1. Targeting and Tailoring Health Care Messages
Suzanne Bakken, RN, DNSc
School of Nursing and Department of Medical Informatics
Columbia University
New York, NY 10032

2. Purpose
Review principles of targeting and tailoring health care messages
Illustrate principles and steps with examples
CAP-IT
MI Heart
HeartCare
Describe medical informatics vs. content-specialist roles and challenges

3. Definitions
Targeting - intended to reach a specific subgroup of the population typically based upon demographic characteristics
Culturally-sensitive video on cervical screening resulted in in Pap smear in Latinas (Yancey & Walden, 1994)
Personalized - use of name to draw attention to a generic message (Kreuter et al, 2000)

4. Definitions
Tailoring - intended to reach a specific individual based on unique characteristics related to the outcome of interest and obtained through an assessment or profile (Kreuter et al, 2000)
Within ethnicity-diversity when exposed to a culturally-similar (CSV) and culturally-dissimilar video for HIV/AIDS intervention
Only CSV effective in African American youths who scored themselves as “know a lot about AIDS” (Stevenson et al., 1995)

5. Tailored communication
individualized
Content of Communication
Interpersonal
communication
Tailored communication
Personalized communication
Targeted communication
generic
Generic communication
Not
assessment
based
Based on
Assessment of
individuals
Level of Assessment
(Kreuter et al, 2000)

6. Where is the State of the Art in Diabetes Care?

7. Rationale for Tailoring
Based upon elaboration likelihood model (Petty et al, 1994)
Superfluous information is eliminated
Information is perceived as more personally relevant
Persons may pay more attention to information they perceive as personally relevant
Personally relevant + attended to is more likely to lead to thoughtful consideration of actors related to behavior change
Personally relevant + attended to + thoughtful consideration will be more useful to help enact desired behavior change (Kreuter et al, 2000)

8. RCTs of Tailored vs. Non-tailored Health Messages
Dietary Change
Smoking Cessation
Physical activity
Mammography
Weight control
Cholesterol screening
Nutritional label reading

9. Tailored vs. Non-tailored Health Messages Are More Likely To:
Catch attention
Be saved
Be discussed with others
Be perceived by readers as interesting
Be perceived by readers as personally relevant
Be perceived by readers as personally written for them

10. Steps in the Tailoring Process
Analyze the health problem
Develop a program framework
Develop a tailored assessment
Design feedback
Write tailored messages
Create tailoring algorithms
Automate tailoring process
Implement the program
Evaluate the program

11. Steps in the Tailoring Process
Analyze the health problem
Develop a program framework
Develop a tailored assessment
Design feedback
Write tailored messages
Create tailoring algorithms
Automate tailoring process
Implement the program
Evaluate the program

12. Examples
CAP-IT
MI Heart
HeartCare

13. Example
Client Adherence Profiling and Intervention Tailoring RCT (Holzemer & Bakken, NR04846)
To compare CAP-IT vs. standard care on:
HAART adherence rates
CD4 count, viral load, viral resistance
Quality of life
Health services utilization

14. Steps in the Tailoring Process
Analyze the health problem
Develop a program framework
Develop a tailored assessment
Design feedback
Write tailored messages
Create tailoring algorithms
Automate tailoring process
Implement the program
Evaluate the program

15. Ickovics & Meisler Framework (1997)

16. Steps in the Tailoring Process
Analyze the health problem
Develop a program framework
Develop a tailored assessment
Design feedback
Write tailored messages
Create tailoring algorithms
Automate tailoring process
Implement the program
Evaluate the program

17. CAP-IT Intervention RCT
Client Adherence Profiling (CAP)
Client characteristics
Knowledge about medication regimen
Knowledge about side effects and symptom management of side effects
Self-care behaviors
Treatment complexity
Engagement with provider
Support systems

18. Steps in the Tailoring Process
Analyze the health problem
Develop a program framework
Develop a tailored assessment
Design feedback
Write tailored messages
Create tailoring algorithms
Automate tailoring process
Implement the program
Evaluate the program

19. CAP-IT Intervention RCT
Intervention Tailoring (IT)
At least one intervention from each category based upon nursing diagnosis
In CAP-IT, this is done by nursing judgment, not by algorithm

20. Potential Gains from an Informatics Approach
Automatic scoring of profile from tailored assessment
Standardized selection of interventions based upon score using decision support rules
Measurement of and ability to measure “dose” of intervention
Data re-use (e.g., from CIS)
Resource re-use (content re-used from message library)
24 x 7 availability

21. Potential Downsides from an Informatics Approach
Access, digital divide issues
Computer literacy
Literacy and health literacy
Where is provider in the loop?

22. Information-Technology-Based Patient Education for Decreasing Prehospital Delay of Patients Presenting with Acute Myocardial Infarct: The MI-HEART Project
James J. Cimino, MD, Principal Investigator
Rita Kukafka, DrPH
Yves A. Lussier, MD
Vimla L.Patel, PhD
Department of Medical Informatics, Columbia University
Supported by National Library of Medicine and the National Heart, Lung and Blood Institute N01-LM3534

23. Research Design and Methods: Overview
Randomized, controlled trial
300 patients will be recruited and randomized into one of three groups
Follow-up at 1, 3, and 6-months

24. Research Design and Methods: Outcomes
Likelihood of action (seeking help in response to symptoms) as reported by patients
Changes in attitudes and beliefs associated with
patient delay

25. MI-HEART Tailoring Variables
Medical Record
Online Questionnaire
Demographics
Health history
Diabetes
Angina
Family History
Variables associated
with increased delay
Somatic and emotional awareness
Expectation of symptoms
Perceived threat
Self-efficacy
Response efficacy
Computer-Related
font size
display

28. HeartCare Project Post-operative CABG care Web TV interface
Web page with access to relevant resources
Targeted information: based upon phase of the recovery process
Tailored information: based upon nurse interview during hospitalization (Brennan et al)

29. Tailoring Recovery Resources to Patients
Establishing the tailoring model
Patient Profiles
Access (TM) database
Delivering WWW resources ‘on-the-fly’, across the recovery period
Active server pages sorting nurse- identified or developed WWW pages

30. Tailoring Health Information
Patient ID
Login
Is Female
Preferred Name
DoB
DoD
Reading Level
Information Method
Condition
Condition Sequence
Description
Patient
Condition
Condition
Keyword
WWW Knowledge
Resources
URL
Screen Title
Male?
Female?
Reading Level
Core
CreationDate
Title
Organization
Comments
Keyword
Keyword
Page
Hcare Menu
Name
Sequence
DaysBegin
DaysEnd
TimePeriod
Patient’s
Menu

35. Discussion
What are potential areas of focus for computer-based educational and behavioral interventions?
Which of the current barriers to education could potentially be addressed through computer-based approaches?

36. Discussion
What are factors that have been used or could be used to target educational and behavioral change interventions?
What are factors that have been used or could be used to tailor educational and behavioral change interventions?
Which of these factors are routinely collected and stored in electronic form?
How can such approaches extend the provider and yet engage the client?

37. Areas for Medical Informatics Contribution
Security and confidentiality of the data
Knowledge representation for re-use
Standardized assessments
Clinical terminology
Logic for decision support
Sharable message libraries
User interface