Health Education Research Advance Access originally published online on June 15, 2004
Health Education Research 2004 19(5):581-590; doi:10.1093/her/cyg080
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Health Education Research Vol.19 no.5, © Oxford University Press 2004; All rights reserved
HEALTH C.H.I.P.s: opportunistic community use of computerized health information programs
1 Hunter Population Health and 2 Hunter Institute of Mental Health, Faculty of Health, University of Newcastle, Newcastle, NSW, Australia
3 Correspondence to: D. Radvan, Hunter Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia; E-mail: deborah.radvan{at}hunter.health.nsw.gov.au
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Abstract |
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Computerized health information programs have been shown to have potential to improve knowledge, attitudes and behavior. However, relatively little is known regarding their capacity to engage the public for opportunistic, spontaneous use in community settings. Two studies were undertaken to provide insight to this practical issue. An intercept survey of adults from a shopping center where a computer kiosk had been located for 7 months was undertaken to investigate exposure to, attention to, use and acceptability of kiosks. A total of 99.7% of participants were exposed to the kiosk, 77.4% of these noticed it and 20.8% of these used it. Program acceptability was high; the most common barriers to use related to time constraints and disinterest. A utilization study was then undertaken to describe program utilization in greater detail, with kiosks installed in 18 community settings over 1 year. These were used 57 064 times (19.4 uses per kiosk per day). Additional data described demography of users, preferred topics selected, preferred formats and presentation styles, and a comparison of use across different community settings. Both studies provide insight to practical application of this health education strategy, indicating that is has substantial capacity to engage people for opportunistic use in community settings.
Computerized health information programs have been shown to have potential to improve knowledge, attitudes and behavior. However, relatively little is known regarding their capacity to engage the public for opportunistic, spontaneous use in community settings. Two studies were undertaken to provide insight to this practical issue. An intercept survey of adults from a shopping center where a computer kiosk had been located for 7 months was undertaken to investigate exposure to, attention to, use and acceptability of kiosks. A total of 99.7% of participants were exposed to the kiosk, 77.4% of these noticed it and 20.8% of these used it. Program acceptability was high; the most common barriers to use related to time constraints and disinterest. A utilization study was then undertaken to describe program utilization in greater detail, with kiosks installed in 18 community settings over 1 year. These were used 57 064 times (19.4 uses per kiosk per day). Additional data described demography of users, preferred topics selected, preferred formats and presentation styles, and a comparison of use across different community settings. Both studies provide insight to practical application of this health education strategy, indicating that is has substantial capacity to engage people for opportunistic use in community settings.
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Introduction |
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In one of the most significant developments in health education delivery in recent times, traditional written health education materials such as pamphlets are being complemented or replaced by high-tech alternatives. In addition to the vast range of Internet sites and CD-ROMs already available, the use of free-standing touchscreen computer kiosks is rapidly expanding (Science Panel on Interactive Communication and Health, 1999
). Although they have been used for over a decade [e.g. (Jones et al., 1993)], it is more recently that the scale of their dissemination has increased. The ‘Michigan Interactive Health Kiosk Project’ has 100 kiosks in community settings (Connell et al., 2003); the UK-based ‘In Touch with Health’ service has around 200, with plans to double this (Nicholas et al., 2001). With the technology continuing to rapidly advance and potential applications set to do likewise, it is essential that the enthusiastic dissemination of new health information systems be matched by appropriate health education research to guide these advances in the most effective directions.
In theory, the potential for positive health outcomes is substantial, because computerized health information programs are so well suited to incorporate evidence-based communication, education and behavior-change strategies. First, they are engaging and appealing. Novel presentation methods such as sound, animation and video are appealing alternatives to traditional written formats, and attention is maintained by giving the user control over their learning environment (Kinzie et al., 1993). Irrelevant content can be automatically filtered out based on information provided by the user (Deardorff, 1986).
