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Randomized Controlled Trial of a Webbased Youth Smoking Intervention

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Jennifer Moses, MSW. Jennifer Reynolds, MEd. Bohdan ... Jennifer Elliott. Sarah Flicker, MPH. Vero Michelli. Meg Morrison, MEd. Mabel Soo. December 10, 2003 ... – PowerPoint PPT presentation

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Title: Randomized Controlled Trial of a Webbased Youth Smoking Intervention


1
Randomized Controlled Trial of a Web-based Youth
Smoking Intervention
  • Oonagh Maley, Cameron Norman Harvey Skinner
  • Department of Public Health Sciences
  • University of Toronto

FUNDED BY
2
Learning Objectives
  • Describe key elements for effective engagement of
    adolescents using a web-based smoking cessation
    and prevention intervention
  • Identify strategies for implementing a web-based
    randomized control study in a school setting
  • Recognize challenges inherent in conducting
    smoking cessation research in schools and using
    web-based resources

3
Presentation Overview
  • Introduce the Smoking Zine website
  • Examine challenges of working with youth about
    tobacco
  • Highlight innovative opportunities of eHealth for
    tobacco control
  • Provide an overview of the TeenNet Project
  • Describe the randomized trial initial results
  • Review Lessons Learned

4
The Smoking Zine
5
Tobacco Youth Challenges and Opportunities

6
The High Cost of Smoking
  • The lifetime medical costs of cigarette smokers
    are approximately 1/3 higher than non-smokers
  • Harvard Report (1996) concluded that nearly
    two-thirds of cancer deaths (US) are linked to
    preventable risk behaviors
  •       30 smoking  
  •       30 adult diet and obesity
  • 5 physical activity level
  • Law and Tang (1995) estimate a cost of 1,500
    (US) for saving a life through routine 5-minute
    advice to all smokers to stop
  • Few procedures in medicine carry so small a cost
    of saving a life

7
Tobaccos Impact on Children Youth
  • Direct Effects 250 million children alive today
    will be killed by tobacco in the future if
    current consumption patterns continue
  • Indirect Effects Nearly 700 million children
    (almost half worlds population) breath air
    polluted by second hand smoke
  • World Health Organization (2001). Tobacco and the
    Rights of the Child. Geneva.

8
Smoking Initiation in Canada
  • Begin - 8 years
  • Increase 11 years
  • Peak 16 years
  • Smoke free at 19 years Little chance of ever
    starting

9
Stages of Change of Canadian Smokers
Source CTUMS, 2001
10
The Challenge is Large….but not Insurmountable
11
Why the Internet?
12
Youth Online
  • United States 73 of youth online, 57 of
    general population using the Internet for health
    information1
  • Canada 99 of youth online, 52 have used the
    Internet for health information2
  • 1 PEW Internet American Life Project (2001)
  • 2 Environics / Media Awareness (2001)

13
Key Reasons for Using the Internet for Youth
Tobacco Control
  • Reaches youth where they are
  • Interventions are not bound by time or space
  • Interactivity and active learning media
    combinations
  • Potential for tailoring to users
  • Easy to update and modify
  • Minimal cost for maximum reach
  • Because the tobacco industry is already there!

14
Designing Effective Interventions
  • Accessible
  • Individualized
  • Remote (e.g.,telephone) Group Counselling
  • Provide opportunities for assisted self-help
  • Strengthen social support networks
  • Use biomarker feedback
  • Must be efficient ( realistic)
  • Population X Reach X Efficacy
  • See Niaura Abrams, 2002

15
The TeenNet Project
Based at Department of Public Health
Sciences Faculty of Medicine University of
Toronto Toronto, Ontario Canada
16
TeenNet Research Project
  • Established in 1995
  • Lead by Dr. Harvey Skinner
  • Based in the Department of Public Health Sciences
    in the Faculty of Medicine, University of Toronto
  • http//www.teennetproject.org

17
TeenNet Project Goals
  • Generate new knowledge and practical tools for
    engaging youth in health promotion
  • Evaluate innovative models for using Interactive
    Communication Technology for health promotion
  • Collaborate for research and capacity building
    locally, nationally and internationally
  • Disseminate best practices and models for
    knowledge translation and sustainability .

