Feasibility of a Kiosk-Based Lifestyle Modification Education System in a Primary Care Clinic for the Uninsured Nancy T. Artinian, PhD, RN, FAHA, FAAN Associate Dean for Research and Professor

Co-Investigators  Julie Gleason-Comstock, PhD  Alicia L. Streator, PhD  Kai-Lin Catherin Jen, PhD  Jessica Timmons, BS  Suzanne Baker, PhD

Acknowledgement  This study was funded by a grant from the Wayne State University Cardiovascular Research Institute, 10/01/10-9/30/11.

Background  Hypertension affects 1 in 3 adults. is a leading cause of heart attack, stroke and congestive heart failure. is a common reason for healthcare provider visits. is controlled to <140 mm Hg systolic and 90 mm diastolic in only 31% of individuals with hypertension.

Background  Pharmacotherapy is a cornerstone of hypertension management, but lifestyle modification, particularly healthy eating behaviors, is critical to the management of hypertension.  Lack of time and a focus on more urgent issues during time-limited visits are frequently deterrents to primary care provider counseling about lifestyle and healthy eating behavior.

Background  Interactive health information kiosks placed in clinic waiting rooms may offer a means to provide counseling about lifestyle and healthy eating.  Interactive kiosks can engage individuals and complement provider advice.

Purposes of Study  The purposes of this 2-group randomized controlled longitudinal pilot study were: examine the feasibility of using an interactive touch screen kiosk with weight scale or blood pressure monitor attachments to provide health information in a primary clinic serving low income adults; determine patient satisfaction with using the kiosk; compare the effects of the Eating for Heart Health (HE) kiosk intervention with a general health attention control (AC) kiosk intervention on blood pressure.

Conceptual Model Kiosk Intervention Increase extent to which individual is well informed about the behavior, motivated to perform behavior, and has requisite skills and confidence to execute the behavior. Improved Health Behavior Improved eating behavior and reduced weight Improved Health Outcome Lower BP

Methods  Non-random sample of African Americans receiving care at the Detroit Health and Wellness Promotion (DHWP) primary care clinic.  Inclusion criteria were: > 18 years, a BMI ≥ 25, no physical/mental challenges that would prevent kiosk log-in.  The WSU-IRB approved the study protocol; written consent was obtained for all participants.  51 adults were recruited, enrolled then randomized to either a general health attention control (AC) group (n = 25) or to a healthy eating (HE) group (n = 26).

Data Collection  Trained RAs collected data by structured interview/brief exam in a private clinic space. Baseline  Height and weight  Demographics  BP (Omron HEM-712c, Omron Healthcare, Inc., Vernon Hills, IL) Immediately following intervention completion (6-weeks)  patient experiences using the kiosk by investigator developed questionnaire. 3 months post baseline  BP (Omron HEM-712c, Omron Healthcare, Inc., Vernon Hills, IL).  Participants were compensated with $25.00 gift card at the end of each data collection visit.

Intervention Overview  Participants in both intervention groups were asked to: Log-in to kiosk (XP Patient Monitor, American Telecare, Eden Prairie, MN) weekly for 6 weeks. Upon card swipe log-in, participants greeted by name and provided a text or voice option to proceed through interactive curricular modules.

Eating for Heart Health (E4H2) Intervention After log-in, participants r eceived instructions for weighing themselves using the attached weight scale. Participants received feedback about their weight. Asked to completed 6 interactive modules about healthy eating and nutrition. Participants asked questions as they proceeded through each of the modules, which they could easily respond to by touching a response option on the kiosk screen.

Data Analysis  Analyses were conducted using SPSS version 20.  Significance level set at p<.05.  Descriptive statistics, bivariate correlations, t-tests, and repeated measure ANCOVA were used to analyze study all study variables and address the research aims.

Results: Sample  Average age (11.8) years.  43 (84.3%) were female; 8 (15.7%) were male.  20% had less than a 12th grade education.  22 (43.1%) were unemployed.  23 (46%) earned less than $10,000/year.  21 (41.2%) reported 1-2 hour clinic wait; 6 (11.8%) reported > 3 hour wait.  Average BMI was 38.3 kg/m2.

Results—Satisfaction with Kiosk  24 (77%) strongly agreed with the statement “I liked using the kiosk to get health information.”  The majority reported that:  the touch screen was easy to use.  they liked that the kiosk could read the information to them.  the words on the screen were large enough to easily read.  What did you like most about the kiosk?  Ability to check weight and keep track of it  Helpful information delivered at appropriate pace; easy to use.

Results—BP Effects There was no statistically significant difference between groups at baseline (t (23) = 1.792, p =.09) or at follow-up (t (25) = 1.668, p =.11). Both groups decreased in SBP, but only the decrease for the HE group was statistically significant t (12) =3.098, p=.009 Age not related to SBP at baseline (r= -.09) or follow-up (r=.05). Baseline BMI not related to SBP at baseline (r =.06) or follow-up (r=.25).

Results There was no statistically significant difference between groups at baseline (t (23) = 0.529, p =.60) or at follow-up (t (25) = 0.326, p =.75). Both groups showed a statistically significant decrease in diastolic reading: HE t(12)= 5.54, p<.001 AC t(11)= =3.470, p =.005 Age was not significantly correlated to diastolic reading at baseline or follow- up. (r’s = -.27 and -.16, for baseline and follow-up, respectively) Baseline BMI was not related to diastolic reading at baseline (r =.19) or follow- up (r=.32).

Summary  Only the HE group showed a statistically significant decrease in both SBP and DBP at three months.  The AC group had a statistically significant decrease in DBP at three months.  Sample size may have been too small to detect the observed between and within group differences.

Conclusions  The kiosk-based intervention:  was feasible for use in a primary care clinic.  was well accepted by low-income African Americans.  led to short-term improvements in BP.