervention Group only (N=3404)
4 weeks post baseline
Sent follow-up assessment + reminder=3350(98.4%)
Returns:
Before reminder
After reminder
Total
968 (28.9%)
817 (24.4%)
1785 (53.3%)
Participants planning quit in 30 days less likely to
return the follow-up assessment (p=0.012)
Follow-up Assessment Outcome
Plan to quit
Abstinent (%)
Not abstinent
(%)
Total
Within 2 weeks
43 (23.5)
61 (76.5)
183
Within 30 days
36 (13.5)
84 (86.5)
267
Within 6 months
66 (4.8)
661 (95.2)
1384
Not planning
35 (2.3)
800 (97.7)
1516
Total
180 (5.4)
3170 (94.6)
3350
2 = 197.48, p<.0001
Length of abstinence by readiness
Respondents not smoking 4 weeks post baseline (n=180)
60
50
%
40
within 2 weeks
within 30 days
30
within 6 months
20
not within 6 months
10
0
1-6 days ago
7-14 days ago
2-4 weeks ago
last smoked
>4 weeks ago
Quit attempts by readiness
Respondents still smoking 4 weeks post baseline (n=1601)
Made quit attempt
Yes(%)
No (%)
Total
within 2 weeks
49(81.7)
11(18.3)
60
within 30 days
52(61.9)
32(38.1)
84
within 6 months
171(25.9)
489(74.1)
660
not within 6 months
102(12.8)
695(87.2)
797
Total
374(23.4)
1227(76.6)
1601
Plan to quit
2=235.698, p<.00001
Conclusions
 The Escape trial has met recruitment targets in
terms of motivation
 By reaching smokers with no plans to quit in the
near future, we are able to provide them with
information that they would not otherwise receive
or seek out
 By completing the Smoking Behaviour
Questionnaire, these smokers are engaging in
reflection about their smoking behaviour
 Might prompt them to consider changes to their
lifestyle and behaviour
 Quitting activity?
Tailored feedback + Proactive Recruitment
behavioural
intervention
principles of the
clinical approach
provide personal, individually
tailored self-help reports
for a large population of
smokers
participation
rates of
public health
campaigns
Co-investigators
Irwin Nazareth, Richard Morris
Department of Primary Care and Population Sciences, UCL
Stephen Sutton
Institute of Public Health, University of Cambridge
Collaborator
Christine Godfrey
Department of Health Sciences, University of York
Trial Co-ordinator
Camille Alexis-Garsee
General
Practice
Research
Framework