18
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19
TeenNets Guiding Principles
  • Participatory
  • Relevant to Youth
  • Autonomy Supporting
  • Active Learning and Fun
  • Accessible
  • Youth in Action Approach

20
Youth in Action Approach
  • Initial needs identification
  • Focus groups with youth
  • Brain storming sessions with youth
  • Concept development and assessment
  • Youth working groups
  • Youth forums
  • Reality checks with youth
  • Professional advisors and/or advisory groups
  • Prototype development and assessment
  • Youth employees
  • Reality checks with youth and practitioners
  • Quality review committee (for website links)
  • Ongoing feedback through website and discussion
    boards

21
TeenNet Research Projects
  • Adolescent Gambling
  • Community Capacity
  • Global Youth Voices
  • Positive Youth Project
  • Smoking Zine Evaluation
  • Youth, Technology and Access

22
Diverse Youth
23
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24
Randomized Controlled Trial Overview
  • Principal Investigator Harvey Skinner
  • Co-Investigators Eudice Goldberg
  • Cameron Norman
  • Program Manager Oonagh Maley

Funded by
25
What was this study?
  • Population Adolescents (grades 9-11)
  • Issue Smoking eHealth Literacy
  • Program Web Face-to-face
  • Setting School
  • Desired Effect Population impact

26
Community Partners
  • Toronto Public Health (Tobacco Team)
  • YMCA Youth Substance Abuse Program, Toronto

27
The Team
  • Team Leaders
  • Oonagh Maley, MISt
  • Cameron Norman, MA
  • Public Health Nurses
  • Mary-Anne McBean
  • Sue St John
  • Sarah Newham
  • Voula Varsamidou
  • Youth Counsellors Research Assistants
  • Lisa Ennis, MSW--RSW
  • Celeste Le Duigou, MSW--RSW
  • Jennifer Moses, MSW
  • Jennifer Reynolds, MEd
  • Bohdan Turok, MEd CCC, CHt

28
TeenNet Support
  • Sherry Biscope, MHSc
  • Shawn Chirrey, MHSc
  • Jennifer Elliott
  • Sarah Flicker, MPH
  • Vero Michelli
  • Meg Morrison, MEd
  • Mabel Soo

29
Initial Research
  • Spring 2000 Instrument Development
  • Summer-Fall 2000 Community-based trial
  • Winter-Spring 2001 Instrument re-development
  • Summer 2002 Community-based pilot tests
  • 1995-2003
  • Ongoing reality checks
  • Test groups

30
Study Design
31
Study Overview
  • A two-group randomized trial
  • Major Research Questions
  • Does the Smoking Zine Intervention promote
    behaviour change in youth smokers?
  • Does the Smoking Zine enhance resistance to
    smoking among non-smokers?
  • Does exposing adolescents to critical appraisal
    tools assist them in building e-Health
    literacy?

32
Study Timeline (Administrative)
  • 2000 Focused partnership with local Public
    Health Department develops
  • 2001 Consultations with School Administrators
    curriculum consultants
  • 2001 Collaboration with YMCA-YSAP
  • 2001-2 Relationship building with individual
    schools
  • 2002 Active Passive Consent Process

33
Study Overview
  • 1. Smoking Zine Website Intervention including
    motivational counseling, virtual group support,
    feedback
  • 2. Control Condition website evaluation task
  • Measures Pre Post intervention, 3 6 month
    follow-up
  • a) Resistance to Smoking
  • b) Intentions to Smoke
  • c) Smoking Behavior
  • Initial Results
  • School by Grade by Sex by Smoking Status
    interaction
  • e.g. decreased tobacco use for grade 9 boys

34
Study Procedures
  • Complete baseline instruments
  • Zine or Web Evaluation (Control) Task with
    booklet in class
  • 10-minute MI Group with booklet
  • Complete Post-test measures
  • CO Monitor
  • Tailored email messages between follow-ups
  • Complete follow-up assessments (3 6 mo.)

35
The Interventions
36
Intervention
  • Intervention The Smoking Zine including access
    to online discussion forum for peer support and
    mutual aid
  • Control Modified website evaluation checklist
    applied to three non-health websites
  • Group-based motivational interview
  • Booklet
  • Follow-up tailored emails

37
Intervention Smoking Zine
38
The Smoking Zine
  • Launched May 2000
  • Based on multiple theoretical approaches
  • Youth empowerment Harm Reduction approach to
    tobacco use
  • Youth in Action approach to development and
    evaluation
  • Multilingual (English, French, Chinese)

39
The Smoking Zine
  • Five stages
  • Self-assessments, games, discussion forum,
    personalized quit plans
  • Builds motivation through
  • Building on readiness for change
  • Enhancing self-efficacy
  • Fostering self-determination
  • Connecting with community/peers
  • Identifying discrepancies between goals and
    behaviour
  • Personal forecasting