Second, communication barriers such as low literacy and cultural or language differences are less problematic. There is less reliance on the written word since video, animation, voice-overs and other sounds, photographs, and diagrams can be used instead (Kinzie et al., 1993). Modified versions of program content can also be provided in different languages or designed to meet specific cultural needs (Street and Rimel, 1997).
Educational materials developed for the lowest literary denominator tend to lack adequate variety, depth and detail of information (Jones, 1999; Campbell, 1999). A third advantage of computerized health information programs is that the user can choose to receive as much or as little information as they require.
Fourth, and perhaps most importantly for health outcomes, computerized health information programs can incorporate tailoring. This capacity to use information provided by the user to tailor appropriate information and advice has been widely shown to increase health outcomes (Brug et al., 1996, 1999; Dijkstra and De Vries, 1999; Stretcher, 1999; Oenema et al., 2001). Tailoring does not guarantee such outcomes, but can maximize their likelihood, particularly if appropriate attention is paid to understanding the cognitive determinants of the behavior to be addressed (Dijkstra and De Vries, 1999), and using evidence-based strategies such as countering user-expressed barriers and self-exemptions, reinforcing positive behaviors, and providing personal, practical and specific advice for risk reduction (Sanson-Fisher and Cockburn, 1993; Paul et al., 1998).
Finally, outcomes can be further enhanced by providing opportunities for rehearsal through interactive problem-solving tasks (Kinzie et al., 1993; Sanson-Fisher and Cockburn, 1993; Paul et al., 1998).
In practice, computerized health information programs have been found to be acceptable to a range of demographic groups (Lapham et al., 1991; Kinzie et al., 1993; Alemi and Higley, 1995) and easy to use (Kinzie et al., 1993; Alemi and Higley, 1995), regardless of the individual's computer skills (Deardorff, 1986). Contrary to some expectations, this has included older people (Rippey et al., 1987; Gillispie and Ellis, 1993; Sweeney and Chiriboga, 2003).
Most importantly, there is also evidence of health outcomes: increased knowledge (Deardorff, 1986; Kinzie et al., 1993; Jones et al., 1999; Oenema et al., 2001; Sweeney and Chiriboga, 2003), increased self-efficacy and intention to change (Westman et al., 2000; Neafsey et al., 2001; Oenema et al., 2001), and health behaviors change including improved nutrition (Kumar et al., 1993; Glasgow et al., 1996), increased exercise (Rippey et al., 1987), improved self-monitoring of cancer warning signs (Westman et al., 2000), and improved self-management of diabetes (Glasgow et al., 1995) and chronic headaches (Schneider et al., 1999).
Reproduction of these outcomes relies on how well developers can incorporate appropriate evidence-based strategies for communication, education and behavior change into their programs. In this context, further research is warranted to determine which strategies will most reliably produce health outcomes, thus guiding evidence-based best practice in this emerging field.
At the same time, there needs to be an equal focus on dissemination research, particularly with respect to the delivery of programs on community-based touchscreen kiosks. Most research studies are closely supervised, with participants often directly prompted to use computer programs in controlled environments [e.g. (Deardorff, 1986; Lapham et al., 1991; Kinzie et al., 1993; Kumar et al., 1993; Alemi and Higley, 1995; Jones et al., 1999; Graham et al., 2000)]. This of course provides the best opportunity to track users and measure outcomes. Evaluating programs designed for opportunistic and spontaneous public use in community settings would be fraught with methodological challenges, including scale and attributable causation (Nicholas et al., 2000)—reason enough perhaps to rely in the main studies such as those already described. However, there is still an unmet need for dissemination research, in terms of the effectiveness of the communication strategy and utilization of the kiosks. Evidence-based, best-practice programs are of little benefit if they are not actually used. Two studies were therefore undertaken to this end: to determine the effectiveness of computerized health information programs in engaging the public for opportunistic, spontaneous use in community settings, and to describe that use in terms adequate to improve future service planning and delivery.
