As noted in a previous post, while smartphones represent an exciting tool for patient education and the support of health-directed behaviors, 80% of Americans don’t have smartphones. What are the opportunities for mlearning for health when it comes to this population?
Remembering the larger picture
If you feel stymied by the limitations of non-smartphones, remember that mhealth services should be part of a larger picture of patient-centered services and that this larger picture includes human beings—doctors, nurses, and support networks of patients and patient advocates. Thus, mobile phones, even the ones that are not so smart, are best used in blended learning strategies.
Face-to-face learning opportunities in a physician’s office are critical to helping patients develop better health strategies. Additionally, these strategies can be enhanced by using internet applications (at home or at libraries). For example, elearning can be used to facilitate self-directed learning behaviors by providing an interface for:
- reflections on progress
- access to social networks for support and advice
- access to resources for evaluating the credibility of online information
- access to health-care providers
- access to personal health records (PHRs)
While self-directed learning allows patients to become truly empowered, this doesn’t mean that patients go it alone. Health care providers, patient advocates, and educators/coaches are vitally important in facilitating self-directed learning.
How can mobile phones be integrated into this larger learning strategy?
Don’t forget that mobile devices can be used for phone calls
Although it seems obvious, when considering mlearning applications, we often forget that mobile devices provide teleconferencing capabilities. This creates important opportunities for:
- social connection
For example, in one program, health coaches contacted patients with chronic illnesses to help them stay on track with their treatments, inform them of treatment alternatives, and to encourage them to communicate with their personal physicians. The program resulted in overall cost reductions because of fewer hospital admissions for the coached patients compared to non-coached patients.
SMS for health
Probably the most popular use of mobile phones, outside of making calls, is texting. Short message services (SMS) allow users of mobile devices to send text messages of 160 characters or less at a time (message length depends on the service). Multimedia messaging services (MMS) deliver text, images, audio clips, and even videos, and require a camera phone to implement. MMS is usually more expensive than SMS, so in this post, I’ll focus on SMS as the way to reach the most people.
As noted in a previous post, texting can be an ideal way to:
- provide short bits of information
- enhance motivation
- encourage behavior change
- provide feedback and even practice opportunities to solidify learning
What to text
The length constraints of SMS mean that information provided through texting needs to be concise. SMS can be used to deliver short bits of information, including important reminders relating to medication use and self-care. But this doesn’t mean that this approach is necessarily devoid of interactivity.
Calls to action
SMS texts can be motivational and action-oriented. For example, SMS texts might encourage exercise or better eating behaviors. Additionally, learners might text a service to note completion of an activity and to record their progress at a Web site.
Answers to questions
SMS texts can be used to provide answers to a patient’s texted questions to a health-care provider or a health coach. As noted above, texting can be part of a larger patient-centered strategy that implicates blended learning approaches.
Games for health
SMS texts can be used to provide health trivia challenges and what-if scenarios. Success at challenges could be used to lead a learner to more and more complex inquiries. Social learning opportunities could be created by encouraging learners to text a friend for help on particular challenges.
SMS texts can be used to generate a backchannel at patient education presentations, creating a shame-free environment in which to ask questions.
When to text
The ability to automate message delivery makes the internet a very useful tool for deploying spaced repetition strategies via text messaging. Basically, spaced repetition theory posits that instruction which is repeated at intervals which are farther apart in time have a greater impact on improving memory than repetitions closer together in time (Ebbinghaus, 1885). Instructors should, therefore, consider the timing of messages as an important part of facilitating learning.
A patient’s readiness for change (Jones & Edwards, 2002; Peterson, 2002) is also an important factor in considering when to deploy particular types of messages.
Stages of readiness include:
- Precontemplation: a person is not ready for change
- Contemplation: the person intends to make changes in his/her health management in the next six months
- Preparation: the person intends to make changes in his/her health management in the next month
- Action: the person has made changes in his/her health management in the last six months
- Maintenance: the person has had good control of his/her health management for more than six months
Thus, in precontemplation and contemplation stages, texts might be used to provide messages relating to how health changes might improve an individual’s quality of life. In the preparation and action stages, texts can be used to support a patient’s plan for change as part of a larger intensive effort as discussed above, blending elearning and coaching interventions. In the maintenance stage, texts might be spaced at longer intervals and include reminder tips, access to support networks, and reminders to schedule doctor’s appointments, etc.
Examples of SMS being used in mhealth
Medication reminders: A new study by Partners Healthcare demonstrated how automated text messages could be used to provide patients with medication reminders and educational messages to improve compliance with treatment and self-care.
Using text-based interventions to reduce self-harm: In this example, individuals created their own healthy behavior prompts and stored them in a personal message bank for withdrawal at times of crisis.
Text4baby: A project to help pregnant women during their pregnancy by providing three SMS text messages each week timed to their expected due date.
Personalizing health texts: Mobile Health Interventions has launched Custom Txts, an open access application which is available for free. Using the platform, health care providers can create personalized text messages that suit the health care needs of individual patients.
This is just the tip of the iceberg in this burgeoning field. A web page to keep an eye on is the SMS Health Education Archive of the mHealth Update site. Have additional resources you’d like to share? Please add them to this open Diigo Group I started for mhealth resources.
Ebbinghaus, Hermann (1885). Memory: A Contribution to Experimental Psychology. Retrieved from http://psychclassics.yorku.ca/Ebbinghaus/index.htm
Jones, H., et al. (2002).Changes in diabetes self-care behaviors make a difference in glycemic control: The Diabetes Stages of Change (DiSC) study. Diabetes Care, 26(3), 732-7.
Peterson, K.A. (2002). Readiness to change and clinical success in a diabetes educational program. Journal of the American Board of Family Practice, 15, 266-71.