40
Linking Theory Evidence
  • Health Behaviour Models (individual level)
  • Self-Determination Theory
  • Social Cognitive Theory (Self-Efficacy)
  • Transtheoretical Model (Readiness for Change)
  • Motivational Interviewing (Decision Balance)
  • Theory of Reasoned Action Planned Behavior
  • Health Belief Model
  • Multisystems - multilevel integration
  • Health Promotion five coordinated actions
  • (1986 WHO Ottawa Charter)
  • Community Capacity Building and Mobilization

41
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42
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43
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44
Meet the Smoking Zine
45
Control Condition Website Evaluation
46
Control Condition Web Evaluation
47
Control Task Website Evaluation
  • Developed with youth health consumers
  • Includes both professional and
    consumer-oriented criteria
  • Focus on both knowledge and skill development

48
Booklets
49
Smoking Zine Booklet
  • Created to allow youth to record results from the
    Zine without printing
  • Wallet card with login information
  • Used in MI discussions
  • May be taken home and re-used as needed

50
Smoking Zine Booklet
51
CyberHealthLiteracy Booklet
  • Created to allow youth to review websites and
    calculate a rating based on five criteria
  • Wallet card with cyberliteracy url
  • Used in MI discussions
  • May be taken home and re-used as needed

52
Booklet Web Evaluation
53
Motivational Interview
54
Motivational Interviewing
  • An approach to fostering change through
    enhancement of a clients readiness and intrinsic
    motivation
  • Motivational interviewing is a client-centred,
    directive method for enhancing intrinsic
    motivation to change by exploring and resolving
    ambivalence (Miller Rollnick, 2002)

55
Motivational Interviewing Adaptation for Group
Setting
  • Uses a single-session model
  • Brief format (10 minutes in duration)
  • Few known attempts at adapting to group form no
    known outcome studies
  • No single-session group models
  • Focus on the Decision Balance (pros and cons) and
    exploring ambivalence about change

56
Sample Discussion Questions
57
Randomized Controlled Trial Outcome Measures
58
Measurement Points
59
Smoker Definition (Mills et al., 1994)
  • Q1 Which of the following statements best
    describes your use of tobacco in your lifetime?
  •  
  • Q2 During the past 30 days, on how many days did
    you smoke cigarettes?

60
Lifestyle Technology Profile
  • 30-item questionnaire on
  • Risk behaviors
  • e.g., Substance use, diet exercise
  • Technology use
  • e.g., email, World Wide Web, Wireless phones
  • Demographics
  • e.g., age, grade, cultural affiliation

61
Measures of Change Likelihood of Action Scale
eHEALS
  • 23-item scale based on the five major behavior
    change theories used to guide the Smoking Zine
    (Skinner, 2002)
  • Pilot tested with youth in community, school and
    clinical settings over 3 years
  • Scale items obtained through tobacco survey
    databases, published scales and partnership with
    other researchers in the area of adolescent
    health
  • eHEALS eHealth Literacy Scale

62
Likelihood of Action Index
63
Data Collection
64
Follow-up
65
Follow-up
  • Response Rates
  • 89 (3-months) 87 (6-months)
  • Participants complete survey in class
  • 25 randomly chosen to complete CO monitoring
    not at 6-month due to SARS outbreak
  • Tailored email support follows until 6-months
  • Participants complete survey in class
  • All participants are informed of the Zine and Web
    Evaluation resources

66
CO Monitoring
  • Validates smoking self-report
  • Potential for bogus pipeline
  • Opportunity to engage youth and reinforce the
    message

67
Data Analysis and Results
68
Study Demographics
  • N1410
  • 760 Boys
  • 650 Girls
  • 214 smokers at baseline (15 of total)
  • 14 urban high schools Public Catholic
    districts
  • 83 classes
  • Grades 9-11
  • Passive and Active Parental Consent
  • Active Youth Consent

69
Key Findings
  • Smoking Zines greatest potential impact with
  • Grade 9 students (cessation and prevention)
  • Boys
  • Smokers (Zine as treatment)
  • High-risk schools
  • eHealth Literacy
  • Main effect
  • ? Small intervention effect with great potential
    cumulative effect on a population level

70
Planned Analysis Results
  • I. Psychometric Assessment
  • Item (reliability) analysis
  • Confirmatory factor analysis
  • II. Impact Assessment
  • Doubly-repeated Measures MANOVA (SPSS v11.5)
  • Structural Equation Modeling (Mplus, v2.14)
  • Hierarchical Linear Modeling (MLwiN v1.1)

71
AnalysisThree Approaches
  • MANOVA Multivariate Analysis of Variance
  • Intervention X Smoker X Grade X Sex interaction
  • HLM Hierarchical Linear Modeling
  • School and Grade level effects
  • Multiple Rs ranging from .88 (post) to .40
    (6-month)
  • SEM Structural Equation Modeling
  • I. Measurement model three factor (latent
    variables)
  • II. Path Model