The first consideration was communication reach. McGuire (McGuire, 1984) provided a theoretical framework for communication describing exposure, attention to and utilization. Jones et al. (Jones et al., 1993) placed touchscreen kiosks in community settings throughout Glasgow, Scotland, and evaluated these within these indicators. After 5 months, a telephone survey of 271 people revealed that 75% had been exposed to the kiosks, 64% of these (48% overall) had noticed them and 35% of those (17% overall) had used them. Although the numbers are relatively small, the potential reach is substantial when considered at a population level, particularly if the most appropriate settings could be selected. Further research in different settings and contexts is needed to guide this. Using the same communication framework, the aim of the first study was to determine the capacity of programs to engage the public in terms of exposure, attention and use, as well as acceptability (to users) and reported barriers (of non-users).
Second, profiling use in terms of user demography, topics selection and comparison of different settings would be useful. Williams et al. (Williams et al., 2001) described users of one kiosk at a UK health center. It was used around 18 times per day and was particularly popular with children under 15. Popular topics included alcohol, nutrition and exercise. Nicholas et al. (Nicholas et al., 2002) reported data from 21 kiosks located in surgeries, information centers, pharmacies and hospitals, again in the UK. Children were again the dominant user group. Kiosks in the information centers were used the most, followed by those in hospital waiting rooms and the authors speculated on the possibility that use was linked either to direct interest (information centers being an appropriate source) or convenience when there is time to spare (in hospital waiting rooms). Such results and speculation could improve future service planning and delivery, but additional research is required. Therefore, the aim of the second study was to describe program utilization in additional settings, including demography of users, topic choice and a comparison of different settings, as well as a new consideration: preferred presentation style.
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Methods |
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Two independent but related studies were conducted in the Hunter Valley Region of New South Wales, Australia—a regional area of approximately 540 000 people (Australian Bureau of Statistics, 2000
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Intervention
A touchscreen health education service called HEALTH C.H.I.P.s (Computerized Health Information Programs) was developed. Health topics (each referred to as a module) included smoking, blood pressure and cervical cancer. Within each module, submodules provided information presented in different styles. Information submodules were encyclopedic in nature, including information such as risk factors and local services. Personal risk assessment submodules were more interactive, using programming algorithms to determine the user's specific risk based on multiple-choice questioning and then providing tailored feedback. Quiz submodules were also interactive, applying active learning principles to test an individual's knowledge (pick the correct answer) or challenge common myths (true/false).
Evidence-based strategies for learning and behavior change outcomes were applied to program design. To encourage engagement and hence foster increased learning (Kinzie et al., 1993), the modules included text, photographs, diagrams, animations, sound and video. All content was readability tested to a maximum reading age of 12 years. Different levels of information detail were provided for users to choose from (Jones, 1999; Campbell, 1999). Staff trained in psychology oversaw the development of appropriate content relevant to behavioral determinants, and strategies included countering user-expressed barriers and self-exemptions, reinforcing positive behaviors, providing practical feedback and advice for risk reduction, and providing opportunities for rehearsal through problem-solving tasks (Kinzie et al., 1993; Sanson-Fisher and Cockburn, 1993; Paul et al., 1998). One hundred members of the general public recruited in shopping centers and licensed clubs provided feedback on modules during pilot testing.
The completed HEALTH C.H.I.P.s modules were installed on touchscreen computers installed in tamper-proof fiberglass computer kiosks. The kiosks were placed in community venues for spontaneous, opportunistic community use.
Methods: Study 1 (intercept survey)
Setting and sample
Participants were quasi-randomly selected patrons of a suburban shopping center, aged 18 years or over and able to complete a short structured interview in English.
Procedure
A HEALTH C.H.I.P.s kiosk was loaded with the three modules available at that time (blood pressure, cervical cancer and smoking) and was installed in the central thoroughfare of a convenience selected shopping center for 7 months. At the end of this period, the intercept survey was conducted over 2 weeks. The quasi-random selection process was that exactly on each quarter hour, trained interviewers stationed at each of the shopping center exits identified and approached whichever patron was nearest to a specific spot (e.g. post or sign).
Measures
The intercept survey consisted of yes/no questions to determine exposure (whether the participant had been in the vicinity of the kiosk), attention (if they noticed it) and use (if they used it). Users of the kiosk were asked additional acceptability questions regarding usefulness, provision of information and ease of use. Non-users were asked the main reason they did not use the kiosk. All participants were asked demographic questions regarding age, gender, employment status and country of birth.
Analyses
The demographic profile of the study sample was compared to the local general population (Australian Bureau of Statistics, 2000) using one-sample z-scores and one-sample t-tests as appropriate, with a probability of <0.05 determining statistical significance. Only significant findings are reported. Descriptive statistics were provided for exposure, attention and utilization, and acceptability (users) and barriers to use (non-users).
Methods: Study 2 (utilization study)
Setting and sample
All users of a computerized health information service located at 17 community venues during a 12-month study period constituted the sample for the utilization study.
Procedure
With additional modules continuing to be developed after the intercept study, 18 in total were available for the utilization study (topics listed in results Table III). To ensure wide public access across the population, five shopping centers, eight licensed clubs (community venues with a license to serve alcohol), four health care facilities and one cinema complex were convenience selected as potential venues. The installation of a kiosk at each venue was negotiated for periods of 1 month to 1 year, dependent on kiosk availability, and the size and needs of venues. All kiosks were installed in central locations such as the foyer or main thoroughfare and were available for the opportunistic, spontaneous use of any patron, free of charge, at any time during opening hours.
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Measures
Utilization data were collected by databases built into the program. Gender and age of users was self-reported (multiple choice questions posed in opening menu). Database tracking modules and submodule use was automated. The number of days each kiosk was available for use in each venue was recorded by the researchers, excluding days that venue was closed or the kiosk underwent maintenance.
Analyses
Descriptive statistics were calculated for kiosk utilization, including module and submodule use. Average utilization rates were calculated (average uses per day and average modules per day) for comparison between venues despite kiosks being available for differing lengths of time. A demographic profile of the local population (Australian Bureau of Statistics, 2000) was again used for comparison to self-reported user demography. However, no statistical analyses were performed on these or other data as the sample size was extremely large, providing such power as to render all differences statistically significant and thereby providing no useful insight to the results.
An important final note on terminology: the number of times a kiosk was used is referred to in the following text as ‘uses’ or ‘times used’. Deliberate avoidance of language such as ‘number of people’ may seem pedantic, but is in fact important to avoid misleading assumptions that one use equals one person. In reality, more than one person might have used the kiosks together; also a single person might use the kiosk on more than one occasion. ‘Users’ is only included in the specific context of the intercept study where individual people were actually interviewed.
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Results |
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Results: Study 1 (intercept survey)
Sample
Intercept surveys were completed by 386 people aged between 18 and 83 years. Compared to the local general population, the study sample was younger (mean age 42.9 versus 45.9 years, one-sample t = –3.61, P < 0.01), more likely to be female (70.2 versus 50.5%, one-sample z = 7.74, P < 0.01) and more likely to be employed (56.7 versus 50.8%, one-sample z = 2.32, P < 0.05).
Exposure, attention and use
Of the 386 participants, 385 (99.7%) were exposed to the kiosk, 298 had noticed it (77.4% of those exposed or 77.2% overall) and 62 had used it (20.8% of those that noticed it or 16.1% overall). The only significant demographic difference between users and non-users was age (users mean age 36.6 versus 44.0 years, two-sample t = –3.244, P < 0.01).
Acceptability
Of the 62 users of the kiosk, 52 (83.9%) described it as a useful means of accessing health information, 60 (96.8%) said it was informative about the specific issues addressed and 61 (98.4%) found it easy to use.
Barriers to use
Only 194 of the 236 non-users were able to provide a primary barrier to use (34 reported the kiosk was already in user by another and eight did not provide an answer to this question). The most common barriers reported were being too busy to stop (n = 96, 49.5%) and lack of interest (n = 70, 36.1%). A further 12 people (6.2%) were uncomfortable using the kiosk in public.