72
Outcome Measures
  • Three Key Scales
  • Resistance to smoking
  • Intentions to smoke
  • Cigarette consumption
  • Smoking Status
  • Satisfaction with Intervention

73
Cigarette Use Scale
74
Behavioral Intention Scale
75
Resistance to Smoking Scale
76
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77
Study Impact
  • Interaction effects indicate strongest effect
    for grade 9s for both prevention and cessation
  • Most noticeable effects with smokers (cessation)

78
Smoking Cessation
79
Resistance to Smoking (p lt .05)
  • Grade
  • Grade by Sex
  • Most noticeable influence on grade 9 boys

80
Behavior Intention (p lt .05)
  • Grade
  • Group by Grade
  • Group by Smoker by Grade
  • Group by Smoker by Grade by Sex
  • Smoker by Grade by Sex
  • Most noticeable influence on smokers (boys)
    in grade 9

81
Cigarette Use (p lt .05)
  • Grade
  • Group by Smoker by Sex
  • Grade by Sex
  • Smoker by Grade
  • Smoker by Grade by Sex
  • Most noticeable influence on smokers (boys)
    in grade 9

82
Key Findings
  • Smoking Zines greatest potential impact with
  • Grade 9 students (cessation and prevention)
  • Boys
  • Smokers (Zine as treatment)
  • High-risk schools
  • eHealth Literacy
  • Main effect
  • ? Small intervention effect with great potential
    cumulative effect on a population level

83
Multi-level Modelling
84
In Progress Multi-level Model
Supra-level
Context School, Grade, Class
Individual Sex, Smoker, Intervention
Base Level
85
Preliminary findings
  • Significant effect for Grade 9 students for both
    smoking cessation and prevention of smoking
    acting on behavior intention
  • Effect most noticeable with boys
  • No class effects

86
Lessons Learned
  • Study Process - Web-based Interventions
  • The Team - Working with Schools
  • Working with Youth

87
Lessons Learned 1 Study Process
  • Pilot..pilot..pilot
  • Build solid community partnerships
  • Communicate with your partners
  • Hire administrative support
  • Debrief and improve process
  • Things always take longer!
  • No two days are alike

88
Lessons Learned 2 The Team
  • Identify a clear chain of command
  • Hire staff to complement each other
  • Ensure a range of experience with youth
  • Select staff with leadership skills
  • Cross train staff on all study roles
  • Have back-up staff available and trained

89
Lessons Learned 3 Web-based Interventions
  • Youth and adult testing
  • Onsite technology assessments
  • Quality of access is an issue
  • Literacy is an issue
  • ESL and Special needs are an issue
  • On-call technical support is critical
  • Establish back-up procedures in advance
  • Upfront development costs extensive

90
Lessons Learned 4 Working With Schools
  • Create partnerships early
  • Persistence is key
  • Consult with educators administrators
  • Reflect school realities in your study
  • Outline school roles and responsibilities
  • Provide value to schools, teachers students

91
Lessons Learned 4 Working With Schools
  • Identify fit with existing activities
    curriculum
  • School level compensation
  • Identify and support a champion
  • Provide ongoing feedback
  • Changing routine is difficult
  • Dont assume support structures

92
Lessons Learned 5 Working With Youth
  • Communicate with respect
  • Provide clear concise instructions
  • They are interested in research
  • Get back to them with results
  • Grade 9 is not Grade 10 is not Grade 11

93
Future Directions
94
Next Steps
  • Follow-up studies examining the interaction
    effects
  • Boys, Lower grades, High-Risk Schools
  • Whole-school approach (including parents and
    community)
  • Smoking Zine in primary care settings
  • International Applications
  • China
  • Brazil
  • Middle East

95
Take Home Message
96
Take Home Messages
  • Ensure authentic youth involvement in all
    phasesdesign,implementation,evaluation
  • Pilot test the intervention in stages (iterative
    development)
  • Build partnerships that respect and recognize
    their needs and challenges

97
Designing Effective Interventions
  • Accessible
  • Individualized
  • Remote Group Counselling
  • Provide opportunities for assisted self-help
  • Strengthen social support networks
  • Use biomarker feedback
  • Must be efficient ( realistic)
  • Population X Reach X Efficacy

98
Thank you ?
99
Contact Us
  • Oonagh Maley
  • oonagh.maley_at_utoronto.ca
  • 416.978.7543
  • Cameron Norman
  • cameron.norman_at_utoronto.ca
  • 416.209.6740
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