Results: Study 2 (utilization study)
Venues
Of the 18 community venues approached, 17 agreed to participate in the utilization study: five shopping centers, seven licensed clubs, four health care facilities and one cinema complex.
Total utilization
Combining all kiosks across all venues, the intervention was available for public use for 2943 days. Table I shows utilization data in total and by setting type. There were 57 064 kiosk uses (averaging 19.4 uses per kiosk per day). Individual modules were used 129 786 times (averaging 44.1 modules per kiosk per day and 2.3 modules per use). Cinemas had the highest utilization in all three measures: uses per day, modules per day and modules per use. Licensed clubs had the lowest.
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Demography of users
Table II shows self-reported demography, again compared to the local population. The most notable result relates to age: 31.4% of uses were by children under 12, the largest proportion in total (and in all settings except cinemas) and over-represented in comparison to the local population. Reading across the table for each age group reveals the setting in which there was the highest relative use: shopping centers for children (less than 12 years), cinemas for young people (12–30 years), health care facilities for adults (31–45) and licensed clubs for older adults (over 45 years).
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Utilization of modules
Table III shows the number of times each module was used in total and by setting, ranked in order from the most (1) to least (18) commonly used. Sexual health, Smoking and Drink driving were the used the most. There was a strong consistency in the selection of module topics across all settings, with the most notable exception being the relatively high use of the cervical cancer program in cinemas.
Utilization of submodules
Not all submodule formats were available in every module. Where there was more than one, Table IV shows the utilization of submodule formats as a proportion of the total use within each module. In all but two modules, interactive submodules (quizzes or personal risk assessments) were used most frequently.
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Discussion |
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The first aim of this research related to communication reach. Differences in methodology and context make a direct comparison with Jones et al. (Jones et al., 1993
) problematic, but some parallels can nevertheless be seen: as a proportion of the total sample, regardless of exposure and attention, the overall utilization rate was 16% in the current study and 17% in Jones et al. Both studies confirm the potential to engage and reach large numbers of people if kiosks are disseminated at population level. In the utilization study alone, over 57 000 people accessed the service: an average across all settings of 19 uses per day and similar to 18 uses per day reported by Williams et al. (Williams et al., 2001). The remarkable similarity of topic choice across settings suggests that use was purposeful rather than random ‘playing’. Given the very high reach and capacity to store large amounts of information on a single kiosk, there is also significant potential for economies of scale for population health education costs (Nicholas et al., 2000). Cost analyses and comparison to other health education channels would be a valuable future investigation. Comparison to traditional health education tools such as pamphlets is, however, problematic. No comparable studies examining exposure, attention and utilization in community settings could be found; in fact, it is difficult to substantiate the actual ‘use’ of a pamphlet at all, unless the user is actually observed to take and read it. An additional advantage of computerized health information programs is therefore their capacity to automatically quantify such use.
Participants of the intercept survey described the kiosk as a highly acceptable source of health information. This is consistent with previous studies (Lapham et al., 1991; Kinzie et al., 1993; Alemi and Higley, 1995) and extends them by reporting non-user barrier data, revealing the most common barrier to be simply being too busy. Given that the objectives of people attending a shopping center would not have originally included (and may have even precluded) the opportunistic, spontaneous use of a kiosk, this is not surprising; in fact, it is unlikely that any other health education strategy delivered in this setting would be successful. This is also likely to be the case for the other main barrier—disinterest. It would be worthwhile investigating the impact of more actively marketing the kiosks to the public, theoretically to increase interest and perhaps prompting planned use.
The second aim was to describe program utilization. Both studies showed that young people were most likely to use the kiosks, even in venues predominantly frequented by older adults such as health care settings and licensed clubs. This was again consistent with previous studies (Nicholas et al., 2001; Williams et al., 2001). The most-used modules were sex, smoking, drink driving and mental health—all issues appropriate for younger uses. Given the apparent appeal of computerized health information programs to this group, it appears that this offers an excellent opportunity to reach young people during the formative years in which many life-long health beliefs and behaviors are established. Again, direct marketing of the service to that population might be a valuable addition to dissemination plans.
Although a large proportion of uses were by young people, the capacity of the service to reach older people should not be overlooked. One in five uses was by persons over the age of 45—around 12 000 uses in study two—suggesting that the service has a capacity to meet the need of a significant number of people in this population as well.
In a new insight to computerized health information program use, data describing submodule selection indicated that the interactive formats (quizzes and personal risk assessments) were used more often than the less interactive information submodules. This is a promising outcome, since interactivity underlies many of the evidence-based strategies such as tailored feedback.
A comparison of settings revealed that the highest levels of use were in cinemas and shopping centers, both of which had a relatively high patronage, and average modules per use was highest in cinemas and health care facilities. As was the hypothesized by Nicholas et al. (Nicholas et al., 2001), the latter perhaps reflects the time people in these settings have to spend, waiting for a film or appointment. Demography of users also varied between settings, in ways that appear reasonable: the highest proportion of small children (less than 12) using the kiosks was recorded in shopping centers, young people (12–30) in cinemas, adults (31–45) in health care facilities and older adults (over 45) in licensed clubs. These findings would also allow service delivery to be directly targeted to different population groups.
Because of software limitations, certain data could not be recorded. Data describing how much time people spend using the kiosks would be valuable, as would correlation between self-reported gender and age with module selection, presentation style preference, and time spent using the kiosks. New versions of HEALTH C.H.I.P.s are being programmed to meet this need.
Some caution must be used when interpreting these results. First, the demographic data rely on unvalidated self-report. However, previous studies have shown that self-report to computerized health information programs has an equal or higher validity than self-report in written form or to health professionals (Erdman et al., 1983; Waterton and Duffy, 1984; Bernadt et al., 1989).
Second, whilst the sample for the intercept study was selected quasi-randomly, no data describing the characteristics of shoppers were available for comparison to ensure that the sample was indeed representative. Likewise, comparisons were not possible for settings in cinemas, licensed clubs and health care facilities. In the absence of this, comparison to the general population was made instead.
Although it cannot be directly tested here, this does raise the question of self-selection bias and it is almost certainly true that kiosk users are a specific, non-representative subgroup of the population, as hypothesized by Nicholas et al. (Nicholas et al., 2000). There is little doubt that the high utilization rate and similarly high rates of self-motivated access to other health information sources such as the Internet (Fox and Raine, 2000) do justify the value of continuing to provide such services—but it is equally important this communication strategy not be promoted as a single health education solution for all. There will always be the need for complementary multiple strategies to achieve population outcomes. People that do not actively seek health information could well be those who need it the most.
Therefore, findings of these studies will be doubly valuable in planning comprehensive population approaches. First, as was the aim, these findings provide an insight to touchscreen kiosk utilization that will improve service planning and delivery. Exposure, attention and utilization were described, as well as acceptability (to users) and barriers (of non-users), and the demographic groups most effectively reached, topics most likely to be selected, submodule presentation styles chosen and finally a comparison of settings.
Second, this and continued monitoring of kiosk utilization may reveal potential health education ‘gaps’. With the effective reach and economies of scale suggested, the effectiveness and cost-efficiency of touchscreen kiosk health education service delivery should save valuable health education resources, which can in turn be channeled into alternative appropriate strategies to fill those important gaps.
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Acknowledgments |
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With grateful thanks to the team that brought HEALTH C.H.I.P.s together: to Lucille Moran, Sue Green and Trevor Hazell for dedicated project management, to John Fejsa and Matthew Hoggard for inspired multimedia programming, to Sally Burrows for statistical advice and keen insight, and to all the members of our Advisory Groups for giving their time and energy to this project.
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Received on March 14, 2003; accepted on November 28, 2003
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